Basketball season has begun and for many podiatric physicians across the country, this will mean players of all ages and skill levels coming in for acute post-injury treatment and preventative care.
I have been the podiatrist for the Indiana Pacers and Indiana Fever for several years now and have learned much over the years from interactions with elite professional players and professional athletic trainers. Due to my long history and affiliation with professional basketball players, I also see several high-level high school and collegiate basketball players for foot and ankle conditions.
If you already work with a local high school or collegiate team, or if you would like to become involved in sports medicine, I hope I can provide some valuable information. This is information you can take to the trainer and/or coach to help them understand the value of having a team podiatrist.
What One Key Study Revealed
There has been little in the way of independent research on basketball specific orthoses to confirm the value of custom-made devices. Most of the literature to date has focused on running orthoses. What little that has been reported in literature regarding basketball devices has been anecdotal and based on personal experience.
However, in 2006, independent research from researchers at the Duke University Medical Center confirmed the importance of orthoses in the elite basketball player.1 This study has received significant coverage in both the medical literature and media outlets. Nancy Major, MD, utilized preseason magnetic resonance image (MRI) screenings of 26 elite college basketball players. The MRI screenings focused on bone marrow edema, specifically of the fifth metatarsal. Only one of the 26 players exhibited symptoms clinically at the time of the screening. However, of the 52 feet examined, 19 (36.5 percent) showed bone marrow edema on MRI screenings.
All of the players were treated with custom orthoses which successfully prevented any stress-related injuries, with one noted exception of a player who developed a stress fracture before receiving his orthoses.
This study is very important in that it shows conclusively that preventative care with custom orthoses is critical in the elite level basketball player. The very frustrating component is that far too often, even the best intentioned trainers and coaches ignore this simple, effective preventative care, resulting in overuse injuries that could have been avoided with proper podiatric care.
Maximizing The Effect Of Orthotics On The Court
Achilles tendon stretching is crucial for orthotic adherence and overall player satisfaction. It is important to educate other team medical staff on the correct technique of measuring equinus deformity via locking of the midtarsal joint and placing the subtalar joint in a neutral position to accurately gauge ankle joint dorsiflexion with the knee extended and flexed.
There may be some pushback from the trainers on the presence of equinus, due to the lack of an absolute definition of equinus and improper clinical examination for equinus. One should educate the trainer and/or coach on the significant pathology associated with equinus and how improved orthotic adherence with night splint therapy can be effective and well tolerated.
In regard to night splint therapy, once an elite basketball player or any elite athlete has adequately stretched, there will be a tendency for re-contracture due to the high level of activity. Therefore, it is very important to utilize some form of maintenance therapy for equinus management. I like to have players use their night splints once a week while they are playing or training in their sport for maintenance therapy.
The basics of basketball orthoses comes down to shock absorption and shear force reduction while simultaneously trying to accomplish some form of hindfoot control and midfoot support. This is certainly a difficult task and often involves a give and take approach to the device. Most elite basketball players do not tolerate a rigid device and prefer a softer, more accommodative orthotic. Many biomechanical experts or orthotic gurus may differ with this statement, but those who have been involved with professional or collegiate basketball players for any substantial amount of time know this to be true.
When I have tried to give an elite basketball player a rigid device, it has been my experience that the orthotic rarely makes it into the player’s shoe. Of course, there are exceptions to this and the players I have encountered over the years who request a rigid device are players with relatively normal biomechanics and have worn custom orthoses for several years.
The majority of the players prefer a semi-rigid (ideally) or an accommodative device (most commonly). Getting a player to wear a semi-rigid device that is indicated clinically when he prefers an accommodative orthotic requires a substantial effort from the medical team. This is when it becomes essential to the overall outcome to educate and communicate with the player, trainer and other medical staff.
I have used a semi-rigid shell, such as a 1/8-inch to ¼-inch polypropylene device, in combination with multiple layers of shock absorbing materials such as EVA and nylene (nylon covered neoprene). In my experience, this device is the best tolerated and accepted by most players through years of trial and error.
Graphite can be a substitute for polypropylene. Graphite is stiffer and less forgiving than polypropylene, but offers the advantages of being lighter and thinner. It is essential to make the device full-length for basketball. I have also found recently that 1/16-inch perforated Poron topcovers provide additional shock absorption and “breathability” to the device.
What You Should Know About Orthotic Modifications
Several modifications, such as a more flexible type of shell, can be useful in basketball orthotic design in order to provide more midfoot support and hindfoot control. A deep heel seat is very helpful in gaining more hindfoot control.
On a side note, one of the first things players typically check when they receive a device is the softness of the heel. I will use an EVA heel post (or similar material) to add further shock absorption for the tremendous forces that occur during playing at heel contact. Making too much of a heel lift is contraindicated in the basketball device because it will raise the height of the subtalar joint axis from the floor and increase the mechanical leverage for ground reaction force, leading to inversion ankle injuries in the athlete.
An arch fill with an accommodative material also provides more support to the midfoot while absorbing shock and reducing friction. The concern with this addition is the increased thickness of the device, which may make shoe fit all the more difficult. A more recent addition that I have been using routinely is a reverse Morton’s extension made of Korex or Poron. This will not only aid in jumping by helping to engage the peroneal longus tendon but additionally provides further shock absorption to the forefoot. Metatarsal pads are useful in taking pressure off the metatarsal area and providing more midfoot support.
Another orthotic consideration is for the elite collegiate or professional player is the need for orthotics for everyday shoes. It has been my experience that these types of players will not move orthotics from their basketball shoes to everyday shoes. Since they will only be in their basketball shoes for two to three hours a day, it is very important for them to have orthotics for their everyday shoes.
Now is the time to contact trainers to become involved with a basketball team. There is a study you can refer to when discussing with a trainer or coach the importance of podiatric care.1 Additionally, I have shared a few insights I have gained over 15 years of experience of utilizing orthotics for professional basketball players. Develop a relationship with the trainer or coach, not to mention the players you will be treating, and your practice will benefit.
1. Major NM. Role of MRI in prevention of metatarsal stress fractures in collegiate basketball players. AJR Am J Roentgenol. 2006; 186(1):255-8.