Basketball is a highly popular sport played the world round, from youth to professional levels. Due to sudden forces as well as gradual stress, foot and ankle injuries are common. This article will discuss common foot and ankle injuries associated with this sport and how these injuries are often treated.
Ankle Sprains
Ankle sprains are common injuries in sports. Ankle sprains in basketball occur because of the force of an opponent landing on another player’s ankle, or when landing awkwardly after a jump while shooting or rebounding, rolling the foot inward.
On the outside of the ankle, there are three separate ligaments: one toward the front of the ankle, one along the side, and one towards the back. These ligaments connect the outermost bone prominence of the ankle to one of the bones of the back of the foot. Most athletes roll their ankle inward during an injury. This motion stretches and tears the ligaments on the outside of the ankle. Usually the first one or two ligaments are injured in a sprain, although severe sprains can involve the final ligament near the back. Sprains in which the ankle rolls outward are uncommon. The inside of the ankle is held by a very strong ligament structure that acts as a single unit. It is difficult to sprain this side of the ankle due to the strength of the ligament, and therefore sprains on this side do not occur with great frequency.
Ankle sprain symptoms include swelling, warmth, bruising, and of course pain following the injury. These symptoms do not necessarily show up at the exact time of the injury. In some cases, the symptoms can be delayed by a few hours. Additionally, a feeling of ankle weakness is also common, due to extra laxity of the ankle joint developing from the ligament tearing. Pain with standing or walking is to be expected. Severe pain in which one cannot even place the foot down without excruciating pain possibly indicates a major fracture in the ankle or foot. The same is true for any sprain in which the ankle looks deformed or is angled off to one side. Several smaller foot fractures have been associated with ankle sprains, which do not necessarily add to the pain of a typical sprain directly. These often go untreated as people assume the pain was solely due to the sprain itself. In essence, a medical evaluation with foot and ankle x-rays is needed for all severe sprains, and most moderate sprains as well.
‘High’ ankle sprains are a somewhat different and more serious variation of the traditional ‘lateral’ ankle sprain, and involve damage to the tissue (syndesmosis) that binds the end of the leg bones that comprise the top part of the ankle joint. The pain is felt primarily above the ankle, and x-rays may indicate separation of these bones.
Treatment of any sprain begins with the usual formula of rest, ice, compression, and elevation, primarily to reduce inflammation and improve comfort. The ankle will need support in order to heal, even if pain is minimal. The use of an ACE bandage or a stretchable ankle sleeve is helpful for very low grade sprains in non-athletes, but is probably of little use in an athlete trying to decrease recovery time. More substantial bracing is often recommended, along with physical therapy as soon as the pain will allow. Sprains that are moderate to severe (or high ankle sprains) may require more aggressive treatment, including a period of immobilization prior to advancement to physical therapy. These injuries obviously take much longer to heal. All sprains should have a medical evaluation, including x-rays, to identify any significant instability, as well as any small fractures that may involve the bones surrounding the injury site. Further tests may need to be done if a full ligament tear is suspected, including the use of an MRI scan. Surgery is sometimes indicated to repair ligament tears that remain chronically unstable, or to immediately repair fractures that occur with the injury. Surgery is also sometimes needed in high ankle sprains.
The long term complications that can occur with an untreated or under treated ankle sprain include instability, pain or stiffness in the ankle joint, ankle arthritis, and frequent spraining due to the inherent weakness of the injured ankle tissue. These symptoms can last a lifetime, and can make even simple walking difficult, especially on uneven surfaces. Proper initial treatment guided by a foot and ankle specialist can help prevent these complications, and lead to a lifetime of healthy ankle function.
Peroneal Tendon Injuries
The peroneal tendons are located on the outer side of the foot and ankle. The tendons begin where the peroneus brevis and peroneus longus muscles end in the lower leg, as the tendon is the attachment of the muscle to the foot. These two tendons then run together behind the outer ankle bone, and eventually split up. The brevis tendon, which is shorter, attaches to the outside of the base of the 5th metatarsal, which can be felt as a bone bump midway along the outside of the foot. The longus tendon, which is longer, dives underneath the bottom of the foot and attaches to bones in the middle section of the bottom of the foot. The purpose of these tendons is to rotate the foot outward, as a direct opposition to strong tendons that rotate the foot inward on the inner side of the foot. This function is vital to the preservation of proper walking.
The tendons can become injured in basketball due to a variety of reasons. Ankle sprains that force the foot inward can stretch and strain one or both of the tendons, while more serious sprains can actually tear the tendons. Poorly supportive shoes or over training can lead to the same strain. Once the tendon becomes inflamed or partially torn, a chronic process can begin that leads to further tendon damage, tendon weakness, and even further splitting of the tendon material. As a result, the ankle can even weaken as the ligaments on the outside of the ankle become strained due to the weakness of the peroneal tendons.
Symptoms of peroneal tendonitis can vary, but nearly always involve some form of pain to the outside of the ankle or foot. This can be an aching pain, a sharp pain, or even a shooting pain up the leg. The pain is worsened when the ankle is turned inward, or the foot is purposely moved upward and outward. Activity will worsen the pain, and in advanced cases pain can even be seen at rest. The foot and ankle may feel weak, and unstable on uneven ground. Swelling and warmth to the outside of the foot and ankle can also be present. Other conditions can cause similar symptoms, including nerve inflammation, 5th metatarsal bone fracture, ankle sprains, and joint damage or inflammation. A foot exam by a podiatrist will help rule these other conditions out.
Treatment of peroneal tendonitis involves reduction of the inflammation and support of the foot and ankle to allow for complete healing. Anti-inflammatory medication, elevation, activity rest, and icing all contribute to the reduction of the inflammation. Injections of steroid compounds around the tendons can be performed, but caution must be exercised as the steroid compounds can weaken the tendons and possibly cause a rupture. At the same time as inflammation reduction, the ankle must be supported to reduce strain. This can be accomplished with an ankle brace, or with a fracture boot in advanced cases. Often, physical therapy can be employed to reduce inflammation and strengthen the tendon integrity. If these measures are not helping, or if a more severe injury is initially suspected, an MRI will be taken to evaluate the tendon substance. Reparative surgery is used when the damage is severe, or if the tendon is not healing with the above measures. This involves repair of any torn or degenerative tendon segments, along with augmentation of any weak tendon areas with graft material. The long term success of all the above measures is fairly high, although some people require long term support with prescription shoe inserts (orthotics) or ankle braces to prevent re-injury.
Plantar Fascia Injuries
One of the most common structures injured in the foot, the plantar fascia is a ligament that passes on the bottom of the foot from the heel bone forward to the base of the toes. In sports that involve sustained running like soccer or cross country, injury to this tissue is more subtle and involves inflammation and microscopic tearing the tissue tissue (plantar fasciitis). In basketball, while plantar fasciitis does occur frequently, the injury to this tissue is at times more specific, and involves more forceful tearing or even rupturing of the tissue. Plantar fascia ruptures are seen when there is a strong push off force during explosive running or cutting. The pain of either a plantar fascia rupture or simply plantar fasciitis is usually felt on the inner side of the bottom of the heel where it meets the arch, although some ruptures can be felt more closely to the middle of the arch. While ruptures can eventually heal, if untreated they can eventually lead to chronic plantar fasciitis which can persist for years. Plantar fascia rupture treatment involves a short period of rest and immobilization in a walking boot to allow the tissue to heal, followed by arch support or taping and gradual return to the court. Treatment of fasciitis is fairly simple, and involves gentile stretching, inflammation reduction, and orthotics to provide greater foot support. Surgery is uncommon.
Toenail Injuries
Bruised nails are common, and are seen in basketball usually when one gets their toes stepped on by another player, or when a tight, poorly fitting shoe causes gradual pressure damage to the nail and the skin below it.
As blood pools under the nail plate, it will turn the color of the nail blue, purple, or eventually black. This color will stay in the nail until the new nail grows outward, where the discolored area will be pushed slowly towards the toe tip. The blood will be liquid initially, and then will eventually dry up into a powder.
Bruised toenails may often be painless, but they also can very painful, limiting performance. Fractures of the bone underneath the nail can also be present, and it is the protrusion of the bone from underneath that sometimes is the cause of the bruising, especially in cases where most of the nail is bruised.
Small bruises involving a quarter or less of the nail’s total size are often left alone, and allowed to grow outward. Larger bruises may require removal of the nail to help drain the blood and prevent infection, and allow for inspection of the skin underneath the nail for any cuts that need to be repaired or bone fragments that need specialized treatment to avoid bone infection. The nail will eventually grow back, although sometimes the injury that caused the bleeding in the first place may be severe enough to damage the nail root cells, leading to a permanently thick or strangely shaped nail. Nail bruises that are painful must be evaluated by a podiatrist or other physician to ensure that a fracture or significant skin injury has not occurred, and any nail discoloration that does not grow out with the nail needs a similar evaluation to rule out nail fungus or a more serious condition.
Metatarsal Fractures
The metatarsals are the long bones in the middle of the foot that end at the bases of the toes. There are five total, just as there are five toes. These bones can be broken in a variety of different ways when playing basketball, including being forcefully stepped on, landing with the foot flexed up or down, as well as when making a hard cut. The 5th metatarsal can be fractured in a particularly nasty way during twisting force on the foot, leading to the infamous Jones fracture at the base of the bone. Jones fractures are very common in basketball, and can follow the same injury pattern as ankle sprains. Overall, metatarsals can break at their bases in the middle of the foot, in the middle of their shaft, or at the neck and head of the bone where it meets the initial toe bone. Metatarsal fractures can occur either alone or in multiple numbers, and some injuries can create multiple fractures in a single metatarsal.
The symptoms of a metatarsal fracture usually include pain, swelling, bruising, and warmth in the foot. The middle or front part of the foot will be painful to walk or stand on, and may be painful to move. In the case of a Jones fracture the pain will be more to the outside of the foot. In some cases, the symptoms of a metatarsal fracture may be minimal and difficult to notice initially, with more pain in the weeks following the actual injury.
Treating metatarsal fractures varies by which metatarsal is fractured, whether the fracture has moved the bone out of alignment, or how stable the bone is during the healing process. Many metatarsal fractures can be easily healed by limiting weight bearing pressure using a walking fracture boot. The healing process is usually six weeks, especially in healthy athletes. More unstable fractures or multiple metatarsal fractures require the use of a cast and crutches for support and complete limitation of weight bearing. If the fracture has moved out of place, it must be returned to a proper position by either externally manipulating the fracture back to a proper position, or by surgically repairing the fracture and securing the bone with medical hardware. Surgery is often necessary for Jones fractures in athletes (the base of the 5th metatarsal bone on the outside of the foot), as this area is often unstable.
Achilles Tendon Injuries and Ruptures
Achilles tendon injuries and ruptures are common, can be quite disabling to an athlete, and full recovery of this injury is often lengthy.
The Achilles tendon is a strong, large, strap-like tissue that connects the two calf muscles to the heel bone, allowing the leg to flex the foot downward. Without this tendon, the foot would uncontrollably flop upward during the walking cycle. Ruptures and simple injuries can occur for a wide variety of reasons. The constant rotational force on the ankle from side to side and quick stopping and cutting movement creates strain on the Achilles tendon. This ongoing action gradually leads to tendon degeneration (tendonitis), and the potential for rupturing. Tightness of the tendon can lead to strain as the body weight forces the tight fibers to stretch beyond what they are easily capable of. Ruptures can occur when degenerative tendon tissue is keeps getting damaged further, and in athletes more commonly when the foot is flexed upward forcibly while one is pushing downward, or sometimes when the back of the heel is forcibly kicked or stepped on.
The symptoms of Achilles tendonitis usually consist of a sharp pain to the back of the heel or just above it, and a dull achy pain can be felt as well when not active. The pain increases as the foot is stretched upwards, and feels lessened when the foot is stretched downward. Achilles tendon pain tends to be especially worse after trying to flex the foot upward after a period of inactivity when the tendon stiffens further. Furthermore, the tendon can be painful when direct pressure is applied to it, even if that pressure is simply from the back of a shoe. The tendon can also feel enlarged and lumpy to the touch where it is inflamed and damaged. Often athletes typically play through the pain, the damage of untreated tendonitis can worsen and eventually lead to a higher chance for rupturing.
Ruptures typically occur at a place above the heel bone where there is poor blood flow to the tendon tissue. A rupture will feel sharp and stabbing, and often a pop or snap is heard. The calf can feel like it has been hit from behind. Walking is extremely difficult, and after the rupture the ability to rise up on the toes is lost. The back of the heel can become swollen and bruised, and there may be a indentation in the heel where the Achilles tendon rupture has formed a gap.
Treatment of Achilles tendonitis involves reducing the inflammation, stabilizing the tendon so it can heal, and mobilizing the tendon to prevent future injury. Inflammation can be reduced by anti-inflammatory medications, icing, and rest. The tendon is typically stabilized by employing a high quality ankle brace to resist excessive ankle motion. This is typically worn during all activity, including at home. At the same time, the Achilles tendon needs gentle mobilization to increase its flexibility and reduce the potential for strain. This is accomplished through stretching exercises, although physical therapy is sometimes needed. Severe cases of tendonitis may need surgery to repair the tendon or stimulate it to heal.
Treatment of Achilles ruptures in athletes usually requires surgery to repair the severed ends of the tendon together. The sooner the repair can take place, the easier the tendon ends will heal together. Lengthy delays in repair, especially those months in duration, will often lead to scar tissue, tendon degeneration, and a widening of the gap between the severed tendon ends. This makes repair very difficult. Once the ends are stitched together, the foot is held in place within a cast for four to six weeks as the tendon heals. Physical therapy is usually started soon afterwards to restore strength and flexibility.
Stress Fractures
Stress fractures are microscopic injuries to bone that cause pain, difficulty walking, and can potentially become true fractures. Unlike true fractures, stress fractures are not usually the result of a twisting injury, crushing injury, or impact injury. These injuries cause an immediate break in the bone material. Stress fractures cause bone damage in a different way. A stress fracture is typically the result of chronic stress to the bone, hence the name. This stress can come from repetitive activity at work or home. On the basketball court, the constant pounding of the foot on a hard surface gives rise to these injuries. Over time, the material within the bone core will become bruised and begin to microscopically crack. This cracking can slowly worsen as the stress continues over weeks and months. Eventually, enough damage will occur that the bone begins to weaken at the point of stress and microscopic fracture. In the foot, this leads to pain, slight warmth, and possibly swelling. As the damage worsens, the outer shell of the bone can eventually crack along with the core, leading to a true fracture.
Stress fractures can be difficult to see on x-rays, at least initially. Eventually, the area with the stress fracture will appear thickened and more dense, as new protective bone if formed to strengthen the stress site. Most of the time, a diagnosis is made based on symptoms rather than the x-ray. An MRI or CT scan can also show stress fractures, and can do so even when the x-ray appears normal. If there is doubt about the diagnosis, one of these two methods may be used.
Common bones that develop stress fractures in basketball include the long bones of the foot (metatarsals), as well as the shin bone in the leg and a bone in the middle inner side of the foot called the navicular.
Treatment of stress fractures involves rest and immobilization of the bone, much like the way a true fracture is treated. This is usually accomplished with a protective walking boot, although some difficult-to-heal stress fractures may need to be immobilized in a cast. Unlike true fractures, a stress fracture can take much longer to heal. It is not uncommon for a stress fracture of the foot to take two to three months before healing is completed. Some stress fractures may even need electronic bone stimulators or surgery if they cannot heal appropriately. To keep this injury from reoccurring, it is important to ensure a sturdier shoe is used which should be changed more frequently during the season, and also should include the use of orthotics to redistribute force across the bottom of the foot.
Scott R. Kilberg DPM 