Given the increasing popularity of baseball, these authors discuss a variety of injuries ranging from contusions and shin splints to Achilles tendonitis and sliding injuries. They also share their thoughts on post-injury rehabilitation and essential treatment considerations.
Baseball is a popular and timeless sport with approximately 15.9 million people of all ages playing baseball or softball in the United States.1 Every year, approximately three million children play baseball and many of these young athletes will continue to play through their adolescent and high school years.2 As with any sport, injuries are inevitable and sometimes unique to the sport itself. With so many active participants, it is not uncommon for patients with baseball injuries to present to a podiatrist’s practice.
According to the United States Consumer Product Safety Commission, softball and baseball are the two main sports contributing to emergency room visits in the U.S. Both acute and chronic foot and ankle injuries are among the most common injuries.3 In baseball, pitchers tend to face upper body injuries such as shoulder and elbow injuries while lower extremity injuries often affect position players.
The decision to return to play after an injury is a multifactorial process involving both physical and psychological criteria.4 Physicians may face a great deal of pressure to clear an athlete to play, especially if the athlete in question is playing at higher levels of competition. It is important to keep in mind that when making these decisions, the responsibility of the physician is to cause no harm and direct the best care possible to the athlete.
Creighton and colleagues developed a decision-based model, which aims to build on the basic elements of the return to play (RTP) process. The three-step algorithm consists of health status, participation risk and decision modification. In step one, the provider assesses health status by evaluating patient demographics, symptoms, medical history, laboratory tests and functional tests. In step two, one focuses on participation risk, including the patient’s ability to protect the affected and injured areas with padding or activity modification, depending on the sport/position. Research shows that athletes with prior injury are at almost four times greater risk of future injury.
Lastly, the third step involves decision modification, which is affected by factors such as pressure on the clinicians to return athletes to play.4-6 Athletes may impart this pressure themselves or patients may hide their symptoms to return to a desired event. Coaches and sports organizations may also impact the patient’s and clinician’s decision-making.
Currently, there is a lack of evidence-based literature related to foot and ankle sports injuries, including baseball, since most research involving return to play decisions are based on serious conditions such as concussions, spinal cord injury or cardiac anomalies.4
Understanding The Importance Of Appropriate Rehabilitation Time For Baseball Injuries
In order to return to baseball, or any sport for that matter, determining the cause of injury, properly diagnosing the pathology and determining the proper post-injury rehabilitation are key. The clinical decision-making process to return to play varies across different types of physically active populations. Rehabilitation programs that emphasize the use of therapeutic exercise to restore range of motion, muscle strength, neuromuscular coordination and gait mechanics show evidence of success.3 Comprehensive evaluation of gait and the lower extremity is crucial for rehabilitating these injuries. Understanding the stresses and strains of a particular sport and position will allow clinicians to identify and treat specific injuries, and any sequelae following the rehabilitation course.
Ankle sprains are common injuries in baseball that require rehabilitation. Athletes can complete isometric and open-chain range of motion while non-weightbearing as these exercises focus on dorsiflexion and plantarflexion of the ankle. One can introduce towel stretches and wobble board range of motion early in the rehabilitation process. Once they are weightbearing during the middle stage of rehabilitation (usually 10 to 20 days post-injury), athletes can perform balance and neuromuscular control exercises.
Rehabilitation exercises and techniques vary tremendously from clinician to clinician. Return to full activity is a gradual progression. Resting and rehabbing helps prevent stress on the associated ligaments and tendons. Clinicians can allow full activity once the athlete regains 80 to 90 percent of pre-injury range of motion and strength.3
Can Prophylactic Bracing And Preventive Taping Have An Impact?
Using the same example of an ankle sprain, clinicians often recommend preventive measures such as prophylactic bracing to provide further stability. However, many athletes do not always utilize these modalities until they have acutely or previously sustained an injury. Ankle sprains may occur while stepping on or sliding into bases, fielding balls or running. Although baseball has an ankle injury rate of less than two percent in high school students, which is lower in comparison to other sports such as basketball or soccer, it is still important to prevent such injuries and any recurrence.5
Braces offer a common preventive measure due to the ease of application, cost-effectiveness and the variety of styles available. The different types of braces include lace-up, stirrup or those of an elastic configuration. Additionally, braces provide the athlete with proprioceptive stimulation. Proprioception can be affected after injury, articular disease and increasing age. Sensory deficit can occur when there is an injury to the receptors that help our joints stabilize, thus causing instability (excess motion) in the ankle. Ankle bracing can increase joint position sense and, in our experience, better proprioception decreases risk.7
Taping is also an effective and customizable option.3 In a two-year prospective study of 2,526 college-aged intramural basketball players, Garrick and Requa found that taping reduced the incidence of sprains and sprains that did result were less severe in comparison to the untaped cohort.8 In a six-month prospective randomized study of 439 male soccer players, Tropp and colleagues found that three percent of athletes in the group using an ankle orthosis sustained an ankle sprain in comparison to a significantly higher percentage of injury in the control group.9 For people with previous ankle sprains, additional sprains occurred in five percent of those who used ankle bracing versus 25 percent in those that did not. These external supports allow the patient to load the damaged tissues in a more protected manner.8,9
Pertinent Considerations With Baseball Cleats
The evolution of baseball cleats is similar to that of football and soccer shoes. Since baseball is played on a variety of surfaces, including grass and dirt, it is important to utilize the appropriate shoes on the appropriate playing surface to prevent injuries. The best baseball shoes will be comfortable yet supportive, allowing players to perform their best without causing injury to their feet.10 Even in baseball, playing surfaces vary by position. For infielders, dirt and clay-like surfaces are more common. In the outfield, players more frequently encounter dirt or grass.
Cleats and shoes that athletes use for baseball have similar features such as stable uppers, torsional rigidity, a firm heel counter, shoe flexion in the forefoot, external and internal lasts, and a single-density midsole.11 Baseball cleats can either be metal or rubber, and both have disadvantages and advantages. Metal cleats are primarily for high school, college and professional players, but they can be allowed in some junior and senior divisions of Little League Baseball.12 There are also interchangeable cleats that allow players to change from metal to rubber depending on the playing surface and the position they are playing.
Rubber cleats provide durable, strong and effective baseball shoes, and spread direct pressure forces over a greater area of the foot. Alternatively, metal cleats provide better traction to dig into the dirt or grass. There are three categories of cleats: high-tops, mid-tops and low-tops. High-tops may provide additional ankle support and at least provide better proprioceptive protection while low-tops are more lightweight. Athletes with a history of ankle injuries would most likely benefit from high-top cleats.
Overall, the main priority of baseball cleats or any shoes should be comfort. Cleats should not be too tight or too loose. There should be some arch support and often that means using an insole for the cleats. Players should be able to move their toes in the toe box. If shoes are too loose, it can cause the foot to be unstable, leading to injuries in the lower extremities, hip and knee pain. Athletes should replace cleats after 70 to 75 hours of activity, or when the shoes show signs of breakdown.13
Key Insights On Sliding Injuries
In recent years, Major League Baseball and Minor League Baseball are paying more attention to the effects of injuries to improve player safety. Research suggests that base runners sustain injury more commonly than batters or position players, and that greater than eight percent of injuries occur as a result of players making contact with a base.14 Hosey and Puffer noted that the overall rate of injury was 9.5 per 1,000 slides in collegiate baseball whereas sliding injuries in softball for recreational athletes reportedly accounts for as many as 70 percent of all injuries.14 Many baseball players are required to play some or all of these positions. Player, coach and medical staff awareness on how to prevent injuries in different situations of game play are important.
Over the years, in an attempt to reduce sliding injuries, experts have suggested different techniques to use within the sport. This includes breakaway or low-impact bases. Janda and team found that breakaway bases reduced the frequency of sliding injuries in softball from 0.072 to 0.003.14 Camp and coworkers reported the second-most commonly affected part of the body in these sliding injuries was the ankle, resulting in sprain or ligament injury.14 Sliding injuries can be very devastating to an athlete and his or her career, which is why further precautions are necessary to prevent them.
Current Concepts In Managing Ankle Sprains
Ankle sprains are among the most common injuries experienced by collegiate athletes. Ankle sprains come in many different varieties, including lateral and medial ligament complex sprains and distal tibiofibular joint sprains, also known as high ankle sprains. Mauntel and colleagues found that, on average, it takes 13.9 days for high ankle sprains to recover in comparison to 8.1 and 10.7 days for lateral and medial ankle sprains respectively.15 The overall high ankle sprain rate was one out of 10,000 athlete exposures with 9.8 percent of of high ankle sprain injuries being recurrent.15
A widely utilized treatment protocol for ankle sprains consists of rest, ice, compression and elevation (RICE), non-steroidal anti-inflammatory drugs (NSAIDs), a lower leg cast for at least four weeks (depending on the severity of injury), functional support such as ankle bracing or taping, exercise therapy and immobilization. Surgical intervention should be a last resort after one has exhausted conservative treatments.
This treatment approach has sparked debate when it comes to high-level athletes. Nonetheless, many studies have found that conservative treatment of ankle sprains provides similar outcomes in comparison to surgery, and that not all patients require surgical intervention.15 It is important to realize, though, the importance of how much time an athlete may need to miss when it comes to conservative versus surgical treatment. Most surgical repairs require at least three months of restriction from baseball while more conservative treatment could lead to a quicker return. However, the goals of surgical repair, in part, include less recurrence of injury.
Addressing Plantar Fasciitis In Baseball Players
In terms of baseball, plantar fasciitis might affect base running or moving across the outfield. Treatment of plantar fasciitis may include medications such as NSAIDs, laser and extracorporeal shock wave therapy, stretching, orthotic devices and taping. Surgical options include fasciotomy, radiofrequency microtenotomy and alternative strategies such as platelet-rich plasma injection and stem cell therapy.16
Meta-analyses and systematic reviews have determined that corticosteroids and orthotic devices are not only some of the most effective treatments for plantar fasciitis, but that the non-invasive nature of these modalities may afford athletes relief without missing significant playing time.16 Over-the-counter orthotics can be both clinically and cost-effective for the recreational athlete. In a study of patients with plantar heel pain, Ring and Otter found that for most of the patients studied, prefabricated semi-rigid insoles provided a short-term benefit equivalent to casted foot orthoses.17 In our experience, however, we have found that prescription orthotics allow for creation of special characteristics that improve outcomes in this patient population. These modifications can include flanges and wedges to further stabilize the foot and ankle as well as accommodative padding and adaptions for the first metatarsophalangeal joint.
Recognizing The Varying Etiologies With Shin Splints
Medial tibial stress syndrome, also known as shin splints, is a repetitive stress overuse injury. Shin splits reportedly account for six to 16 percent of injuries in runners with common symptoms including pain and discomfort in the leg from repetitive activity on hard surfaces, usually resulting in muscle inflammation.18 These are both bone-related and muscular-related pathologies, meaning that stress injuries can lead to stress fractures.
Treatment for shin splints consists of the aforementioned RICE protocol and NSAIDs. For those athletes who have shin splints with muscular origination, foam rolls are excellent. One can educate athletes on how they can utilize the foam roll by running it over the shins and calves for several minutes, several times a day to loosen the fascia.
Improper shoe wear can also cause shin splints since it creates biomechanical problems in the feet and resultant stress load on certain muscles. This reiterates the importance of utilizing shoes with proper arch support and motion control. If one has linked shin splints to a stress fracture, it is critical to counsel the athlete to use dynamic rest. Swimming and cycling can keep an athlete fit during the healing process while allowing the stress fracture to resolve and rehabilitate.19
How To Treat Achilles Tendonitis
Achilles tendon injury can be acute or chronic, ranging from tendinosis to ruptures. In baseball, the stop-start and quick cutting motions can create pain and tightness in the calf, causing injury over time.20 To reduce inflammation and irritation to the tendon, it is important the player rest and take time off from playing. This can be a challenge, especially with some high-level athletes. Time off for Achilles tendonitis can range from two weeks to two months. In our practice, we see that braces, dry needling, physical therapy and orthobiologics can speed recovery for some patients.
Icing can help decrease inflammation as well as cool down the soft tissues, causing a temporary restriction of blood flow to the tendon, and reducing swelling and pain. Ice therapy is best in approximately 10- to 15-minute spans. Wearing orthotics or heel pads can also help reduce tension on the tendon.
Another important aspect of healing is strengthening exercises. Home exercises can be helpful and may include the towel stretch, standing calf stretch and soleus stretch, step-up, balance and reach exercises. If pain does not improve, one may need to consider physical therapy. Physical therapy protocol varies depending on the type of Achilles injury. In a single-blind, randomized clinical trial, Kedia and colleagues found that conventional physical therapy consisting of gastrocnemius, soleus and hamstring stretches along with ice massage and the use of heel lifts and night splints with or without eccentric training is effective for treatment of insertional Achillles tendinopathy.21 NSAIDs and bracing may also reduce inflammation and pain with bracing also providing protection as well.
Addressing Contusions And Stress Fractures
Contusions, which are frequent in baseball, may occur from impact with other players or the ball. Contusions can range from minor injuries that allow players to quickly return to play to major injuries that limit players for months. Treatment for contusions consists of the aforementioned RICE protocol and NSAIDs. Major contusions may require immobilization.
A stress fracture is defined as a partial or complete fracture of the bone due to repeated stress lower than that required to fracture the bone in a single-loading situation.22 The tibia is the most common site of stress fractures, followed by the metatarsal and tarsal bones.23 According to Iwamoto and Takedo, in baseball players, particularly pitchers, the ulnar olecranon is the most common area for a stress fracture. This does not mean that stress fractures cannot occur in the lower extremity in baseball players. In general, it takes about six to eight weeks for stress fractures to heal. Most stress fractures are uncomplicated and one can manage them with rest and restriction, but again, this relies on athletes adhering to time away from sport.23
Identifying and correcting any predisposing factors for stress fracture is the first step. Intrinsic factors, such as hormonal factors, medical abnormalities, age and nutritional status, are important to consider. With low-risk stress fractures, one should emphasize a resting period anywhere from one to six weeks with limited weightbearing followed by low-impact activities such as swimming and biking. High-risk stress fractures can progress to more complete fracture or non-union, requiring a more aggressive approach including non-weightbearing, immobilization in a cast or boot, and/or a longer rehabilitation process.22-23
In the pediatric patient population, apophysitis, especially that of the calcaneus, is also a great concern. Clinicians should treat apophysitis conservatively and in the same manner, emphasizing rest and restricted activity. In cases of mild calcaneal apophysitis, patients generally require two weeks of immobilization with proper modifications on return to activity. More significant cases can require two months of immobilization or more.
Although baseball is not often considered “high contact,” baseball-related injuries do occur in the foot and ankle, and can be catastrophic. Injuries often not only require professional treatment, but athlete awareness and an understanding of the sports medicine behind the injury. Accordingly, it is important to educate athletes and facilitate a safe and prompt return to play after an injury, and strive to prevent injury recurrence.
Dr. Haley is the Chief of the Podiatric Surgical Service at Christiana Care Health System in Delaware. He is a Fellow of the American College of Foot and Ankle Surgeons, the American Society of Podiatric Surgeons, and the American Academy of Podiatric Sports Medicine.
Dr. Benjamin Green is the Chief Resident in podiatric medicine and surgery with the Christiana Care Health System in Delaware.
Dr. Nguyen is a second-year podiatric medicine and surgery resident with Christiana Care Health System in Delaware.
Dr. Nicholas Green is a first-year podiatric medicine and surgery resident with Christiana Care Health System in Delaware.
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