When a foot and ankle specialist is involved as part of the medical staff for a college or professional basketball team, the demands on injury prevention and rehabilitation are significant. This high level of specialized care in the professional and collegiate setting involves several people, including the players, coaches, trainer, other medical staff and management in professional teams. Since treatment can involve the careers of those associated with the team, there is a certain amount of pressure on the treating physician. With so much at stake, two critical factors play an integral role in injury prevention and rehabilitation. Custom-molded orthoses and proper Achilles stretching therapy are of the utmost importance in overall treatment outcomes. The type of orthotic one emphasizes for the elite basketball player, implementation of orthotic use and proper equinus treatment require a well-orchestrated team approach based on education, communication and regular critical evaluation of the treatment plan. 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. Recently, however, new independent research from Duke University Medical Center confirming the importance of orthoses in the elite basketball player has been receiving significant coverage in both the medical literature and media outlets. This recent study by Nancy Major, MD, utilized preseason MRI screenings of 26 elite college basketball players and stressed the use of custom orthoses in injury prevention and rehabilitation.1 The MRI screenings focused on bone marrow edema, specifically edema of the fifth metatarsal. Only one of the 26 players exhibited symptoms clinically at the time of the screening.1 However, out of the 52 feet the researchers examined, 19 (36.5 percent) showed bone marrow edema on MRI screenings. These abnormal findings led to treatment with orthoses and therapy, which led to successful prevention of any further stress-related injury with one noted exception of a player who developed a stress fracture before receiving his orthoses.1 Why Basketball Players Are Especially At Risk Several factors place the elite basketball player at risk regardless of the player’s foot structure and biomechanics. First, consider the movements that occur on a basketball court and the extreme amounts of resulting stress involved. The quick starting and stopping, lateral movements, linear running and sprinting, and jumping all lead to significantly elevated pressure levels on the forefoot and midfoot. The size of basketball players and the type of playing surfaces also play a role in the increased peak pressures occurring in the forefoot and midfoot. As with any type of elite athlete, the amount of time playing and practicing can additionally lead to stress-related injury. Kevin A. Kirby, DPM, has also found this to be true. “Basketball is a side-to-side sport and, as such, requires that the orthoses be constructed specifically to allow the foot to perform its necessary three dimensional motions relative to the floor,” states Dr. Kirby, an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College.2 Common lower-extremity injuries with basketball players essentially fall under two types: overuse chronic and stress-related injuries, and acute traumatic injuries. When treating elite basketball players, clinicians often see overuse types of injuries, including Achilles tendonitis, plantar fasciitis, posterior tibial and peroneal tenosynovitis, and metatarsalgia. The stress-related injury of primary concern is a stress fracture, which can be a prelude to a true fracture. This type of injury can lead to a substantial amount of missed playing time and may become career threatening. Another consideration one should examine is the relationship of chronic stress-related injures that may lead to an acute traumatic injury. Pertinent Pearls On Orthotic Selection Before discussing basketball orthoses, one must address the current state of basketball shoes for a realistic evaluation of basketball orthoses styles, materials and modifications. In order to make basketball shoes lighter, manufacturers have made them increasingly narrow and form-fitting, making orthotic fit difficult at best. The standard width of an orthosis is often too wide for today’s basketball shoe. One tip that I have learned over the years is to send the player’s shoes to the lab with the negative cast impressions to have the devices ground to fit the shoe. This makes things go much smoother once the player gets the orthoses. It also removes a potential negative impression in the player’s mind that can doom his or her compliance from the start (see “Secrets To Ensuring Improved Compliance With Orthotics” below). The basics of basketball orthoses come down to ensuring adequate shock absorption and shear force reduction while concurrently achieving 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. Granted, there have been exceptions to this and the players whom 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 where education and communication with the player, trainer and other medical staff are essential to the overall outcome. Through years of trial and error, I have found that combining a semi-rigid shell, such as a 1/8-inch to 1/4-inch polypropylene device, with multiple layers of shock absorbing materials, such as ethyl vinyl acetate (EVA) and nylene (nylon covered neoprene), has the best tolerance and acceptance by most players. Graphite can be a substitute for polypropylene. While it offers the advantages of being lighter and thinner, graphite is stiffer and less forgiving than polypropylene. It is essential to make the device full length for basketball. Dr. Kirby emphasizes the importance of a full-length device and top cover materials. “Full-length foot orthoses with vinyl or leather or other shear-resistant topcovers are a requirement to increase top cover durability and to (prohibit) the orthoses (from sliding) within the shoe,” notes Dr. Kirby.2 How Modifications Can Bolster Orthotic Success When using a more flexible type of shell, clinicians may employ several useful modifications in basketball orthotic design in order to provide more midfoot support and hindfoot control. A deep heel seat is very helpful in providing more hindfoot control. One of the first things players typically check when they are handed 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 at heel contact during playing. However, making too much of a heel lift is contraindicated in the basketball device. As Dr. Kirby states, “Excessive heel contact point thickness (i.e., excessive heel lift) in basketball orthoses is contraindicated since this will raise the height of the subtalar joint axis from the floor and increase the mechanical leverage for ground reaction force to cause inversion ankle injuries in the athlete.”2 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 to the device, which may make shoe fit all the more difficult. A more recent addition that I have been routinely using 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 also provides further shock absorption to the forefoot. Metatarsal pads are useful in taking pressure off the metatarsal area and providing more midfoot support. Dr. Kirby has found first ray accommodations to be very helpful in the basketball orthoses. “Forefoot accommodation for plantarflexed first metatarsals is common since plantarflexed first rays are very common among athletes involved in basketball,” he states.2 Additional Tips For Orthotic Management Another very important aspect to the overall outcome of orthotic therapy is to address the individual player’s foot biomechanics and any clinical deformities. From a correction standpoint, I will usually post the forefoot to the cast measurement and the rearfoot to vertical posting. Regarding rearfoot posting, Dr. Kirby cautions, “Excessive varus correction or medial heel skive in basketball orthoses should be avoided to prevent inversion ankle injuries, unless the athlete also has a significant flatfoot deformity with significantly medially deviated subtalar joint axis.”2 Dr. Kirby also relays a point of concern regarding posting and an athlete with a history of chronic lateral ankle sprains. “Athletes with chronic inversion ankle sprains should be treated with orthoses that have a lateral heel skive and forefoot valgus forefoot extensions, and may need additional ‘bracing’ from high-top shoes or ankle taping before each game and practice,” he says.2 Impression techniques are also very important in the fabrication of a custom device. I have tried all types of impression methods and scanning over the years, and have come back to the traditional non-weightbearing, neutral position, suspension casting. One additional technique I have employed that seems to have increased overall outcomes is plantarflexion of the first ray during the impression taking while loading the lateral column. Special Considerations For Dealing With Elite Athletes One must take several considerations into account when treating elite athletes like basketball players. An often overlooked aspect of total care is making a device to be worn during non-playing times. It is important to stress to the player the need for a continuum of care. This is the time for a rigid functional device if indicated. Once an acceptable device is agreed upon and the player wears it, one should keep an adequate supply of devices on hand and monitor the wear of the orthoses being used. Players should replace them on an as-needed basis in order to maintain maximum shock absorption, friction reduction, hindfoot control and midfoot support. Communication is also very important. It can be very difficult to get much information out of elite athletes about their orthoses but their input is very important for adjustments and modifications. Getting them to spend a few minutes discussing their orthoses with the DPM and the trainer can make all the difference in their satisfaction and overall treatment. Secrets To Ensuring Improved Compliance With Orthotics Compliance is another important aspect of orthotic therapy in the elite athlete. This can be very difficult and frustrating for a physician. A common player’s error is a lack of a “break-in” period prior to using orthotics in practice and game situations. The typical scenario is for the player to put a new device in his or her shoe and practice or play in game situations immediately. This results in discomfort or pain from the device. The player then takes the devices out of the shoes and gives up on them altogether. Ensuring an adequate “break-in” period is especially important for players who have never worn a custom-made device as they need an adequate adjustment period. It is crucial to discuss this adjustment period in detail with the player and trainer upon dispensing the orthotic. I like to have the player wear the device for one hour the first day in a gym shoe during normal walking and daily activities. Then one can increase this an hour per day so the player is wearing the devices full time by the eighth day. After the player is wearing the orthoses full time, he or she may start wearing them during shoot-around. Once he or she is comfortable with this, the next step is to wear the orthoses in practice. Wearing the orthotics during the game should be the last step in the process. If the player has worn orthoses previously, then there should be no need for this break-in period unless there has been a significant prescription change. Achilles tendon stretching is crucial for orthotic compliance and overall player satisfaction. It is important to educate the team’s other medical staff on the correct technique of measuring equinus deformity (i.e. locking of the midtarsal joint to gauge ankle joint dorsiflexion accurately with the knee extended and flexed). Team medical personnel routinely stretch elite players. Therefore, in order to achieve adequate equinus reduction, utilizing a night splint becomes practically essential. Compliance is very difficult for several reasons. Elite basketball players travel quite a bit and may forget to bring their night splint with them on a road trip. This is where the help of the trainer, who also travels with the team, becomes crucial. The trainer often carries things such as extra pairs of orthoses, shoes, etc., with him or her and it should be very little trouble to add a night splint. Trainers also have the ability to monitor the player’s use of the night splint while on the road. In Conclusion In summary, clinicians should first know the player’s biomechanics and pathology. Then find an orthotic lab that the DPM, the players and the trainer are comfortable with using. This season, I requested a sample basketball device from several orthotic labs and actually went over each sample with the trainer. Semi-rigid devices with multiple layers of shock absorbing materials should be the goal in most cases. Use modifications as needed for each particular case. Send the shoes with the cast to the lab so the lab’s technicians can ground the devices to fit the shoe. Evaluate and adequately treat equinus deformity. Discuss an adequate break-in period with the player and the trainer. Maintain open lines of communication about the orthoses and the potential need for adjustments. All of these suggestions can potentially increase the overall success of preventative treatment and rehabilitation of the elite basketball player. Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, and is a Diplomate of the American Board of Podiatric Surgery. He is also a team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. DeHeer is in private practice with various offices in Indianapolis.
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