Given the considerable demands pro basketball players place on their lower extremities and the increase of missed games due to lower extremity-related injuries, this author emphasizes keys to preventative care to reduce the risk of ankle sprains and metatarsal stress fractures.
Basketball is a very physically demanding sport. At the professional level, it has progressed in my 34 years with the Utah Jazz from a finesse sport to an almost rugby-like sport with tremendous size, speed and strength built into most all of today’s players. Taking a charge from a driving Karl Malone at full speed can be a near death experience for those who are unprepared. (Ask Isiah Thomas, who ended up in the hospital with a large facial laceration after getting blasted by Malone in a game at the Utah Delta Center.)
The need to keep the players healthy is the first approach in professional basketball. This includes proper diet, weight control, flexibility, proprioception, physical strength (which includes plyometrics and weight training) and proper endurance.
Basketball is primarily an anaerobic sport with multiple short spurts of intense activities.
Basketball has more side-to-side cutting, stopping, sudden acceleration and vertical leaping/jumping than it does linear running. The multiple stops, jumps and changes of direction that are required during a game is not something that the physical body of muscle, ligaments, cartilage and bone can adapt or accommodate to in just a month of preseason training. It takes months of concerted effort to strengthen bone, ligaments and cartilage to the stresses required of the repetitive forces to the athlete’s joints.
Even then, with all of the proper training and hopefully positive accommodation, certain body types (i.e. Yao Ming with a height of 7’6”) cannot handle the stress load of the 82 regular-season games, plus pre- and postseason games.
The college athlete plays about 30 games during the season and then postseason may take him or her up to a total of 40 games in a season. Alternately, the professional basketball player will play eight preseason games, 82 regular-season games and if he makes it all the way to the NBA Finals, will play another possible 28 games (if each series went to seven games) for a total of well over 100 games during the season. There are very few physical bodies that can stand up to this level of stress loading to joints, tendons and ligaments, let alone the occasional laceration or lost tooth from flying elbows that occur each and every game.
It is even more amazing when you consider these numbers for John Stockton, a member of the National Basketball Association Hall of Fame and a gold medalist with the “Dream Team” in the 1992 Olympics in Barcelona, Spain.
Games Played: 1,504 of a possible 1,526 (third all-time in NBA history). He played in every single NBA game in 17 of his total 19 seasons.
Minutes Played: 47,764 (fifth all-time in NBA history). Most “good” players never make it past 30,000 minutes.
Career Field Goal Percentage: .515
Career Assists: 15,806 (NBA all-time leader)
Most Assists, Season: 1,164 (1990-91, NBA record)
Most Assists, Game: 28 (1/15/91)
Highest Season Average for Assists: 14.5 (NBA record, 1989-90)
Most Seasons Leading the League in Assists: 9 (1987-88 through 1995-96, NBA record)
Consecutive Seasons Leading the League in Assists: 9 (1987-88 through 1995-96, NBA record)
Career Steals: 3265 (NBA all-time leader).1
This is even more amazing when you consider Stockton did this with a 6’1”, 175-lb. body, always playing against much larger bodies.
Both talent and injury determine the longevity of players in the National Basketball Association but oftentimes, neither is in the control of the player. Those players who play the longest in the NBA have a synergistic combination of talent and ability to stay away from career-ending injury. The NBA career longevity database provided by the NBA reveals an interesting view of the “standard” NBA player:2
Center: 8.8 years
Forward: 7.8 years
Guard: 7.3 years
The average number of years played by position certainly was related to the amount of mileage the player would encounter in his position.
Those players who had the fewest injuries per year were also the players to have the longest career longevity.
Played 1-5 years 1.5 injuries per year.
Played 6-7 years 1.3 injuries per year.
Played 8-10 years 1.2 injuries per year.
Played 13-20 years 0.9 injuries per year.3
The NBA players reportedly missed nearly 65 percent more games due to foot-related injuries in 2009 than they did in 1989.4 It is also interesting to note that the injury rate among NBA players is twice that experienced by the collegiate player (but the NBA player also plays twice as many games in a season).5
Injury prevention is thus very important to both the player’s career and the team’s investment in the player. Some injuries are not as preventable as others. Even some of the acute injuries can be influenced by wise preparation of player conditioning and strengthening of weak areas of need. Improving flexibility, appropriate shoe gear selection and timely replacement of the shoes, and the use of orthotics help in functional weight distribution of foot and ground reaction forces.
There are several examples of preventative medical care that can be beneficial for basketball players.
The return to activity of the athlete from the offseason (or time off for recovery from injury) and strengthening to a competitive level of participation requires a certain level of stress changes to bone, ligaments and cartilage. Wolff’s law dictates that these structures will adapt to the application of eternal forces to bone, ligaments and cartilage, but only at a certain rate. When these forces exceed the ability of bone to adapt, negative changes begin to occur within the structure. This creates an eventual fault or, in the case of bone, a stress fracture. One can reduce the risk of a stress fracture by balancing a certain level of weightbearing loading in the offseason with the need to recover from the season’s stress level as well.
Linear running in stable running shoes provides both aerobic conditioning and the needed weightbearing to the joints. Most NBA players continue to play basketball in the offseason but are strongly encouraged to avoid playing in the neighborhood “pickup” games, in which someone may try to prove his manhood by taking the “NBA player” to the out of control limits of the game.6
Of all the fractures that occur in the NBA, the metatarsal stress fracture is the most frequent. This is followed in frequency by tibial stress fractures and navicular stress fractures. These are truly overuse injuries. These are injuries which preventative medicine can have a great impact on both competitively and fiscally (money lost to the team by not having the player available).
Both the navicular and Jones fracture injuries do not heal quickly and with professional basketball players (as well as with most athletes), we typically perform surgical repair to facilitate an appropriate, timely return of the athlete to competition. (See “How To Treat Navicular And Jones Fractures” at right).
In my experience, players with any past history of plantar fasciitis or more than one stress fracture of the foot will benefit from the use of an accommodative orthotic device. Players frequently enter the NBA with a past history of previous metatarsal stress fractures from the college career. During my time in the NBA, the use of orthotics in the league has slowly increased from the low 40 percent range in the 1990s to currently upward of 80 percent of players on some teams, such as the Utah Jazz. Orthotics range from soft accommodative or shock absorbent materials to a semi-rigid polypropylene device with an accommodative top cover.
There is also less taping of the foot and ankle now than we have used in the past for NBA players. In the 1980s, the player could be fined for not getting taped for game or practice. Now it is not uncommon for the player to use a commercially available ankle splint or even play without any preventive taping. Last year, several Utah Jazz players utilized the Adidas ankle splint (Adidas adiZero Speedwrap Ankle Brace) instead of the standard ankle taping.
Proper shoe gear has a strong relationship to the performance and stability of foot function within the shoe. Those shoes that complement foot requirements for stability, flexibility and shock absorption can greatly aid in dissemination of stress to foot structure. This being said, much has changed with the use and function of shoe gear. Shoes have gotten much lighter (not unlike the changes to running shoes — think minimalist). The use of the high top basketball shoe is becoming much less frequent. Players are opting for lighter weight and lower cut “fashionable” shoe gear.
At their highest point, according to the market research firm NPD Group, high tops accounted for about 20 percent of the United States market for basketball shoes. That number declined to 8 percent in 2010 while low tops grew from 11 percent in 2002 to 29 percent of the market in 2010.4
Assessing the stride and gait of runners, Perl and colleagues recently found that minimally shod runners “are modestly but significantly more economical than traditionally shod runners regardless of strike type.”7
The amount of stress applied to the shoe gear before replacement with a new shoe also has a profound influence upon protecting the athlete. The sports medicine practitioner readily recognizes the need of timely replacement of running shoes to prevent and treat existing injuries. In my experience, most runners are encouraged to replace shoe gear every 350 to 500 miles, depending upon the size and weight of the runner, and his or her running environment (i.e. road surface, trail running, moisture and mud).
The same should be true of the basketball player. I have found that the average runner will spend approximately 66 hours running to accumulate 500 miles on a pair of running shoes (8 minute/mile pace times 500 miles). In my experience, the average high school or college basketball athlete will easily work out 72 hours per month. Basketball shoes are now made of the same types of materials, namely ethyl vinyl acetate (EVA) or a polyurethane midsole and harder outer sole material. These materials all have a fatigue factor that greatly influences function of the foot and stress delivered to bone and adjacent soft tissue structures.
Accordingly, I recommend that in high school and/or college, the athlete should replace his basketball shoes every month at least, due to the fatigue of the midsole material that subsequently ceases to protect the foot from the external forces of shock impact of running, cutting, and jumping. On the Utah Jazz, I recommend that players change shoes at least every two weeks and that the larger players (250-300 lbs.) change their shoes at least weekly, if not sooner.
A positive secondary byproduct of frequent shoe change is that of protective influence of shoe gear on the foot and ankle stability in response to the external forces. As the player accumulates hours of wear on the shoe, the leather or synthetic uppers slowly begin to stretch and/or fatigue in response to the repetitive rotational forces as well as the considerable moisture buildup that occurs. Also, midsole material slowly deforms or compresses in response to the repetitive ballistic starting and stopping of the workout or game. As these external forces to the shoe continue, the rotational movement of the foot within the shoe slowly increases in range of motion and velocity, and thus slowly begins to decrease in its ability to diminish the external forces to the foot. Indeed, worn out shoe gear is certainly one of the great causes of metatarsal stress fractures and plantar fasciitis.
The most common injury over my many years in the NBA is the lateral inversion injury to the ankle. Even with all of the proper use of shoe gear, taping or ankle supports, inversion injuries still are a frequent occurrence in basketball. In my 34 seasons with the Utah Jazz, I have seen many ankle sprains. However, I am still impressed that in those 34 seasons, not one surgical repair has been required or performed to get the injured player back to full speed again.
The sooner that “RICE” can begin, the quicker the player is back to full recovery. This also consists of rest until the athlete is pain-free to proprioceptive strengthening exercises. Compression wrap of the injured ankle is also very important in keeping the post-injury edema reduced to allow for the benefits of the ice and elevation of the affected ankle. The quicker one addresses post-injury edema and applies a compressive wrap to the ankle, the sooner the player will begin to recover and may initiate his strengthening proprioceptive exercises. We always address these injuries immediately as opposed to waiting until the next morning. Accordingly, one does not see the presence of “woody” edema with the rapid treatment of injury.
If the athlete is tender enough, one should place a cast boot on the athlete in the training room and have him or her use crutches. Crutch usage will typically end in 24 to 48 hours and the cast boot will come off when the athlete can bear full weight without pain, usually two to four days post-injury (thus enabling range of motion to begin to leg muscles and the ankle joint with continued daily physical therapy and compression wraps).
Proprioceptive deficits are frequent post-injury findings of ankle inversion injuries. The player must have a return of strength and proprioception, or his ability to perform highly ballistic movement with that ankle becomes unlikely. Secondly and just as important, without strength and proprioception, the rate of re-injury of the same ankle is significant.8,9
Dr. Lowe is the team podiatrist for the Utah Jazz. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Lowe is a Diplomate of the American Board Of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons. He was the podiatrist for the 2002 Winter Olympics and the 2002 Para-Olympics.
1. National Basketball Association. Available at http://www.nba.com/history/records/index.html  Accessed December 3, 2012.
2. NBA Career Longevity Study, 1991.
3. NBTA Injury Reporting System, Utah Jazz Physician’s Report.
4. Biderman D. Why the hightop has one foot in the grave. Wall Street Journal. May 19, 2010.
5. Starkey C. Injuries and illnesses in the National Basketball Association: a 10-year perspective. J Athl Train. 2000;35(2):161-167.
6. Taylor PM, Gordon G, Lowe MK: Basketball injuries. In: Subotnik SI (ed): Sports Medicine of the Lower Extremity (2nd edition), Ch. 31, W.B. Saunders Co., Philadelphia, 1999, p. 695.
7. Perl DP, Daoud AI, Lieberman DE. Effects of footwear and strike type on running economy. Med Sci Sports Exerc. 2012; 44(7):1335-1343.
8. Malliou P, Gioftsidou A, Pafis G, et al. Proprioceptive training (balance exercises) reduces lower extremity injuries in young soccer players. J Back Musculoskeletal Rehabil. 2004; 17(3-4):101-104.
9. Verhagen E, van der Beek A, Twisk J, et al. The effect of a proprioceptive balance training program for the prevention of ankle sprains. Am J Sports Med. 2004; 32(6):1385-1393.
10. Holme E, Magnusson SP, Becher K, et al. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports. 1999; 9(2):104-109.