As spring yields to summer, more baseball players may present to your office with injuries sustained while batting, sprinting around the bases or sliding into home. Accordingly, this author presents a guide to treating common forefoot, midfoot and rearfoot injuries as well as contusions and dermatological conditions. Springtime brings warmer temperatures, the anticipation of summer and the start of a new baseball season. We welcome spring baseball with the crack of the bat but it can also lead to an unwelcomed crack of the bones and other baseball-related injuries. As sports medicine specialists of the lower extremity, we should be able to accurately diagnose and appropriately treat lower extremity injuries in order to return the injured baseball player to the diamond as quickly and safely as possible. We should also recognize the full scope of baseball’s popularity and trends. Organized baseball in the United States is now among the most popular and safest sports. Over 20 million people play annually. The majority of baseball players are children and adolescents with an estimated 8.6 million children ages 6 to 17 participating.1,2 Baseball is one of the safest high school sports in the United States with a reported injury rate of 1.26 injuries per 1,000 athletic exposures.1 Although baseball is a relatively safe sport in comparison to many other athletic activities, highly publicized occasional catastrophic injuries (such as commotio cordis) from the direct impact of a ball or bat frequently raise safety concerns.1 The U.S. Consumer Products Safety Commission reports that in 2012 more than 400,000 Americans had treatment in hospitals, doctors’ offices and hospital emergency rooms for baseball-related injuries.1 Nearly 300,000 of the players treated were 18 years old or younger. Although baseball is a non-contact sport, most serious injuries are due to contact — either with a ball, bat, or another player. Eleven- to 14-year-old children represent the majority of those injured and the most frequent areas of the body injured are the head and face, including the eyes and nose. Nearly 20 percent of baseball injuries occur at the lower extremities and injuries to the foot and ankle can cause significant disability if one does not diagnose and treat them appropriately.1 Many young athletes are now focusing on just one sport and are training year round, causing an increase in overuse injuries at younger and younger ages. We should encourage youth athletes to play multiple sports and activities, and to take time off from only playing one single activity year round. Safety of the athlete is a constant focus of attention among rule-making officials and governing bodies. Subsequently, youth baseball rules control the maximum pitch count, required rest periods and age recommendations for throwing various types of pitches. Additionally, important factors in minimizing the risk of injury include appropriate field maintenance and awareness of environmental conditions such as extreme heat, thunderstorms and lightning.3 Injury patterns may change with the level of competition from youth to high school, and college to minor and major leagues. It is critical for sports medicine physicians to identify and appropriately treat baseball injuries in a timely manner. Youth baseball injuries need evaluation with special concern for open growth plates whereas minor and major league injuries are often more chronic due to the overuse from extensive daily repetitive training regimens. Equipment considerations in the prevention of baseball injuries should include a position-specific evaluation of cleats, socks, bats, helmets, insoles, orthoses, field conditions and even fixed versus breakaway bases.4 Installing breakaway bases on all playing fields may significantly decrease sliding injuries.2 A preseason physical examination is important for both younger and older players with the goal of preventing or reducing the risk of injuries and illnesses by identifying any potential medical problems. Preexisting medical problems may include asthma and allergies as well as heart, dermatologic, biomechanical or orthopaedic conditions. Patients should have a thorough lower extremity screening examination provided by a foot and ankle specialist to help identify and decrease the risk of in-season injuries.
Key Pointers On Footwear RecommendationsAppropriate shoe gear will offer protection, support and cushioning for the athlete. Shoes or baseball cleats in particular should have the following features: 1) firm heel counter; 2) torsional rigidity; 3) shoe flexion in the forefoot; 4) stable upper material with hard leather preferable; 5) single density midsole; 6) external last (straight last increases control); and 7) an internal last (board lasted). Additionally, the shoes should have an outsole with cleats that are usually square made of molded rubber, polyurethane-like material or metal. Some models have detachable replacement cleats. Turf cleats have shorter and more numerous rubber studded cleats. Baseball shoes should also have appropriate cushioning. The use of an ethylene vinyl acetate (EVA) wedged midsole increases cushioning.5 Tim Dutra, DPM, a Past President of the American Academy of Podiatric Sports Medicine (www.AAPSM.org ), has addressed special features of baseball cleats in detail.5 These added features may include the following: an ankle strap for increased lock down; flex grooves in the forefoot of the shoe; a full-length midsole to increase cleat pressure dispersion; or a multidirectional pattern outsole for maximum traction. Other features include a nylon pull tab in heels, a molded EVA sock liner, a lightweight synthetic and mesh upper combination, a molded heel for lateral support, and differing the number of spikes for traction. Poorly fitting shoe gear may actually cause blisters as well as nerve and toenail problems. Cleat-related injuries may result from existing pathology such as hammertoes, bunions, hallux limitus, sesamoiditis, neuromas and retrocalcaneal bursitis. Improperly fitting cleats can also cause additional nerve-related pathologies such as compression neuritis of the medial dorsal cutaneous nerve and the intermediate dorsal cutaneous nerve, but patients can often adjust shoe gear by using an array of different shoe-lacing patterns.6
An Overview Of Common Baseball InjuriesBaseball involves rapid accelerations and decelerations, straight ahead sprinting, rounding bases, sliding, batting, throwing and pitching. Sprinting involves running the bases and fielding the balls. Side-to-side movements include taking leads off the base, running bases and fielding balls. The feet remain neutral to give the body an increase in stability for the lower extremity to compensate for the force that the upper body force exerts. There is also more demand on the right foot and shoe due to running on the base paths, where the shoe contacts the inside corner of the base. Injuries to base runners occur slightly more at home plate than at first base with the majority of the base runners being injured while sliding.1,7 The injury rate is higher for feet-first slides (7.31 per 1,000 slides) than for headfirst slides (3.53 per 1,000 slides). The majority of these sliding injuries reported were minor with only 11 percent causing the athlete to miss more than seven days of participation. As I previously mentioned, breakaway bases will significantly decrease the risk of sliding injuries. Pitchers also have the increased demand of pushing off the back foot during their pitching motion so the more rigid the sole of the shoe, the better support is during push off. The catcher requires more flexion in the ball of the foot as the position requires the athlete to be in a squatting position most of the time with weight equally distributed on both feet. There is no predilection of foot types with rectus, planus and cavus foot types equally applicable for baseball.5,8 Baseball injuries and treatments are numerous so I will not address every injury. However, I will discuss some of the more common injuries and general treatment recommendations. Examination of the injured baseball player should include a thorough history and complete physical examination, including shoe evaluation as well as a dynamic gait assessment. In the higher level and professional athletes, I will often perform a pre-treatment and post-treatment video gait analysis on the baseball field of play.
Pertinent Insights On Treating Contusions And Dermatologic ConditionsContusions occur with player contact during sliding or a collision with another player, but frequently result from the baseball impacting a player’s foot or ankle from a pitched ball, foul tip or line drive. Usually, these contusions require short periods of rest, ice and compression. They can leave the player bruised but the player may return quickly. Should pain persist, radiologic examination may be necessary to rule out a fracture. Dermatologic conditions commonly include ingrown toenails, subungual hematomas, fungal infections, interdigital intertrigo, corns and calluses. Good regular hygiene such as cleaning the skin with soap and water, drying well, and using antifungal sprays or powders in shoes can help diminish skin irritations. Definitive diagnosis and treatment of all of these skin conditions by a podiatric physician has a high success rate, allowing the baseball player to return safely to competition with minimal disability. Nail surgery, skin debridement, topical and prescription medications, and additional padding and shoe adjustments are frequent treatments.
A Guide To Handling Orthopedic InjuriesOrthopedic injuries may be acute but are frequently chronic. Fractures require immediate care including X-rays to determine whether splinting, casting, closed reduction, immobilization or open reduction with internal fixation (ORIF) are necessary. Point tenderness, inability to bear weight (without pain) and a history of injury raise the suspicion of a possible fracture. Additional ancillary diagnostic testing such as musculoskeletal ultrasound, bone scan, magnetic resonance imaging (MRI) and computed tomography (CT) scanning may be helpful if the diagnosis is still in question, or if one cannot otherwise determine the extent of the injury. Forefoot. Common forefoot conditions include: digital fractures, turf toe, sesamoiditis, interdigital pathology, neuromas and lesser metatarsophalangeal joint (MPJ) capsulitis. One can immobilize digital fractures using buddy taping or fabrication of a custom orthodigital device.5 Turf toe and sesamoid injuries often require a period of protected immobilization, taping with padding, and rigid custom foot orthoses with a stiff-shanked shoe. Interdigital pathologies respond well to shoes with wider toe boxes and interdigital spacers, and neuromas may require shoe adjustments, orthoses, injections or surgery if recalcitrant. Clinicians can treat lesser MPJ capsulitis conservatively but they must rule out a plantar plate rupture, which may require surgical repair. Midfoot. Midfoot injuries include Lisfranc fracture dislocations, metatarsal fractures and navicular fractures. As I noted previously, X-rays will assist in diagnosing each of these conditions in order to determine whether splinting, casting, immobilization or ORIF are necessary. Ancillary testing can be helpful in making a definitive diagnosis. One can monitor non-displaced, low-grade navicular fractures on MRI and successfully treat them non-operatively. Higher-grade navicular fractures usually require ORIF in the athlete. Rearfoot. Rearfoot injuries include plantar fasciitis, plantar fascia rupture, Sever’s disease in children, Achilles tendinopathy, ankle sprains, anterior ankle impingement (especially in catchers), ankle fractures and peroneal tendinopathies. Catchers are prone to plantar fasciitis due to the excessive mechanical strain on the plantar fascia but their treatment can be successful with standard heel pain protocols including custom foot orthoses. Ruptures of the plantar fascia may seem devastating initially but respond fairly quickly to protected immobilization and orthoses. Sever’s disease (calcaneal apophysitis) is common in 8- to 12-year-olds due to the open growth plate and high-level activity on a soft grass surface as well as wearing baseball cleats with a minimal midsole (creating a “negative heel”). Short periods of rest, ice, stretching, heel lifts and orthoses are usually helpful. The rapid start-and-stop movements required in baseball can often aggravate Achilles tendon problems, which one can treat with standard Achilles protocols, incorporating regular stretching of the posterior calf muscle groups.9,10 Ankle pathology can occur and one should obtain a definitive diagnosis before simply treating all ankle pain as an “ankle sprain.” Recurring peroneal tendinopathies may require MRI to rule out partial tears or peroneal subluxation, which may require surgical repair. Leg. Leg injuries include medial tibial stress syndrome and tibial stress fractures. Exercise-induced compartment syndromes are less likely due to the short duration of running or sprinting in baseball although I have had to perform several emergent fasciotomies for cases of acute compartment syndrome of the leg caused by the high impact of the ball striking the leg. Medial tibial stress syndrome requires an evaluation of the foot, ankle and leg biomechanically to determine underlying pathology as well as flexibility. This condition may require the use of physical therapy and custom foot orthoses. When it comes to tibial stress fractures, one can emphasize activity modification, proper shoe gear and custom foot orthoses. Anterior tibial stress fractures can become a chronic, debilitating problem and may ultimately lead to the “dreaded black line” on radiographs, which is an ominous sign necessitating intramedullary rod fixation.
How To Ensure A Safe Return To PlayAn injured player’s symptoms should resolve completely before the return to play. For example, if the injury involves a joint, the player should have no pain, no swelling, full range of motion and normal strength as well as the ability to perform simulated same-sport movements before returning to the field of play. In cases of an overuse injury, the player should gradually return to activity, increasing the number of repetitions depending on the length of time away from play and the player’s specific position.11
In SummaryBaseball remains as popular as ever as our national pastime. Although baseball injuries are relatively infrequent, they do occur and affect the lower extremity up to 20 percent of the time. The sports podiatrist should have a good understanding of the popularity of the game and key trends as well as common baseball injuries and treatments. Preventive measures should include proper evaluation of equipment including shoes, cleats and inserts, and screening of the athlete. Dermatologic conditions can occur and one should identify and treat them. Common lower extremity orthopedic injuries occur at the forefoot, midfoot, rearfoot, ankle and leg. These injuries include contusions, sprains and fractures, which the sports podiatrist can manage to allow a quick, safe return to play. Readers interested in more in-depth learning and becoming involved in growing a sports medicine practice should attend sports medicine conferences, and join sports medicine organizations such as the American Academy of Podiatric Sports Medicine (www.AAPSM.org ) and the American College of Sports Medicine (www.ACSM.org ). Dr. Werd is a Fellow of the American College of Sports Medicine, a Past President of the American Academy of Podiatric Sports Medicine, and a Fellow of the American College of Foot and Ankle Surgeons. He has authored numerous sports medicine texts, including, “Athletic Footwear and Orthoses in Sports Medicine.” Dr. Werd is the team podiatrist at Florida Southern College and a consulting physician for the Detroit Tigers spring training team. He has also coached his son’s baseball teams at all youth levels in Lakeland, Fla. References 1. American Academy of Pediatrics. Policy statement on baseball and softball.Council on Sports Medicine and Fitness. Pediatrics. 2012; 129(3):842-56. 2. Lyman S, Fleisig GS. Baseball injuries. In Maffulli N, Caine DJ (eds): Epidemiology of Pediatric Sports Injuries: Team Sports, vol. 49. Karger, Basel, Switzerland, 2005, pp. 9–30. 3. Andrews JR, Ireland ML, Fleisig GS. Available at http://www.stopsportsinjuries.org/baseball-injury-prevention.aspx . Accessed March 25, 2014. 4. America’s pastime. Available at www.aapsm.org/baseball.html . Accessed March 25, 2014. 5. Dutra T. Baseball specific recommendations. In Werd MB, Knight EL (eds): Athletic Footwear and Orthoses in Sports Medicine, first edition, Springer, New York, 2010, pp. 95-101, 303-6. 6. Werd MB, Knight EL. Lacing techniques. In Foot! Care, Prevention, and Treatment, chapter, ISC Division of Wellness, Lakeland, Fla., 2004, pp. 59-65. 7. Hosey RG, Puffer JC. Baseball and softball sliding injuries: incidence, and the effect of technique in collegiate baseball and softball players. Am J Sports Med. 2000; 28(3):360-3. 8. Donatelli R, Wooden M, Ekedahl SR, Wilkes JS, Cooper J, Bush AJ. Relationship between static and dynamic foot postures in professional baseball players. J Orthop Sports Phys Ther. 1999;29(6):316-25; discussion 326-30. 9. Werd MB. Achilles tendon sports injuries: a review of classification and treatment. J Am Podiatr Med Assoc. 2007; 97(1):37-48. 10. Werd MB. Achilles tendon injuries in the athlete. Foot and Ankle Quarterly audio lecture. 2013; 24. 11. Baseball injury prevention. Available at http://orthoinfo.aaos.org/topic.cfm?topic=A00185 . Additional References 12. American Academy of Podiatric Sports Medicine. Available at www.aapsm.org . 13. American College of Sports Medicine. Available at www.acsm.org . 14. Professional Baseball Athletic Trainers Society. Available at www.pbats.com . 15. American Sports Medicine Institute. Available at www.asmi.org . Little League Baseball. Available at www.littleleague.org/Assets/old_assets/media/pitchcount_faq_08.pdf . 16. Prevention and Emergency Management of Youth Baseball and Softball Injuries. American Orthopaedic Society for Sports Medicine. 2005. Available at http://www.foothealthfacts.org/Content.aspx?id=2070 . For further reading, see “Secrets To Preventing And Treating Baseball Injuries” in the May 2008 issue of Podiatry Today.
Sunny greetings! Excellent article. Timely, informative and inspiring to PLAY BALL! Congratulations, Dr. Matt and to the fabulous picture of our sliding into home safe athlete, Matthew! Wow, what a coup to land on the front cover and looking handsome as ever! What a grand, thorough and scholarly article. It hits the mark for a perfect score. A blue ribbon winner. Very interesting to know the high safety records of playing baseball and the various types of treatable accidents. Emphasizing diversity in sports for young athletes ranks as high importance. Great to see this highlight along with many other interesting points. The x-rays were fascinating as well. Being aware of the environment, field conditions and general heat conditions remains overlooked in the zeal of the day. Sending all a very HAPPY SUMMER indeed with safe play and lots of fun. Again, a solid home run hit with the article! To the top surgeon: CONGRATULATIONS!