Can We Prevent Ankle Injuries?

If you've played basketball, then you've probably had an ankle injury. The "big 3" foot and ankle injuries I think of first are sprains, Achilles tendon injury, and fifth metatarsal fracture (e.g. Kevin Durant)...the outside transitional bone between heel and toes. In this article, I'll share some recent science (studies) examining ankle injury and injury prevention. 

Outside view of the ankle. 

Focus above the foot on the fibrous band of tissue called the "anterior talofibular ligament"...between the tibia (the big shin bone) and the fibula (the bone on the side of the shin). When you "roll" your ankle, it can be injured. 

Significance. "Ankle and foot injuries are the most common injuries in basketball at any level. A recent study found that ankle and foot injuries accounted for 40% of high school basketball injuries, followed by the knee (15%), head/face/neck (14%), arm/hand (10%), and hip/thigh/upper leg (8%)."

What is a sprained ankle? A sprained ankle occurs with ligament injury...resulting in pain, swelling, heat, and loss of function. 

What is a "high ankle sprain"? A high ankle sprain involves more extensive injury to the tissue connecting the tibia and fibula. It usually has a longer recovery period and may have more associated injuries (including fracture). 

Initial treatment. PRICE (Protection, rest, icing, compression, elevation). 

"It must be the shoes." Do shoes matter? This is an elegant article comparing high-top and low shoes and measuring muscle stabilizing activation with electrodiagnostic tools. The article suggested that high top shoes produced a detrimental effect on ankle stability. High top shoes don't prevent ankle injury. 

Braces. In 2011, a controlled study showed a reduction of ankle injury using ankle braces. From the American Journal of Sports Medicine, "The rate of acute ankle injury (per 1000 exposures) was 0.47 in the braced group and 1.41 in the control group (Cox hazard ratio [HR] 0.32; 95% confidence interval [CI] 0.20, 0.52; P <.001)."

Taping. Does ankle taping work? A study in European soccer professionals was stunning, "ankle inversion ROM in a taped ankle increased after 45 minutes of soccer from 7 degrees to 12.6 degrees, a figure which reflects 90.3% of the inversion ROM in an untaped ankle.  In other words, after 45 minutes of soccer match play, the ‘residual mechanical effectiveness’ of a professionally applied ankle taping job is minimal."

Exercises. Can ankle exercises prevent injury?  A Netherlands study showed that a home-based training program using a one-legged stance program and a "balance board" reduced ankle sprain recurrence. The training improves proprioception, our unconscious awareness of spatial orientation. 

The takeaways are that some common beliefs about footwear and taping fail under scrutiny and that some exercise programs and braces have modest value in preventing injury or recurrent ankle injury. 

Atlantic Division Sets - Brooklyn

"Share something great." We don't need to implement everything we see. But we can get ideas on improving what we do and how we do it. Do more of what works and less of what doesn't. What works in the Atlantic Division? 

Brooklyn's offense scored the third most points per game in the Atlantic, which is saying something with their talent. Kenny Atkinson migrated the offense from Atlanta and the video shows Hawks running the sets at times. 

Similar setups and spacing. What could we run...before examining what they do? 

1) On the "Strong" set, it's easy to see "Triangle" basics. 
2) On the "Weak" set, you could run Flex with 2 coming off 5 and then 5 getting the downscreen from 4 or bring the 3 up and run "pinch post" offense. 

Let's see a few examples of what they do. 

From "Strong" they enter they get wing entry, then reverse the ball off weak side screening and then reverse again to the post who has drifted to get a "corner 3". 

They look to ball reversal to get postups or slips. 

If they don't get entry, then how about a double staggered screen? You can visualize this coming off a horns set with the guard passing to one post then cutting opposite to set up the stagger. 

Or the stagger turns into a "pick and dive". 

They also used what I call "Bucks" action, because the Bucks hurt the Celtics with this using Brogdon and Antetokuompo. 

Here, 'weak' flows into pick-and-roll action. Personnel dictates who you want finishing. 

Or, the Nets can go screen-and-roll into ball reversal against sagging defenses. 

Realistically, we need simplicity, but we learn through seeing and understanding how offenses get separation. 

Steve Kerr Leadership Concepts

The Team Building Strategies of Steve Kerr is a little book sharing big ideas. "Team Building" is so small that I reread it while on the treadmill yesterday. 

We know that students learn more from a 1000 word summary of a chapter than reading the entire 5000 word chapter. So I encourage students (and myself) to create summaries that build our knowledge and perspective. 

The authors divide the book into three sections: MENTORS, CULTURE, and MINDSET. I'll share a couple of quotes and summarize key takeaways. 

"That's been a good lesson for me: run six or eight things really well, instead of 20 things in a mediocre fashion."

"Write down everything. Everything you've learned, everything you want to do. Everything you'd change. It'll organize your thoughts. Develop your philosophy." 

"The knowledge that every teammate truly wants the best for you, and will sacrifice whatever it takes in the moment to help both you and the team - that has to be a powerful feeling."

"Does everyone in the organization feel as if their voices are being heard?"

"Good ideas can come from anywhere. Don't let your ego prevent you from getting advice or counsel from others." 

MENTORS

Kerr played for or coached with many outstanding coaches, including Lute Olson (Arizona), Lenny Wilkens, Phil Jackson, and Gregg Popovich. But he didn't just observe, he kept notebooks of information he valued and plays he liked. He built not only a resume' but a dossier of things he liked in a Powerpoint presentation. A career backup, he understood the value of engaging everyone on the team. With parents who were educators and his time with Popovich, he encouraged players to learn more about the world and keep perspective outside of basketball. 

He also learned in the broadcast booth, spending valuable time with Jeff Van Gundy and interviewing NBA coaches about their beliefs and strategies. 

CULTURE

Kerr didn't tear down the foundation that Mark Jackson built, as Kerr inherited a fifty-one win team. He emphasized enhancing what was already working, on getting better. He encouraged fun and blasted rock music at practice. He met with players during the offseason to discuss his vision, even flying to Australia to meet with Andrew Bogut. He had the spontaneity to take the coaches from practice to a dip in the Pacific, because they needed a break. 

MINDSET

Kerr is a constant learner and an avid reader. Earlier in his career, he asked to participate in a Spurs coaching retreat. He values input from everyone, and the story of how he got input from Video Coordinator Nick U'Ren in 2015 that led to a lineup change (inserting ultimate Finals MVP Andre Iguodala into the lineup) speaks to his flexibility and openness. 

Kerr might be labeled kinder and gentler by some. But he walks the walk, an adult orphan whose father, a Middle East politics expert, was killed by terrorists. He values equality and respect, another part of his playing history as a reserve.

The primary lessons from 'Team Building' are communication, openness, inclusiveness, respect, attention to detail. and the power of culture to get the most from our teams.  

A Look at Mastery

Mastery doesn't just happen. Like experiencing a journey, we make it happen but not independently. 

Robert Greene wrote the bestseller Mastery. Mastery examines how students, craftsmen, or professionals arrive at high performance levels. This translates to basketball at many levels. 

Greene cites numerous examples, like Benjamin Franklin, an aspiring journalist, who eschewed training in the family business (candle making) for a longer (nine year) apprenticeship in printing.

First, he advises us to match our work with our passion. Some players participate as surrogates for their parents. That dog won't hunt. 

Second, focus on the process - the apprenticeship, experimentation, and skill enhancement that occurs over years. You know the 10,000 hours rule...professional skill levels are time-sensitive. 

Third, maintain a childlike fascination with learning. Kevin Eastman says, "be a learn-it-all, not a know-it-all." We encounter true geniuses; don't believe that applies to us. 

Fourth, pay attention to detail. Da Vinci was an autodidact, he taught himself to draw, through meticulous observation and concern for detail. 

We can combine key elements as an acronym, SALT. 

S - skill of the craftsman (hone your craft)
A- attention to detail
L - learning both direct (trade-oriented) and indirect (other fields). Basketball shares excellence, leadership, teaching, learning, exercise physiology, psychology, and even applied mathematics. 
T - time. 

Near the top of Coach Wooden's 'Pyramid of Success' flank the words, FAITH and PATIENCE. Short cuts and mastery don't mix. 

Green notes that in early apprenticeship, OBSERVATION has a larger role. With time, trainees get more 'hands on' experience. 

I served in the Navy during the tragedy of the turret explosion on the Battleship Iowa. Before the investigation concluded, an elderly patient and former gunner's mate explained that powder loading required considerable technique and experience. He said, "I could still do that. Kids don't have the experience." There was no corporate memory bringing battleships from mothballs. Young players with limited experience make mistakes inherent in the process. Mastery isn't free. 

Here's some valuable advice about Nobel Laureate Richard Feynman via fourminutebooks.com:

During yesterday's part 3 of Best of Enemies, ESPN dredged up the tempest in a teapot between Isiah Thomas and Larry Bird. The issue was never race, but mastery. Isiah spoke, perhaps awkwardly, that his craft evolved through working long hours on his game. Every NBA player pays the price to achieve that success and mastery. 

Thomas wanted people to know that work not gifts got him to the NBA. Kobe Bryant shot a thousand jumpers a day for a hundred summer days (100,000 shots). Spencer Haywood's path to the NBA traversed winning a challenge to make fifteen consecutive free throws to earn a scholarship to Detroit. Work, toughness, and persistence inform mastery. 

The ACL and Basketball

I'm not an orthopedist, but I am a physician and an anterior cruciate ligament (ACL) reconstruction patient. Here's an overview with the caveat that one should always consult with his/her physician. 

Relevance. ACL tears are among the more common serious basketball injuries. A meta-analysis (review of multiple studies) showed that women have a 3:1 increase for ACL tears in basketball but did not show an effective injury prevention strategy. Another study showed, "in girls, the highest ACL injury risks per season were observed in soccer (1.1 percent), basketball (0.9 percent), and lacrosse (0.5 percent). In comparison, the highest risks per season for boys were observed in football (0.8 percent), lacrosse (0.4 percent), and soccer (0.3 percent)."

Normal knee anatomy/function. The knee has a pair of stabilizing ligaments (fibrous bands) that limit side to side (collateral ligaments) and front to back (cruciate/crossing ligaments) movement. The large muscles of the leg also help stabilize the knee. In the ACL deficient knee, the large bone, the femur, tends to roll forward over the tibia, producing a 'give-way' sensation. 

Stresses on ACL. Injury may be contact or non-contact. If the planted knee is hit from the side (tackling, clipping), the ACL may be overstretched and rupture (break), sometimes with additional injury (meniscus tear, medial collateral ligament) called the "unhappy triad". Rapid directional change can also hyperextend the knee stressing the ACL. 

Women have higher ACL injury rates for a variety of reasons, anatomical, hormonal, and physiological (different jumping styles). 

The injury 

Diagnosis. Participants describe acute pain and sometimes describe feeling or even hearing a pop and noticing almost immediate swelling. With a complete tear, internal bleeding occurs, resulting in a joint effusion, which can be aspirated (removed) with hemarthrosis (blood in the joint). The injured player tends to protect the joint with lack of movement and adopt a partially flexed knee posture to reduce pain. 

Generally, an MRI confirms the diagnosis. 

Options. Surgery isn't necessary for everyone. If a 68 year-old man tears his ACL skiing, he may or may not want to accept the age-related risk and prolonged rehab. Some athletes return to full play without reconstruction (e.g. Buffalo Bill great Thurman Thomas). But many opt for surgery. 

The American Academy of Orthopaedic Surgeons (AAOS) cites an 82 to 95 percent success rate for surgery. They discuss reasons for graft failure and surgical complications as well as differing surgical repairs. Some of this will depend on the surgeon's training (which technique learned) and experience. The goal is a stable knee with return to full activities including high intensity sports. 

Recovery. AAOS states, "Physical therapy is a crucial part of successful ACL surgery, with exercises beginning immediately after the surgery. Much of the success of ACL reconstructive surgery depends on the patient's dedication to rigorous physical therapy." ACL rehabilitation is lengthy and demanding. Regardless of surgical or non-operative treatment, osteoarthritis is likely over time. 

Return to sport. Competitors want the earliest return possible. Physicians want to balance optimal recovery and function with early return. Return too soon risks reinjury. The author writes, "Time questions aside,  I don’t allow return to Level I sport (soccer, basketball, football) until there is no pain with activity, no swelling, full range of motion, good stability, strength close to equal to the opposite side." The surgeons in this article discuss their criteria for return and rehabilitation strategies. 

Miscellaneous. Recovery is both physical and psychological. Many athletes have a (realistic) fear of reinjury. It took several years for me to resume playing basketball without 'thinking' about possible injury. 

As coaches, we need to understand that 'medical clearance' for athletes to return isn't the same as "the athlete is one hundred percent". 

Anterior cruciate ligament-Injury & management from Anand Rao

Looking at Basketball Burnout

Burnout, what it is, what it isn't, and what can we do about it?

The NCAA describes a continuum resulting from stress - staleness, overtraining, and burnout. It's the antithesis of Csikszentmihalyi's "flow state". Joy disappears and priorities shift from process to outcomes. "motivation shifts toward extrinsic rewards such as trophies, scholarships, money, celebrity, or approval."

Burnout isn't synonymous with depression. Anti-depressant medications do not repair burnout. 

How common is it? "1 percent to 9 percent of female athletes and 2 percent to 6 percent of male athletes had experienced symptoms of high-level burnout." 

This isn't unique to athletes. Although burnout is distinct from depression, studies of physicians-in-training (residents) showed that a third experience clinical depression. 

Who gets it, wannabes and losers with no future? WNBA superstar Elena Delle Donne, a top UCONN recruit, stepped away from basketball in 2008 with burnout. 

What are the symptoms? The spectrum of burnout develops as fun becomes a chore. The routine of conditioning, practice, and competition becomes overwhelming, especially for the single sport athlete. Fun and friendship disappears into the backdrop of "more".

But it's healthy for them to play. What do statistics say? 

"According to the book, Sports Specific Rehabilitation by Robert Donatelli, "In 2001 an estimated 18 million children were treated for a sports/physical activity-related injury. Approximately, 50% of those injuries (9 million) were attributed to overuse mechanisms resulting in muscle damage."

Great professionals honed their talents playing multiple sports. Hakeem Olajuwon credited soccer for some of his great footwork. Michael Jordan had a fling with professional baseball and played youth football. LeBron James was an All-State receiver. Wilt Chamberlain was a standout in track and volleyball. 

Find balance. The great Pete Newell discusses the triad of footwork, maneuvering speed, and balance. We need to find balance in our lives. Joy Hollingsworth, former college standout and WNBA assistant, discusses the need for life balance. Playing sports in college can be great, but it's a job and you're an employee. Practicing 25-30 hours a week (forget about NCAA 'limits') while maintaining a full course load overtaxes many serious students. As a walk-on college baseball player, I did this as a premed, while also working 12 hours a week slinging burgers. Ridiculous. 

Gustafsson shares his dissertation, a magnum opus on burnout here, discussing the feelings of entrapment with physiological and psychological impairment. 

Training exposes athletes to a variety of outcomes...from Kentta, 2001. 

More isn't necessarily better. Educators, parents, and coaches should learn about the training continuum and familiarize themselves with the potential physical and mental adverse effects of overtraining. 

Sport Versions of CFIT (Controlled Flight into Terrain)

"Controlled Flight into Terrain (CFIT) occurs when an airworthy aircraft under the complete control of the pilot is inadvertently flown into terrain, water, or an obstacle. The pilots are generally unaware of the danger until it is too late." - Wikipedia

CFIT relates distraction to crashes. We lack a similar term in basketball, but good teams implode. Why? Reframe this into "what distractions and decisions create disaster?" 

Coaching changes. Chuck Fairbanks transformed the Patriots from also-rans into contenders. During the 1978 season, he accepted the Colorado coaching job and the Patriots lost in the first round of the playoffs with Fairbanks suspended. Some consider the 1976 Patriots team the most talented in franchise history. 




The Raiders won the Super Bowl that year, but the Patriots hammered them 48-17 during the regular season. The Raiders beat the Patriots in the playoffs abetted by several controversial officiating calls. History may not have repeated itself but rhymed as Bill Parcells defected in the 1996 postseason with the Patriots losing in the Super Bowl. 

Underachievement. The Celtics upset the Cavs in the 2010 Eastern finals, 4-2, after the Cavaliers had a sparkling 61-21 regular season. LeBron was mortal, shooting 44.7% from the field, 27% from three, and 74% from the line in the series. To be fair, the surrounding cast (Shaq, age 37, Antawn Jamison, age 33) wasn't championship caliber. 

Mistakes in judgment. The classic poor decision was Chris Webber's timeout call in the 1993 NCAA championship. 




Fewer people remember the missed travel call leading up to the timeout. 

Len Bias' cocaine death in 1986 forever changed the fate of the Boston Celtics. The second choice in the NBA draft was joining the powerhouse of Bird, McHale, and Parish...almost certain to extend their careers and possibly give them additional championship opportunities...never happened. 

Relationship failures. I knew a strong high school team headed into a basketball postseason. A player on the team began dating a teammate's 'significant other' just before the playoffs. The team fractured and lost in the first round. 

Questionable coaching decisions. The Spurs, up 3-2 in the 2013 Finals, led the Heat 94-89 with 28 seconds left. Tim Duncan was substituted out of the game twice in those fateful moments, missing two critical defensive possessions. Some consider this game the biggest blemish on Gregg Popovich's majestic career. The Heat tied the game in regulation and won in OT. 

Officiating. Officiating, at every level, presents challenges. From player inconsistency (youth) to speed of the game (higher levels), officials get criticized. But rarely, officials go off the rails. Tim Donaghy claimed officials received instructions from the league and he bet on games he officiated. He plead guilty to corruption charges. "The revelation that Donaghy had been betting on games for four years — against league regulations — underscores the N.B.A.’s inability to detect such conduct." 




And there's robbery. 

The unifying themes behind these CFIT episodes were leadership failures, varying from organizational, coaching, and individual choice. I'm sure that you can find many more examples from your experience.