Return to Play Protocol for Sports Injuries
The Return to Play Protocol for Ankle Injuries and Achilles Tendonitis in Basketball
The development and implementation of return to play strategies is of importance to all sports stakeholders across the spectrum of training and competition. The successful development of injury prevention strategies requires a multidisciplinary approach that includes strength and conditioning coaches who will play an important role in the process. When taking into consideration sports injuries the role of SC coaches extends beyond observing exercises in addition to prescribing training to facilitating the development of a robust and resilient athlete. The scope of their work should include providing a broad overview of injury prevention processes as well as working to promote the wellbeing and safety of the athlete. In basketball strength and conditioning, coaches play important roles including overseeing all the physical aspects, monitoring the development of players as well as monitoring the nutrition and recovery programs of players during injury recovery allowing the players to maximize their performance whilst maintaining their health all year round.
As basketball players defy the force of gravity on the playing field they are prone to some of the most common injuries to include Achilles tendonitis and ankle sprains. In basketball, ankle sprains are common and severe. According to an Australian study, ankle sprains account for the most missed shots by players (McKay, Goldie, Payne, 2001). The NBA season is one of the most famous and important basketball seasons, according to statistics recorded by Herzog, Mack, Dreyer, Wikstrom, Padua, Kocher, Marshall, 2019 there were approximately 796 ankle sprains among 389 players and 2340 unique NBA player seasons reported in the league from 2013-2014 through 2016-2017. The risk of incurring an ankle sprain was at 25.8%. Ankle sprains affect about 26% of NBA players each season and account for a large number of missed NBA games at an aggregate. With an increased number of young players and players with a history of ankle sprains it is important to develop ankle injuries management, rehabilitation and return to play programs.
Achilles tendonitis is also one of the most common injuries in basketball, tendons are the tissues that connect the muscles to the bones, and the Achilles tendon is one of the largest and strongest tendons in the human body. They are responsible for connecting the heel to the calf muscles, therefore these muscles are involved in activities to include standing, moving, and jumping. Achilles tendonitis is likely to develop from basketball due to the sprinting, jumping and pivoting that is involved in this popular sports (McKay, et al., 2001). Achilles tendonitis means the inflammation of the tendons that is as a result of tiny tears in the Achilles tendons. A tear of the Achilles' tendons is likely to have devastating effects on the life of a player, for instance, Kevin Durant’s career took a turn after suffering from a tear of the Achilles tendons in 2018 and did not come back to the court for a year. Also, legendary basketball player Kobe Bryant suffered from Achilles tendon tear in March 2013 at age 34 (McKay, et al., 2001). Elton Brand also suffered from the same in August 2007 at the age of 28, and after returning to the field he claimed that he was a little bit slower after the injury.
Discussion
Ankle injuries are prevalent in almost all sports but there is a predominance in basketball, in this sports players engage both their feet while jumping and landing and at times players land off-balance with a twisting action. The ankle is flexible enough to allow various motions as well as strong enough to bear the weight of the entire body but it can still be injured. Ankle sprains develop from sudden blows and twists, they mainly affect the outside ligaments. They also occur when the foot suddenly turns under the leg thus causing a stretching effect on the ligaments (McKay, et al., 2001). The seriousness of the sprain depends on the amount of ligament tearing, a sprain can either be described as mild, moderate, or severe. A mild sprain only occurs with minimal force with only a slight tearing of the ligaments, a moderate sprain occurs when the ligaments are partially torn while a severe sprain occurs when the ligaments are completely torn. A moderate or severe ankle sprain should be taken seriously as improper treatment could result in a chronically unstable ankle that would be prone to further injuries and in a serious event limit a player’s ability.
Ankle sprains are some of the most common injuries and most severe that are sustained by basketball players. Ankle sprains are common occurrences, therefore it is important to understand the risk factors associated with ankle injuries before SC coaches can develop preventive strategies to prevent ankle sprains (McKay, et al., 2001). Studies have previously been conducted in laboratories while paying special attention to the sporting environment as well as biochemical assessment. Laboratory studies have commonly examined the effectiveness of variables to include ankle tapes, braces, and cut of shoe performance to include restriction of postural sway, and sporting activities to include jumping, pivoting, and running. Also, laboratory studies have focused on personal muscle activity and peroneal reaction time and how they influence ankle sprains (McKay, et al., 2001). There are three most common ankle sprain predictors according to an Australian study; a history of an ankle injury, the availability of air cells in the heels, and stretching during warm-up (McKay, et al., 2001). A previous occurrence of an ankle injury is the most common predictor of ankle sprains. Basketball players who had previously suffered from ankle injuries are five times more likely to suffer from ankle sprains while compared to players who have never suffered from ankle injuries. According to that study, three quarters (70%) of basketball players with ankle sprains had reported a previous ankle injury.
The second most predictor of ankle sprains is the presence of air cells in heels of shoes worn by the players, players wearing shoes with air cells are four times likely to suffer from an ankle sprain while compared to their counterparts who were not wearing shoes without air cells (McKay, et al., 2001). Stretching during warm-up is the third strongest predictor of ankle sprains according to the Australian study. Players who fail to complete the general stretching program as part of their warm-up routine are two times likely to suffer from ankle sprains. Jumping and landing are sporting activities often performed by basketball players therefore 45% of ankle sprains are sustained during landing while 30% of ankles sprains are sustained during sharp twists and pivoting (McKay, et al., 2001). Cutting and changing directions are an integral part of basketball and they involve sharp twists, twist, and turning injuries are sustained while weight bearing on the court surface (McKay, et al., 2001). The risk of ankle injuries is not related to factors that players cannot alter to include age, height, and sex. Also, changeable factors to include the player’s weight, hours spent on training, number of games played a week, the position of the player on the court, and the quarter of the game played are not related to the occurrence of ankle sprains.
Achilles tendonitis results from stress and the overuse of affected Achilles tendon, tendonitis is indicated by symptoms to include inflammation and irritation. Basketball increases the intensity and the duration of physical activities and most especially at the beginning of a basketball season and this can create a lot of stress on the tendon. Calf muscles also strain a lot during basketball activity and this is likely to result in stress and irritation of the tendons. Also, directional changes in the sport can irritate the tendons (Richie & Izadi, 2015). Lastly, improper jumping and landing techniques can contribute to tendon stress. The most common symptoms of tendonitis that can be spotted in players include swelling and inflammation along the back of the heel, pain along the Achilles tendon as well as stiffness along the tendon (Amin, McCullough, Mills, Jones, Cerynik, Rosneck, & Parker, 2016). Noteworthy, a player can exhibit no sign of Achilles tendonitis, nevertheless it important to spot the most common signs that include pain, swelling, the lack of ability to stand on the toes and the injured leg, a popping sound when the injury occurs and pain while pushing the leg forward while walking.
Athletic endeavor has increased the rate of Achilles tendon injuries. The treatment of Achilles tendonitis is similar to that of many sports injuries, the application of ice packs each day assists in reducing discomfort as well as assists with the healing process. For players, it is advisable to reduce physical activity to allow the injury to heal quickly. When the tendon has completely healed and the athlete can begin rehabilitation of the heel and tendon to ensure that they are fully healed (Siu, Ling, Fung, Pak, & Yung, 2020). An Achilles tendon rupture is a career-changing injury to any basketball player. According to a study conducted by Siu, Ling, Fung, Pak, & Yung, (2020) most elite athletes tendon rapture undergo surgical repairs and about 80% of players are ultimately able to play again. There are many tendon repairing surgical techniques that have evolved as well as post-rehabilitation protocols. However, there is controversy on which tendon repair method is superior and which rehabilitation protocol is the best (Siu, R., Ling, Fung, Pak, & Yung, 2020). An Achilles tendon rupture is detrimental to the performance of an NBA player, studies have revealed that players injured after a long career in the NBA show reduced efficiency after returning to the court. Also, players that suffer from a rapture of the tendon are likely to be more seasoned therefore they have undergone more wear and tear over the course of their career.
The risk factors that are associated with Achilles injuries include changes in the training schedule of the athlete such as taking part in plyometric exercises that demand explosive movements to include box jumps. Tight or weak calf muscles are another risk factor for Achilles tendonitis, these muscles can be overstretched thus damaging the tissues (Chinn, & Hertel, 2010). Excessive pronation which is the rolling inward on the foot whilst running or walking is also a risk factor. Lastly, the intake of fluoroquinolone antibiotics to include gemifloxacin puts a player at a temporary risk of suffering from a tendon injury. A player is at risk of developing chronic tendinopathy after suffering from numerous tears as well as when players are unable or unwilling to take adequate rest after a tendon rupture.
Lateral ankle sprains are defined by the excessive inversion and plantar flexion of the reafoot on the tibia (Chinn, & Hertel, 2010). While treating an athlete for lateral ankle sprains the severity of the ligament damage is responsible for determining the type of treatment. Lateral sprains are also divided into three grades, grade one, grade two, and grade three depending on the extent of the injury. In grade one there is minimal stretching of the ligament accompanied by little or no pain. Subsequently, after the initial management for pain and swelling in grade one sprain, rehabilitation of the athlete can begin immediately (Chinn, & Hertel, 2010). In grade two sprains there is some tearing of the ligament that is accompanied by a moderate instability at the ankle. The pain is moderate and in most occasions immobilization is required for a few days. Grade three sprains are defined by the complete rapture of the ligament that is accompanied by the total loss of stability at the joint (Chinn, & Hertel, 2010). Also, this grade is defined by pain and swelling, and for about two weeks weight bearing is not tolerable.
The rehabilitation expectations include regaining full-motion capabilities, neuromuscular coordination, and strength. Open chain range of motion and isometrics are an example of activities that athletes can engage in but only those that are none weight-bearing (Chinn, & Hertel, 2010). During the early rehabilitation of lateral sprains towel stretches and wobble boards are examples of motions that can be introduced since they are tolerable. Dorsiflexion and plantar flexion motion can be improved through activities to include stationary biking, however, it must be done in a controlled environment whilst ensuring that the athlete is engaging in cardiovascular workouts. Joint mobilization is another rehabilitation technique that is used to assist in dorsiflexion.
Once a player tolerates weight-bearing, the middle stage of rehabilitation is started. Exercises aimed at enhancing neuromuscular control are introduced at this stage. Players suffering from lateral ankle injuries can be required to complete activities that involve the throwing and catching of weight balls as well as perform one leg squats while also performing single-limb balance and reaching exercise. Having one’s range of motion backs is important, therefore, the player should continue with wobble board training while paying special attention to the heel cord stretching (Chinn, & Hertel, 2010). Figure one below is an illustration of single-limb standing that is effective in the rehabilitation of lateral ankle sprains.
Figure 1; Single Limb Standing
Restoring neuromuscular strength is important as ankle sprains do not only cause damage to the ligaments but also to them mechanoreceptors that are located within the ligaments and the retinacula that are found around the ankle joint. They provide information to the central nervous system about joint movement. Therefore, an effective rehabilitation program should ensure the incorporation of a wide range of exercises and programs that are aimed at restoring neuromuscular control. Regaining muscular strength is also an important component of neuromuscular control and also vital for proper movement patterns when an athlete returns to sport (Chinn, & Hertel, 2010). Once evaluation, treatment, and rehabilitation of an injury have been completed the strength and conditioning coach can ultimately decide on whether the player is ready to return to the sport.
Once the swelling and pain are controlled, exercises aimed at increasing strength can be initiated. It’s important to pay attention to dorsiflexion and plantarflexion strength, weight-bearing calf raise and squats are good at the beginning (Chinn, & Hertel, 2010). As the ligament continues to heal it is important to ensure that inversion and eversion strengthening is tolerable. During middle stage rehabilitation it is paramount for the athlete to be re-educated on the proper mechanics of walking as well as other functional activities. Moving forward functional rehabilitation exercises such as jogging and walking can be introduced. Once the player can perform these simple exercises without a problem then jumps, hops and skips can be introduced. The player should also be encouraged to perform lateral movements in addition to shuffling (Chinn, & Hertel, 2010). As the ligament continues to heal and the player becomes more comfortable him/her can begin to exercise while wearing typical shoes for that sport.
On most occasions, players and coaches believe that lateral ankle sprains are not serious and players can return to their sporting activities fast, but this is not always the case. Every stakeholder must understand the risk posed by ankle sprains and the chances of recurrent sprains (Chinn, & Hertel, 2010). The importance of letting the ligament heal as well as regaining full range motion, balance, and strength should be prioritized. Prophylactic support can be offered to provide mechanical stability. However, it is offered depending on individual preference as well as the budget of the athlete. According to a substantial amount of research taping and bracing minimize the risk of a player suffering from ankle sprain again. Braces are cost-effective and provide the player with proprioceptive stimulation while taping is designed to fit the requirements of specific athletes and instabilities.
To determine the player's ability to return to play SC coaches have to utilize both quantitative and qualitative data that have been availed over time. Despite the strides that have been made in the treatment and rehabilitation of injuries there are no evidence-based guidelines that can be used to clear a player to RTP following an ankle sprain makes this challenging (Clanton, Matheny, Jarvis, & Jeronimus, 2012). There are various foot and ankle scoring systems however none of them have been validated to assist in the making of RTP decisions. The World Health Organization dictates that assessments of an athlete’s readiness should be evaluated in terms of function. The tests already available determine balance, muscular stabilization, as well as coordination at the ankle joint. These tests include the Dorsiflexion Lunge Test that is for functional testing as well as the Agility T-Test that tests for Agility.
The dorsiflexion lunge test is described as a weight-bearing test that is conducted by placing the player’s foot perpendicular to a wall and lunging the knee towards the wall. This test is necessary because dorsiflexion is necessary for a range of motions (Clanton, Matheny, Jarvis, & Jeronimus, 2012). During this test, the foot is gradually moved in a sequence far from the wall until the player can be able to achieve total dorsiflexion. The heel needs to remain on the floor throughout the process. In addition, the subtler joint should remain locked. The distance from the wall to the foot should be less than 9cm and the tibial shaft angle should be less than 350 (Clanton, Matheny, Jarvis, & Jeronimus, 2012). Both the intra and interrater reliability have been ascertained. The below image is an illustration of the test.
Figure 2; the dorsiflexion lunge test that evaluates the range of motion.
The agility T-test measures the movement of a player in multiple directions. Agility is the player’s ability to change direction rapidly. Agility is a necessity for field sports for a variety of reasons to include neuromuscular control as well as the overall performance of the player. Ankle sprains often reduce the agility of a player. During the test, the player must navigate a T-shaped course for effective results the horizontal and longitudinal arms are 10 yds each (Clanton, Matheny, Jarvis, & Jeronimus, 2012). To complete the test the player will sprint from the base of the longitudinal arm to the center of the horizontal arm. Then while forward the player is required to sidestep to the end of the horizontal arm while ensuring he/she does not cross feet and continues to the other end. To successfully complete the test the player sidesteps back to the center of the horizontal arm and runs back down the longitudinal limb to the starting point (Clanton, Matheny, Jarvis, & Jeronimus, 2012). The duration of time that an athlete should take to complete the test is 8.9 to 13. 5 seconds (Clanton, Matheny, Jarvis, & Jeronimus, 2012). The reliability of this test has been ascertained.
Figure 3; the agility T-test
The recovery process from Achilles tendonitis is a slow process that depends on the extent of the damage done to the tendons. The first step of treatment includes wearing a heel cup that ensures less stress is placed on the area thus making the player comfortable. During the initial stage of treatment rest and activity, modification is very important. It is important for the strength and conditioning coach to emphasize to the injured player on the importance of allowing the tendon to recover completely. Also, at the initial stage cross friction massage is introduced to allow the tendon to heal (Chinn, & Hertel, 2010). At this stage massage that generates friction in the damaged area is introduced with a focus on breaking down adhesion as well as ensuring the proper flow of blood to the area. At this stage, the stretching of the gastrocnemius soleus complex should be tolerable. Towel stretching as indicated below in figure 4 and slant board stretching should be part of everyday exercises (Chinn, & Hertel, 2010). As the player continues to regain motion and stability he or she can get rid of the heel cup to ensure that the muscles and tendons do not develop adaptive shortening. At the beginning of the rehabilitation program, coaches should ensure that they incorporate progressive strengthening exercises to include toe raise and resistive tubing. As the pain and inflammation subsidies, the player can start engaging in activities to include machine weight, lunges as well as basketball-related exercises. For most athletes suffering from Achilles tendonitis, eccentric exercises are very beneficial and vital for the complete healing of the tendons (Chinn, & Hertel, 2010). As rehabilitation continues it is important to evaluate the player`s foot structure and gait mechanics for purposes of orthotic benefits since in most occasions Achilles tendonitis results from the over-pronation which is an abnormality that can be addressed through foot orthoses.
Once the player has regained a range of motion, endurance and strength he or she should slowly progress into more vigorous activities to include walking and jogging. The player should also ensure that work out is done on a flat surface most of the time. Walking and jogging should begin with slow mini- bursts of speed to ensure that the tendons can handle the pressure and stress applied as the exercises are aimed at increasing the amount of stress then tendons can handle. Once the tendons can tolerate enough stress and the overall endurance has been increased running and sprinting can be introduced (Chinn, & Hertel, 2010). Once the SC coach is certain that the player has regained full range of motion and strength the player can be allowed back to the court. It indicates that the player has regained endurance in the involved limb he/ she should be able to complete full practice sessions without pain. Throughout the rehabilitation program, it is important to emphasize Achilles tendonitis will not go away without the proper required treatment and enough rest.
Educating the player is necessary as one needs to be knowledgeable of the risks of Achilles tendonitis. Activities to include lack of proper sports shoes, lack or rest and flexibility puts the player puts the player at risk of Achilles tendonitis (Chinn, & Hertel, 2010). Hill workouts are responsible for increasing the pressure and strain applied to the Achilles tendons, to ensure that the body has ample time to heal hill work outs should only be done once a week. It is vital to evaluate any foot injury. Similarly, the lack of flexibility is a major cause of Achilles tendonitis and it is important to emphasize the importance of stretching often. With a focus on providing prophylactic support it is important to use the heel cup to reduce tension and the stress placed on the Achilles tendons. However, as the player regains flexibility the heel cup (Chinn, & Hertel, 2010). The players can opt to use special tapes that assist in reducing the stress placed on the Achilles tendon.
Irrespective of the treatment and rehabilitation path taken the most crucial part is returning the player to the court while ensuring that there is a low risk of reinjures. Inadequate rehabilitation and returning to the court prior to full recovery of the tendons is a risk that can be mitigated by appropriate guidance on how to return to sport (Grävare Silbernagel, & Crossley, 2015). It is important for the SC coach to ensure that the return to play process is gradual and controlled progress as this will provide the player with the maximum time to recover. The resumption of activities to include running and jumping is only recommended when the pain and swelling have both subsided. For a player that had suffered from Achilles tendonitis, he/she is not allowed in court for a minimum of 12 weeks of exercise (Grävare Silbernagel, & Crossley, 2015). Factors to include the tendon injury, tendon recovery and pain and symptoms should be put under consideration while returning to play.
Conclusion
The strengths and conditioning coaches play an important role in ensuring the successful recovery of athletes following an injury. The above discussion entails the return to play protocol for two of the most common injuries in basketball; Achilles tendonitis and ankle sprains. As players strive to defy the force of gravity in the court they are bound to suffer from these injuries. Over the years there is recorded evidence on the seriousness of these two injuries as they are career-threatening if not treated effectively. Achilles tendonitis occurs when the tendons which are the strongest muscles in the body are stressed by activities to include jumping as well as standing. Ankle sprains are some of the most common injuries as well as most severe in the sport, they occur when stress is applied to them ligaments causing a tear. Lateral ankle sprains are the most common ankle sprains while treating athletes for ankle sprains the severity of the damage determines the type of treatment. The rehabilitation expectations of lateral ankle sprains include regaining agility as well as strength. The treatment of Achilles tendonitis is slow as tendons take a relatively long time to heal. The initial step of treatment includes wearing a heel cup. Activities such as towel stretching should be tolerable. As treatment and rehabilitation continue activities to include jumping and running can be introduced. All in all, ankle sprains and Achilles tendonitis are serious injuries in basketball and the successful return of players in the court depends on the collaboration of different stakeholders to include Strength and conditioning coaches in the treatment and rehabilitation of players.
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References |
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