The most common injury in the sport of basketball is the ankle sprain (3). Typically due to a plantarflexed and inverted foot and ankle landing on an uneven object (typically an opposing player’s foot) or to a sharp, cutting, or pivoting movement, the inversion ankle sprain most frequently occurs as a result of inherent weakness and instability of the ankle joint. Chronic ankle sprains are seen more frequently from a combination of intrinsic and extrinsic factors. Muscle weakness, poor proprioception, and altered foot mechanics lead to instability of the subtalar joint. Improper shoewear may affect forefoot mechanics, predisposing to excessive pronation or supination and altered gait patterns. Each muscle group works jointly with the others in different phases of the gait cycle and stabilizes the subtalar joint through its motion. Observation of callus buildup medially or laterally on the plantar foot assists in determining the pronated from the supinated foot and their respective wear and stress patterns seen with walking, running, and jumping. A thorough biomechanical evaluation with a supervised rehabilitation program and well-fitted orthosis can assist in providing a neutral subtalar joint and balanced muscle patterns around the foot, ankle, and lower leg. Ankle manual medicine techniques are also discussed in Chapter 24, Foot and Ankle.

Other common, but less frequently assessed structural changes in the foot and ankle include cuboid subluxations, fibular head dysfunctions (proximal tibiofibular joint), distal tibiofibular joint alignment, the talocalcaneal articulation (subtalar joint), and midfoot and metatarsophalangeal joint restrictions. Cuboid subluxations typically present as midfoot pain along the lateral and plantar surface of the foot. Clinical examination includes a palpable cuboid prominence along the lateral plantar foot with associated localizing pain. Relative discomfort
and cuboid position versus the unaffected side are the hallmarks for diagnosis.

Manual Medicine Techniques. Manual medicine techniques are based on athlete tolerance and mobilization of the cuboid. High-velocity, low-amplitude (HVLA) muscle energy, and counterstrain techniques often adequately reduce the cuboid. Pain resolution and enhanced mobility at the articulation are signs of a successful reduction.

Dysfunctional tibiofibular articulations proximally, and less so distally, are commonly seen in inversion mechanism ankle sprains. The proximal articulation is intimately related to the knee and ankle. Restriction at the proximal articulation affects knee and ankle mobility. Typical anterior-posterior glide is directed by actions of the biceps femoris muscle and its local insertion (4). Evaluation of ankle injuries should include palpation, joint play evaluation, and articulatory techniques to the proximal and distal tibiofibular articulations (5). Standard treatment is rehabilitation with muscle stretching, and neural tension stretches should be maintained to ease biceps femoris tightness and contraction. Anterior and posterior restrictions should be manipulated, using HVLA and muscle energy techniques.

Restriction of the talus superiorly at the tibiofibular-talus articulation and distally at the tibiocalcaneal articulation (subtalar joint) significantly restricts ankle motion (4). Ankle stability is greatest in dorsiflexion, while limitation of motion in this plane affects ankle and foot function. Talus position affects ankle motion control, and dysfunctions at this articulation may lead to recurrent sprains due to altered mechanics. Mobilization techniques include muscle energy and HVLA maneuvers. Assessment of subtalar motion is critical following all acute and chronic events to ease ankle mobility and limit mechanical alterations in the gait cycle.

Lower leg injuries often include shin splints and stress-related changes to the tibia or fibula. Medial tibial stress syndrome involves an overuse mechanism to the soleus and deep muscular fascial attachments along the middle and posterior distal tibia (3). The actual pathology is somewhat unclear, but is believed to be due to fasciitis or possibly a local periostitis. Treatments follow conventional RICE protocol (rest, ice, compression, and elevation) with cross-training to tolerance. Structural assessment of foot biomechanics, fibular head and subtalar motion, and muscle tightness through the plantar fascia, gastrocnemius-soleus complex, and into the hamstrings is essential. Lengthening of specific tight muscle groups and strengthening of muscle imbalances should be keys to recovery. Assessment of shoewear to provide either additional motion control for the pronated foot or added cushion for the supinated foot deserves attention as well.

Stress-related changes to bone include periostitis, stress reactions, or the more common stress fracture. A result of many factors including overtraining, poor foot biomechanics, muscle imbalances, hormonal alterations, and dietary deficiencies, stress fractures typically present along the posterior medial aspect of the tibia and the second and third metatarsals of the foot in athletes involved in jumping and running sports. Rarely seen early on standard radiographs, local pain early into training with persistent discomfort at rest should raise suspicion for stress-related changes to the bone. Frequently, bone scan or magnetic resonance imaging (MRI) is required to confirm the diagnosis.

Anterior tibial stress fractures are less common but more ominous due to traction forces across the bone, poor bone remodeling, and lengthy time to recovery. Whereas typical tibia, fibula, and metatarsal stress fractures require 6 to 8 weeks before return to play, anterior tibial stress fractures may require greater than 6 months and frequently surgical intervention for complete healing. Fibular stress fractures typically present secondary to biomechanical changes following previous injury. In this instance, foot and ankle overcompensation applies undue stress laterally onto the lower leg and ultimately leads to stress changes on the fibula.

Metatarsal stress fractures follow the pathophysiology and overload characteristics of tibial injuries. Lack of mobility of the second and
third metatarsals puts them at greatest risk when overload and excessive stress forces are applied.

Standard treatment first includes changing the training environment or routine of the athlete, and relative rest. Strengthening and flexibility training should start in an organized therapy program. Correction of all extrinsic and intrinsic precipitating factors should be achieved prior to a return of functional exercise. Shoe insoles or orthotics may help distribute weight more effectively to where it should be loaded.

Manual Medicine Techniques. Manual medicine techniques should focus on the kinetic chain and treatment of the dysfunctions and restrictions along the leg. Second and third metatarsal restriction can be treated by anteroposterior joint play techniques, remembering to add HVLA at the restrictive barrier. Dorsiflexion and plantarflexion of the ankle can be treated with a talar release technique, then muscle energy to reset muscle lengths. Treat any other dysfunctions along the kinetic chain, including sacral torsions, hip flexor and anterior capsular restriction, and fibular head dysfunction.

Previously described as the “career-ending injury,” the anterior cruciate ligament (ACL) tear has now become a part of sports culture and a relatively routine repair, allowing top-level athletes to return to previous levels of function and performance. The magnitude of the injury on a player and the team is often devastating, but with aggressive rehabilitation and functional bracing, men and women alike are returning to their sport more quickly and with fewer complications. The medial collateral ligament sprain and meniscal pathology found in high-level athletes have also affected careers, but typically for short durations and with less fanfare. Meniscal repairs and excision have provided a means to return athletes back to their sport relatively quickly. Secondary degenerative changes along bony articular surfaces have a greater impact on longevity. The advent of the osteoarthritis transfer system (OATS) repair and the use of viscosupplementation have progressed a once debilitating injury to one that may only minimally impact an athlete’s career. Many athletes are now returning to sport with few repercussions.