Basketball began in 1891 when James Naismith designed a game with minimal hazards to keep his summer athletes in good physical condition throughout the winter. The game has preserved its non-contact nature over the years while developing as a major international sport. Penalties for illegal contact, particularly violent fouls on the shooter, have become progressively severe since the first formulations of the rules of play. The result has been an effective system of control over competitive behaviour which protects participants and prevents many of the injuries associated with field games occurring. Basketball is by no means injury-free, generating its own peculiar trauma as well as injuries common to vigorous explosive effort and team games.
HOW INJURIES OCCUR
Catching the ball
As basketball demands skill in ball handling, it is inevitable that the hands and fingers are subject to trauma. Powerfully delivered passes may be imperfectly caught: this causes finger pains which may be aggravated when a player moves quickly towards the ball, thereby increasing impact speed. The phalangeal and metacarpo-phalangeal joints may be damaged in the resultant forced hyperextension. A ‘stubbed finger’ from a mis-catch can produce a painful joint injury, including dislocation of a finger or thumb. The cause is the compression force due to the ball striking the outstretched finger. A common practice deprecated by medical practitioners is for the coach to forcefully pull on the dislocated phalange of the finger to restore the joint.
Players closely guarded and about to receive the ball from a pass are coached to reach for it to prevent its interception. Contact on the arm by an opponent can obstruct the catch, causing a ‘stubbed finger’ in the process.
Catching a ball rebounding from the backboard requires a fast snatching action in which the ball is pulled from a height down into a protective position. During this action the ball may be rammed onto the fingers of an opponent contesting possession, with consequent trauma.
When finger injuries are suffered, a common practice in basketball is to tape the injured digit to the adjacent one. This acts as a splint, immobilises and protects the injured finger and allows further play.
The fingers are highly exposed to injury in any attempt to block a pass, dribble or shot. In particular, blocking an attempted outlet pass intended to travel the length of the court can lead to severe trauma through great impact speed. As a basket ball weighs 0.62kg (22oz) it constitutes a comparatively heavy missile.
Held ball situation
If a defender can legally manage to retain a grip on a ball held by an opponent a stalemate is reached. Play is resumed with a ‘jump ball’ which gives the two contesting players a chance to tap the ball to a team mate. Often one player is in a disadvantageous position in the ‘held ball’ incident. One participant may attempt to wrest possession from the other before an official intervenes. The techniques employed consist of vigorously pulling and jerking, using the arms and upper body. The player retaining a strong grip while in a mechanically poor position can injure the hands, the elbow or the shoulder joint. A natural response is to try to pull the ball horizontally around the body and away from the opponent. This occasionally leads to a characteristic Cumberland-style wrestling throw, hyperextending the elbow or shoulder joint in the process. The part the officials play in forestalling violent wrestling incidents is critical in preventing such injuries.
Falls to the floor may occur on losing balance while running or after leaping for the ball. A sudden drive towards the basket by an attacker usually calls for a countering action by the defender to stay with him or block his path. This may lead to a collision with one or both players being knocked over . Pride suffers most in such situations, though awkwardness or lack of coordination may promote injury. Landing heavily on the buttocks or the hips can cause bruising and the back of the head may hit the floor with resulting contusions or concussion; elbows, wrists and hands also may suffer painful contact with the floor. For preventive purposes gymnastic and tumbling techniques can be introduced into the training programme to teach the art of falling and rolling. If an arm is extended by a player in the attempt to break his fall, it may act as a rod which will transmit the force of the fall through the limb to the shoulder joint. Among the injuries received in this way are clavicular and scaphoid fractures and dislocations of the elbow or shoulder, particularly the acromio-clavicular or sterno-clavicular joint. A fallen player may accidentally bring down an opponent: Bachman (1970) reported incomplete tear of a medial collateral ligament of the knee in such an incident.
Falling on the run usually means that the upper body is propelled ahead of the legs and putting an arm down to break the fall carries all of the risks already referred to. A player unable to execute a protective roll may slide along the surface of the floor incurring skin abrasions which, for obvious reasons, are called ‘strawberry burns’. The practice of players is either to play on immediately or after cleansing the wounds.
Some players wear protective knee pads while others wear shorts fitted with light internal padding to protect the iliac crests. Most players prefer a feeling of lightness and mobility, and seldom wear additional items apart from hair bands, sweat bands or elasticated elbow, ankle and knee supports. Dirty floor surfaces represent a particular hazard when skin abrasions arise; open wounds incurred through contact with the floor require sterilising treatment at once.
Basketball is an extremely fast game with play often changing rapidly from end to end. Players are constantly involved in abrupt acceleration, deceleration and changes of direction. These changes put considerable stress on to the legs and their joints with the ankles and knees particularly vulnerable. Feet in poor postural positions are more susceptible to injury when subjected to abnormal stresses with unilateral weakness predisposing the weaker foot to injury (Conway, 1969).
Bachman (1970) reported that many basketball players have bony outgrowths in the lower shin, secondary to repetitive forced dorsiflexion of the ankle. The tension during violent twisting movements can result in injuries to the semilunar cartilages, the collateral or the cruciate ligaments of the knee, as well as to the ankle joint. Ankle sprain usually involves an inverted and equinous position with damage incurred to the talofibular ligament (Lunceford, 1971). The extent of the damage depends on the forces operating. This injury has been attributed to use of resin on the shoes to assist in abrupt halts and turns (Lunceford, 1964).
Another area subjected to stress is the lower back. This may be the result of repeated powerful trunk actions which combine flexion, extension and rotation from a variety of postures and occasionally landing with the body fully extended or the back arched. Excessive use of defensive techniques involving a crouched posture may place the spine at a disadvantage. For all these manoeuvres compatibility of the footwear and the type of floor is stressed. To provide constant conditions courts should be regularly cleaned of dust, sweat and grease. The practice of running the palm of the hand along the court surface or a trial sweep with a broom soon shows the state of the floor. Large halls can, during cold humid weather, experience condensation, usually in parts near to external walls and doors. Slipping and falling into a split position can lead to injuries particularly in the adductor and hamstring muscle groups, or to tendon and ligament damage in the lower limbs.
Jumping and landing
Repetitive jumping may promote patellar tendinitis or the condition known as jumper’s knee. Poorly controlled landings may cause bruising of the soft tissue beneath the heel and this injury may become chrome (Blazina et al, 1973).
Jumping is performed off one foot or both feet -landing is usually executed with both feet hitting the floor simultaneously or almost together. Players are frequently trained to disregard personal safety when jumping. Taking defenders on in ‘one-on-one’ situations, driving into the heart of a defence and leaping upwards and in towards the basket to shoot, engaging fiercely in contesting rebound and loose-ball possession, represent areas of physical risk that players accept . When a player takes off on a powerful upward leap, contact by another player can cause imbalanced landing, possibly not on the feet. If in such situations his full concentration is on scoring, injury is more likely. Falling backwards with the back extended can cause considerable shock. A player may land on another’s feet. It is not unknown in basketball for players to drive up and in towards the basket with a high knee lift designed to test the courage of defenders. Some coaches advocate this practice, the reasoning being that having once stood in the way of such an attacking move a player is unlikely to do so again. The knee can cause severe bruising and even fracture ribs and the defender can be knocked over backwards with injuries incurred in falling.
Play close to the basket
An attacker in attempting to score may have alternative objectives. These could be to score a basket, draw a foul or gain the rebound if the shot is unsuccessful. These objectives play a great part in the fashioning of shooting techniques. Leaping upwards and in towards the basket to shoot invariably gets the best results . Most profitable is the ‘three point plus foul’ play which occurs when a player is fouled in the act of shooting but still scores. He is awarded one free throw which if successful earns an extra point while a foul is recorded against the opponent. Some coaches encourage antagonism in defenders in practices so as to accustom and toughen attacking players to learn the art of scoring despite being fouled.
A defender may interpose himself between an opponent and the basket when a shot is made to ‘screen’ (or ‘box’) him out, while the attacker may attempt to force past. Coaches advocate a strong defensive crouch with arms held up and elbows out. After an unsuccessful shot the rebound is likely to be contested vigorously to secure possession. In such incidents the elbow represents one of the most dangerous weapons in the game. The raised elbows are usually level with the head of an opponent and therefore in forcing past or in protecting a rebound, injuries to the head can ensue. Numerous injuries attributable to accidental or intentional use of the elbows range from contusions on the skull, eye damage, fractured cheek and nasal bones to split lips and broken teeth. Cracked ribs can result from digging backwards at an opponent when being closely guarded. A further damaging action may occur when a closely guarded attacker attempts to drive upwards and in towards the basket to score: the elbow of the shooting arm is liable in this instance to hit the defender in the face. Current tactics dictate that players attempt to release the ball as near as possible to the ring.
A player who drives hard for the basket and uses a powerful ‘lay up shot’ is especially exposed. On collecting the ball at the end of the dribble and taking off, the head is lifted to focus on the target. Taller players attempt on occasions to ‘dunk’ the ball , or force it powerfully into the basket from above the ring. The worst foul in basketball can occur in this situation and is commonly referred to as ‘tunnelling’, ‘bridging’ or ‘submarining’ . These terms describe the action of a defender who moves to assume a crouched position underneath the shooter. In this way he tunnels underneath the attacker and creates a bridge, the result being alarmingly spectacular. The defender acts as a fulcrum over which the shooter revolves forward and down. The shooter can land head first on the floor with a possibility of numerous injuries of varying severity, the most serious being to the head and spine. Two factors contribute to the extent of the injury. A player is trained to concentrate on scoring after take off and so may be caught unprepared by the foul, while the coordination of the attacker may enable him to emerge unscathed.
ATTITUDE TO PLAY
If a player competes without adequate physical preparation he is more likely to get injured. The lure of match play entices him to participate before he can safely endure the high demands of the game. Similarly, recently injured players are anxious to return to play either to maintain or regain their team position. In basketball such players often attempt to conceal the extent of their injuries. Additionally an unsympathetic attitude on the part of the coach and the non-injured players tends to discourage his complaints. Determined players attempt to participate if it is at all possible and as a result they learn to adapt their game to protect the injury. Players are sometimes known to compete through a full season with a recurring trauma, continued participation inducing the recurrence. Jammed fingers, contusions and abrasions are all considered part of the game and seldom stop the dedicated players who learn to live with them. In many cases it may be that athletes are willing to pay the price of a deteriorating condition for the current self-fulfilment that the game brings.
At a high level of competitive basketball the accent is on winning. This emphasis has repercussions in the behaviour and attitude of coaches as well as players. One of the personality types described by Ogilvie and Tutko (1971) was the ‘hard-nosed coach’ who attempts to produce extremely fit, highly motivated and totally controlled players. The search for success is pursued without many scruples, and training methods which attempt to develop the traits the coach desires in his team are utilised. To develop toughness and controlled aggression, practices are devised to highlight physical contact situations in which contact beyond the constraints of the rules is encouraged. The practices initially used by the Belgium national coach in 1960 provide an example of the promotion of aggression in contesting rebounds and tolerance to physical contact. The ball is tossed at the basket by the coach to initiate play, underneath which a group of players are assembled; each player attempts to gain possession of the ball and score while the others prevent his doing so; play is continuous and rules relating to travelling and drib- bling violations are not enforced; physical contact is permissible. The practices at times become so aggressive that the coach has to part players whose tempers are high. In one-on-one practices a dribbling attacker attempts to go past a defender and score, an exceedingly common incident in competition. The coach emphasises that the attacker takes his opponent on, while the defender is allowed more than normally permissible contact and provides a strong physical challenge. Similarly, conditioned practices ensure that a team, when scrimmaging, plays the game in an extremely aggressive fashion, the coach making additional rules or conditions.
The coach may attempt to maintain motivation levels of his players by introducing punitive measures. If players or the team do not maintain certain standards they are required to do extra work or may be withdrawn from scrimmages for a period. As in all the practices designed to promote aggression the incidence of injury may be greater than in match play, since the training sessions are prolonged and there is much more contact between players.
As a rule basketball coaches are not noted for their sympathy to injured players; the tendency is to shrug off the injury as not being serious. This may be due either to lack of appreciation of and training in first aid principles or to a concern for the game in progress. The coach may well have conflict between a humane regard for his players’ well-being and his desire for victory. The ignorance of coaches to the signs, symptoms and treatment of injuries may lead to either lack of immediate and appropriate action or erroneous action exacerbating the condition.
PREVENTION OF INJURIES
Techniques and tactics
Biomechanical analysis of basketball actions may reveal faulty techniques predisposing to injury. A player suffering from pain and degenerative injury can prevent further degeneration or avoid undue stress by modifying and adapting his play. A coach can protect a player by modifying his tactical role. Training schedules appropriately based can ensure gradual recovery from injury.
The control of attitudes towards fair play is largely the concern of each individual. With regard to dangerous and reckless play, the coach and the captain can exert a great deal of influence over individual players.
Safety should be a major concern in the choice of playing shoes; a player should carry a variety of different designs of footwear to meet with the prevail- ing floor conditions. Manufacturers could market a range of footwear as a kit. Improperly fitted shoes can cause hammer toes, mallet toes and mycotic infections of the nails (Conway, 1969).
The floor should be adequately cleaned and prepared before every training session and game. Periodic maintenance checks, particularly underneath the baskets are necessary. The floor areas near the basket endure the most wear and tear as the most vigorous activity is concentrated there. The hardwearing densely constructed gymnastic and sports hall floors are not entirely suitable for basketball play as their lack of resilience can cause sore feet and blisters, and the exacerbation and recurrence of old injuries. A standard, setting a desirable degree of friction, would represent some surety of a good grip and increase player safety.
The forming of the laws and their interpretations, officiating systems and disciplinary procedures, play a vital part in exercising control over the behaviour of players. Intentional fouls can vary in degree from merely attempting to prevent a score or by lessening his potential threat by intimidating an opponent, to seeking to seriously incapacitate him so that he is unable to take further part in the game. Basketball, with careful categorisation of fouls and deterrent penalties, and positive and precise instructions to officials, has made dangerous foul play fruitless.
Training in the art of falling and rolling may prevent the occurrence of serious injuries. The training should ensure that physical conditioning for all aspects of the game is achieved.
It is desirable that a person with adequate first aid or medical training should be in attendance at every game and training session for immediate treatment of injuries. Associations should include first aid treatment of minor injuries in the training syllabus of basketball coaches and officials. An appropriate first aid kit should be available at all times. The National Associations could arrange a section dealing with injuries at their conferences which would ensure that officials are competent to deal with contingencies. Additionally the safe return of the player to training and match play would be accelerated.
Bachman, D. C. (1970). Medical aspects of professional basketball. Illinois Medical Journal, 137, 149-154.
Blazina, M. E., Kerlan, R. K., Jobe, F. W., Carter, V. S. and Carlson, G. J. (1973). Jumper’s knee. Orthopaedic Clinics of North America, 4, 665-678.
Conway, D. H. (1969). A survey of basketball players in the Rochester area. Journal of the American Podiatry Association, 59, 390-393.
Lunceford, E. M. (1964). Basketball. In J. R. Armstrong and W. E. Tucker (eds). Injury in sport. Staples, London.
Lunceford, E. M. (1971). Acute and subacute injury. In L. A. Larson (ed). Encyclopedia of sports sciences and medicine. Macmillan, New York.
Ogilvie, B. and Tutko, T. (1971). Problem athletes and how to handle them. Pelham, London.