Keywords
Achilles' tendon rupture - basketball - review - sport
Currently, according to data from the Federation of International Basketball Associations
(FIBA), more than 450 million people in the world practice basketball,[1] thus ranking among the five most popular sports on the planet.
Basketball in Spain is the second most popular team sport as the most federated after
football. There are 3,619 clubs with 385,100 licenses of which 36% correspond to women
and 66% to men.[2] Spain ranks as the second-best national team in the FIBA World Ranking after the
United States in men, and third after the United States and Australia in women.[1]
The most frequent injuries in the practice of this sport are those of hands and shoulders
in upper limbs, along with ankles and knees in lower limbs. The Achilles tendon rupture
does not stand out for its frequency, but rather for its severity, making it impossible
for 20.5% of those affected to return to the usual practice of basketball in the case
of professionals.[3]
Sports activity is the most frequent cause of Achilles tendon rupture. In the United
States, basketball is the sport in which the injury in question most frequently occurs,
while in Europe it is soccer.[3]
It occurs more frequently in adults under 55 to 60 years of age and is related, in
most cases, to basketball. This makes it responsible for 48% of the ruptures related
to sports, and 32% of all ruptures according to Raikin et al.[4] It has also been related to gender, body mass index (BMI), ethnicity, and both the
practice of professional and amateur sports.[4]
The objective of this work is to assess the relationship between Achilles' tendon
ruptures and basketball.
Material and Methods
This systematic review was conducted according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist.
Neither protocols nor registration have been assessed.
During January and February of 2020, a literature search was conducted on the prevalence
of Achilles tendon rupture in basketball. Multiple databases were used such as PubMed,
Cochrane Library, and ClinicalTrials.gov. The electronic search strategy used was
“Achilles' tendon rupture and basketball.” Studies were screened by title and/or abstract
to determine study eligibility based on inclusion criteria. The inclusion criteria
were descriptive epidemiology studies that described prevalence of Achilles' tendon
rupture in professional or amateur basketball players.
We have considered the following as inclusion criteria: all those published articles
that contain the keywords, with data that highlight the relationship between the Achilles
rupture and basketball. Exclusion criteria include systematic review articles, case
reports, series where sport was not listed and where basketball was not included,
series that did not present epidemiological data, and articles published in languages
other than English or Spanish.
After the search, 24 results were found that were filtered according to the year of
publication. The literature review shows an increase in publications from the year
2013 compared with the limited publication of studies in previous years. It was then
decided to apply, saying year as a temporary filter obtaining 13 articles. Subsequently,
the resulting articles were evaluated by title and abstract without considering the
type of study, outcomes, gender, and/or interventions performed. Subsequently, 10
articles discussing other topics, such as treatment or prognosis of the injury, were
excluded.
Finally, the following three articles were selected for their epidemiological content
of relevance. First, “Epidemiology and Video Analysis of Achilles Tendon Ruptures
in the National Basketball Association” of Lemme et al[3] published in August 2019 by The American Journal of Sports Medicine. Second, “Epidemiology of Achilles Tendon Ruptures in the United States” of Lemme
et al[5] published in November 2018 by Orthopedic Journal of Sports Medicine. And finally, “Achilles Tendon Injuries in a United States Population” by Raikin
et al[4] in April 2013 in Foot & Ankle International magazine. The three above are descriptive epidemiology studies with good quality assessment
by the National Institute of Health (NIH) quality assessment tool ([Table 1]).
Table 1
National Institute of Health quality assessment tool ratings
|
Authors (year)
|
Quality rating
|
|
Lemme et al[3] (2019)
|
Good
|
|
Lemme et al[5] (2018)
|
Good
|
|
Raikin et al[4] (2013)
|
Good
|
The search and selection are detailed in [Fig. 1]. Independent data collection process was conducted.
Fig. 1 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow
diagram.
Results
After the search and selection, three articles were obtained, all of the epidemiologically
descriptive designs[3]
[4]
[5] are presented in [Table 2] with a summary of the most relevant aspects. Only the study by Lemme et al, published
in 2019, specifically deals with the Achilles tendon rupture in basketball, specifically
in the National Basketball Association (NBA) of the United States.
Table 2
Epidemiological designs
|
Authors (year)
|
Participants
|
Source
|
Incidence
|
Total cases
|
|
Lemme et al[3] (2019)
|
National Basketball Association players between the 1969 to 1970 and 2017 to 2018
seasons
|
Public data obtained from injury records, press communication, and player profiles
|
0.92 per 450 people-year[a]
|
44 cases between the 1969 to 1970 and 2017 to 2018 seasons
|
|
Lemme et al[5] (2018)
|
1.6 billion people-year at risk between 2012 and 2018
|
National Electronic Injury Surveillance System (NEISS)
|
2.1 per 100,000 people-year
|
32,906 cases between 2012 and 2016
42.6% of the total related to basketball
|
|
Raikin et al[4] (2013)
|
Patients who visit an orthopaedic clinic in need of tertiary attention with diagnostic
and surgical treatment of a torn Achilles' tendon between August of 2000 and December
of 2010
|
International Classification of Diseases ninth edition code for the Achilles tendon
rupture in Misys Healthcare Systems software
|
2.66 per 1,000 people-year[b]
|
406 cases between August 2000 and December 2010
32% of the total related to basketball
|
a Calculated in a population at risk of 450 players/sports season.
b According to data from Moller et al in 2001[6] included in the study.
The 2018 study by Lemme et al[5] and the 2013 study by Raikin et al[4] were included because of their epidemiological relevance and relationship to sport,
specifically basketball.
The study by Lemme et al[5] determined the incidence and risk factors of the Achilles tendon ruptures in the
United States. Patients registered in the National Electronic Injury Surveillance
System (NEISS) database, who came to the emergency department with this lesion between
2012 and 2016, were selected. The incidence was calculated according to the following
variables: gender, age, race, and analyzing other variables such as the location where
the injury occurred. Likewise, cases were classified according to the mechanism of
injury, performing a subanalysis of injuries with sport. A significant increase in
incidence was detected from 2012 with 1.8 cases per 100,000 person-years to 2016 with
2.5 cases per 100,000 person-years (p < 0.01), and a global incidence of 2.1 per 100,000 person-years. Of the 32,906 cases,
77.1% affected were men while the remaining 22.9% affected were women. The greatest
increase in cases occurred in female patients between 40 and 59 years of age (78%
of the increase). The most common injury mechanism detected was participation in sports
or leisure activities (81.9%), with basketball being the most frequent cause among
all (42.6%), followed by American football (9.9%), tennis (6.9%), and athletics/climbing/stretching
(5.8%).
Raikin et al[4] reviewed 406 cases of the Achilles tendon rupture in the U.S. population. Patients
who attended a tertiary care orthopaedic clinic with diagnosis and surgical treatment
of the Achilles tendon rupture, between August 2000 and December 2010, and registered
in the International Classification of Diseases 9th edition code for Achilles' tendon
rupture in Misys Healthcare Systems software were selected. Patients >55 years of
age and with BMI > 30 kg/m2 were more likely to rupture the Achilles tendon in nonsport activity and more likely
to have an initial misdiagnosis. Likewise, it was established that age and BMI were
directly related to the time of diagnosis of the lesion. Of the 406 cases, 83% affected
were men while 17% were women. Sports activity was responsible for 68% of injuries,
in patients <55 years of age with 77% of injuries compared with 42% in patients >55
years of age. Basketball was the most involved sport, being responsible for 48% of
the breaks related to the sport, and 32% of the total ruptures of the Achilles tendon.
This is followed by tennis (13 and 9%) and football (12 and 8%). Other sports such
as squash, volleyball, or soccer accounted for 31% of total injuries and 46.5% of
those related to sports.
The distribution by sport of the above-mentioned studies[4]
[5] is detailed in [Fig. 2].
Fig. 2 Percentage of sports injuries according to the sport performed on the total Achilles
tendon tears.
In August 2019, Lemme et al[3] published a study based on epidemiology and video analysis of the Achilles tendon
ruptures in the NBA, the American men's professional basketball league. The objective
of this descriptive design was to identify risk factors for the Achilles' rupture
in professional players of the best basketball league in the world, identifying cases
from available public data on injury reports, press releases, and player profiles.
Video analysis was used to identify the mechanisms of injury and the most frequent
game situations where such injuries occurred. In 48 years, 44 players had Achilles'
tendon ruptures. The average age of the injured players was 28.3 years with an average
of 6.8 seasons played in the league. A higher prevalence was seen at the beginning
of the season (27.3%), followed by the preseason (18.2%) and the end of the season
(18.2%). The average recovery time was 10.5 months. In more than one-third of the
cases (36.8%), the patients had to retire or were holders in less than 10 games to
the rest of their sports career. The video analysis available in 12 cases showed that
the injuries occurred without contact. The most frequent mechanism of injury was the
beginning of the action starting from the resting position, with dorsiflexion of the
foot, early knee flexion, and hip extension. In addition to age and time of the season,
other characteristics of the lesion present in [Table 3] were analyzed.
Table 3
Characteristics of the lesions analyzed of the 44 National Basketball Association
players injured by Lemme et al in 2019[3]
|
Variable
|
Category
|
Percentage of injury (n)
|
|
Laterality of the injury
|
Right
|
50 (21)
|
|
Left
|
50 (21)
|
|
Age (y)
|
<30
|
68.2 (30)
|
|
>30
|
31.8 (14)
|
|
BMI
|
<25
|
40.9 (18)
|
|
>25
|
59.1 (26)
|
|
Field position[a]
|
1–3[b]
|
31.8 (14)
|
|
4–5[b]
|
68.2 (30)
|
|
Place of injury
|
Game
|
78.3 (29)
|
|
Practice
|
21.7 (8)
|
|
Point in the season
|
Out of season
|
15.9 (7)
|
|
Preseason
|
18.2 (8)
|
|
Start of season
|
27.3 (12)
|
|
Midseason
|
15.9 (7)
|
|
End of season
|
18.2 (8)
|
|
Postseason
|
4.5 (2)
|
|
Seasons played after recovery
|
0
|
20.5 (9)
|
|
1 season
|
15.9 (7)
|
|
≥2 seasons
|
63.6 (28)
|
Abbreviation: BMI, body mass index.
a Identified in 37 cases (84.1%).
b 1, point guard; 2, shooting guard; 3, small forward; 4, power forward; 5, center.
Discussion
This review investigated the relationship between Achilles' tendon rupture and basketball.
Numerous works coincide in the increase in Achilles' tendon ruptures in recent decades,
assuming an incidence between 8.3 and 24 per 100,000 person-years[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14] in the general population. It is necessary to highlight that the samples of the
studies analyzed in this review were made in the U.S. population, with the limitation
that it implies in terms of external validity. However, it should be noted that the
professional basketball league in the United States has the best players in this sport,
in addition to having a great social impact and a high demand in terms of sports load.
Gender was decisive in the analysis in addition to BMI and age. The present data show
a greater number of injuries in men compared with women in the U.S. population as
shown in [Table 4]. Moreover, the only study of such injury in basketball professionals was performed
on men, while there is not enough available data in women. In the future, the relationship
of these injuries could be analyzed in the professional women's league of the Women's
National Basketball Association (WNBA) in the United States.
Table 4
Gender distribution of Achilles' tendon tears
|
Authors (year)
|
Gender
|
Percentage of Injury (n)
|
|
Raikin et al[4] (2013)
|
Masculine
|
83 (331)
|
|
Feminine
|
17 (69)
|
|
Lemme et al[5] (2018)
|
Masculine
|
77.1 (25,374)
|
|
Feminine
|
22.9 (7,533)
|
According to the data shown in the studies, sport is the most frequent injury mechanism,
assuming 68 to 81.9% of injuries mainly in <55 years of age and BMI <30 kg/m2.[4]
[5] Basketball, causing 42.6% of injuries according to Lemme et al[5] and 32% of the lesions according to Raikin et al,[4] is considered as the sport in which the Achilles tendon ruptures most frequently
occur in the United States. In contrast, soccer is the sport most involved in these
types of injuries in Europe.[8]
[10]
[11]
According to [Fig. 2], at the population level, basketball is the sport where the Achilles tendon breaks
most frequently, followed by American football according to Lemme et al[5] and basketball and tennis according to Raikin et al. On the contrary, in professional
practice, there are discrepancies. According to Parekh et al in the National Football
League (NFL), there were 31 cases of the Achilles tendon rupture in the league over
a period of 5 years (1997–2002).[15] This data are unquestionably superior to that of the NBA, where in 48 years, there
were only 44 cases. Therefore, it is essential to differentiate Achilles' tendon ruptures
in amateur players compared with professionals in basketball and other sports.
In the NBA in 48 years, there have been only 44 cases of the Achilles tendon ruptures.
The average age of the injured is 28.3 years with a higher prevalence of injuries
in players with BMI > 25 kg/m2. Precisely, the age between 28 and 32 years is when players assume their highest
level of sports performance. Injuries occur mostly at the beginning of the season
(27.3%) and in matches (78.3%). It is a more frequent injury in players of the power
forward and BMI (body mass index) center positions (68.2%), and according to Amin
et al,[16] with an average height of 200 cm (between 180.0 and 221.0).
In case of return to the sport, the average recovery time is 10.5 months. However,
in 36.8% of the cases, the players retire or are holders in less than 10 games to
the rest of their sports careers. In 20.5% of the cases, the players are forced to
withdraw when they suffer this injury. Also, 15.9% will play only one more season
after their recovery, and the rest will play two or more seasons after recovery (63.6%).
Therefore, in professional basketball, the Achilles tendon rupture is not frequent
but is an extremely serious injury.
Despite the above data, although there is sufficient evidence of the relationship
between basketball and Achilles' tendon rupture, we are surprised by the low number
of articles published globally, in relation to the number of cases that occur worldwide.
Even establishing a clear relationship between basketball and injury, more studies
are needed in both amateur and professional basketball players and in both genders.
Conclusion
The relationship between Achilles' tendon rupture and basketball is clear. While among
sports, at the population level, the most frequent injury mechanism is basketball,
and at the professional level, there are uncertain results. Therefore, there is not
enough evidence to determine the relationship between this sport and the injury in
question, and further studies (both professional and amateur and in both genders)
are needed to determine this.
