BASKETBALL LOCOMOTION AND KNEE INJURY

Human locomotion requires specific movement configurations of all body anatomy. Examples are walking, running, jumping, lifting, throwing, striking and swimming.

Sideways locomotion is not one of the customary human locomotion movements. It is important to have proficient mechanics during walking and running locomotion customary for human running and walking forward. Excellent mechanics result in less energy expenditure and conservation for a specified speed of movement and safety.

The main human gaits are bipedal walking and running, but humans might employ other gaits occasionally in tight positions, including a four-legged crawl in tight spaces. However occasional gaits are not always energy efficient and safe.

“Understanding Balance explains in detail how an animal or a person is able to stand up and move about without falling over. A realistic assessment of the nature of the problems that arise, together with a clear explanation of the underlying principles, leads to the development of insights into the normal functioning of the mechanisms of balance and locomotion.” [Understanding Balance: The Mechanics of Posture and Locomotion Tristan David Martin Roberts, Nelson Thornes, 1995]

Unlike humans, some animals have unusual gaits that are used regularly or occasionally, such as crabs moving sideways and caenophidian snakes that use the fast and unusual method of sidewinding and snails slither.

Superb Athlete mechanics equals good physiological economy. More economy means increased speed for a quantitative metabolic power output. A model accounting for the energy expenditure in human motion, Margaria Law. has been thoroughly researched and explained. [1.]

Now about sideways locomotion: Crabs have five pairs of legs. The first pair with claws (or pincers), are attached at the sides. Crabs are chiefly marine, but some are on sand or land for long periods. Although they are capable of locomotion in all directions, crabs tend to move sideways on dry land; swimming crabs have the last pair of legs flattened to form paddles. [2.]

Humans are not designed and equipped like crabs. It doesn’t take a genius to conclude that crab-like locomotion among humans, like side-to-side-slide of repetitive man-to-man defense, is not anatomical and physilogical designed movement configurations; it potentiates correct neuromuscular signals to and from the brain, normal endocrine and hormonal differences, promotes abnormal limb and joint mal-alignment, muscle imbalance, joint inflexibility and is mechanically underpowered, energy inefficient and predictably injurious and teams run out of gas during sports participation.

[Roberts, Tristan David Martin (1995). Understanding Balance: The Mechanics of Posture and Locomotion. Nelson Thornes. p. 211]

Most Coaches recruit tall basketball athletes because the rim is 10 feet above and not in the floor. Otherwise, Coaches would recruit and sign mostly short athletes. The amateurish attempt to require tall basketball players with a long femurs to train, exercise and compete with the same agility, while squatting, “sitting down”, equal to short athletes, is preposterous. Additional overuse injuries will result.

Athletes who train, exercise and compete in games will exercise to exhaustion more rapidly, become energy depleted and develop more over-use injuries, particularly, hips, knees and ankles, in a predominantly man-to-man defense with crab-like human locomotion.

Pushing and Punishing Athletes during practice with over the physical and emotional limits of crab-like man-to-man locomotions characterized by excessive repetitions and increased time durations of training drill and Pushing Athletes during game competitions with the same abnormal locomotions will cause exercise to exhaustion faster and overuse injuries over the long haul. Conditioning will not overcome intrinsic anatomical, biological and biomechanical makeup and risk factors.

Running is a means of terrestrial forward locomotion allowing a human or an animal to move rapidly on foot. Humans do not walk or run sideways. In athletics running is called gait.

During the running cycle both feet are regularly, at intervals, off the ground. In contrast to walking, where one foot is always in contact with the ground, the legs are kept mostly straight and the center of gravity vaults over the legs in an inverted pendulum fashion.

During running there are changes in kinetic and potential energy within a stride that occur. Energy storage is achieved by springy tendons and passive muscle elasticity that are ready to release energy. Running can be many speeds ranging from jogging to sprinting.

Many Athlete injuries are associated with running because of continuous impact against the underneath surface, usually ground or court. Runners knee, shin splints, pulled muscles, twisted ankles, iliotibial band syndrome, plantar fasciitis, Achilles tendinitis, stress fractures, naming a few.

Repetitive stress on the same tissues without enough time for recovery or running with improper form can lead to many of the above. Locomotion in general, sideways to be exact is improper form, for which humans have not been designed or evolved, with added insuficient recovery time are injruious.

Runners generally attempt to minimize these injuries by warming up before exercise, focusing on proper running form, performing strength training exercises, eating a well balanced diet, allowing time for recovery, and “icing” (applying ice to sore muscles or taking an ice bath). 3.

Humans evolved from ape-like ancestors researach tells us. They ran long distance to hunt animals in Africa. The ability to run shaped our anatomy that determined how we are today. Running shaped human evolution and made us human anatomically. The evolution of humans is tied to the evolution of running. That is the conclusion of a study by University of Utah biologist Dennis Bramble and Harvard University anthropologist Humans did not evolve running sideways or with a side-to-side-slide. Crabs evolved with a side to side locomotion because of the combination of pinchers for prey collection and their hard exoskelton for protection. Humans do not have an exoskelton.

Humans are poor sprinters compared with other running animals. Human endurance running ability has been inadequately appreciated. Bramble, “What is important is combining reasonable speed with exceptional endurance”. Humans began running to catch their prey in Africa.

Here are anatomical characteristics that are unique to humans and that play a role in helping people run, according to the study:

The connection between the pelvis and spine is stronger and larger relative to body size in humans than in their ancestors, providing more stability and shock absorption during running.

“Human buttocks ‘are huge’, says Bramble. “Have you ever looked at an ape? They have no buns. He says human buttocks are muscles critical for stabilization in running” because they connect the femur—the large bone in each upper leg—to the trunk. Because people lean forward at the hip during running, the buttocks keep you from pitching over on your nose each time a foot hits the ground”. Crabs don’t have a buttocks. Next trip to the beach check it out.

Long legs, unlike other species, allow humans to take long strides when running, Bramble says. Long ligaments, tendons and the Achilles tendon function like springs. They store and release mechanical energy during running. Thus long tendons and ligaments cause human lower legs to be less muscular, therefore lighter, requiring less energy for running movement.

There are also larger surface areas in the hip, knee and ankle joints, for improved shock absorption during running.

Bones in the human foot create a stable arch that makes the whole foot more rigid, therefore, human runnesr can push off the ground more efficiently and utilize ligaments on the bottom of the feet as springs.

Humans also evolved with an enlarged heel bone for better shock absorption, as well as shorter toes and a big toe that is fully drawn in toward the other toes for better pushing off during running.

The study by Bramble and Lieberman concludes: “Today, endurance running is primarily a form of exercise and recreation, but its roots may be as ancient as the origin of the human genus, and its demands a major contributing factor to the human body form”. 4. Contrast the Human to the Crab.

Basketball man-to-man defense requires dynamic squatting while sliding side-to-side. Coaches, trainers and sports announcers call it “sitting down” on defense, squatting. This defensive posture and the theory of man-to-man are widespread. Some regard it as the be-all and end-all of defense. But not so fast.

The interface of training and trainers, coaching and coaches, medical expertise and doctors is a triangular comprehensive model. In this instance, each is trying to comprehend what the other 2 are trying to accomplish. It is not active collaboration. Often they butt heads; its more comprehension than comprehensive.

Training that attempts to correct neuromuscular signals, endocrine and hormonal differences, limb and joint malalignment, muscle imbalance, joint inflexibility are challenging to down right impossible. Add to that the amateurish attempt to make a tall basketball player, with a long femur, training to play with the agility, while squatting, as short athlete. Overuse injuries result. Over the limit repetitions and exercise duration will cause overuse injuries in the above endeavors.

Muscle weakness and instability are conceivable, attainable, realistice, improvement training goals.

“Overuse injuries result from repeated submaximal stress followed by inadequate recovery. Youth Athletes {less than age 22} incur specific overuse injuries as the result of growth. Strategies for preventing overuse injuries include

 Use of varied practice to reduce join stress and enhance learning.
 Planned Rest
 Gradual Progression
 Cross-Training” 5.

The potential for submaximal exercise knee and ankle loading and overuse injuries from excessive squatting repetitions and prolonged duration is significant. There appears to be greater female to male gender overuse loading differences during Squatting Movement Patterns.

Anterior Cruciate Ligament injuries draw most of the knee injury attention. But let it be known that there are many other overuse knee injuries.

“Most ACL injuries occur during eccentric deceleration” from jumping, stopping or cutting. Squatting should be accomplished by sitting the players hips back, knees should stay over their toes, not in front, knees should not knock together. Knees knocking together in front of the toes is improper. To re-learn squatting begin with the athlete sitting down in a chair and build to a squat, pushing back at the hips, not bending the knees. Knees that move inward are likely week. Girls are stronger in adduction (knocking knees together) than abduction (moving them away). 6.

When lifting weights, “short femurs are a blessing for squatting. They allow you to stay more upright at the torso and have less forward knee movement (mechanically disadvantageous). Forward knee movement shifts your center of gravity, has the potential to make you raise your heels and dump the weight forward. 7.

A long femur is problematic in this squatting basketball position just like weight lifting. The long femur shifts the knees forward beyo0nd the toes for gravity balance and makes it more difficult than short femurs for side-to-side-slide for zone defense. Short femurs are a blessing for man-to-man-defense. Short athletic athletes are better at man-to-man defense.

During a dynamic single-leg squat Zeller and associates reported that female athletes had significantly
 greater ankle dorsiflexion,
 ankle pronation,
 hip adduction,
 and hip flexion than males.
 begin the movement in greater valgus alignment
 and remain in this alignment throughout the squat. 8.

Training errors and poor technique when combined with intrinsic gender physical characteristic differences contribute to Overuse Knee, Ankle and Hip Injuries. Squatting in man-to-man defenses repetitively for prolonged periods of excessive reputations can cause overuse injuries.

Table 1. Risk Factors That Contribute to Overuse Injuries 9.

Intrinsic Extrinsic
Malalignment Training errors
Muscle imbalance Equipment
Inflexibility Environment
Muscle weakness Technique
Instability Sports-acquired deficiencies

“A literature review reveals that 30% to 50% of all sports injuries result from overuse. Overuse injuries occur when a tissue is injured due to repetitive submaximal loading. The process starts when repetitive activity fatigues a specific structure such as tendon or bone. With sufficient recovery, the tissue adapts to the demand and is able to undergo further loading without injury.”

“Without adequate recovery, microtrauma develops and stimulates the body’s inflammatory response, causing the release of vasoactive substances, inflammatory cells, and enzymes that damage local tissue.” Rubor, calor, and dolar, or erythema, heat and pain in the affected area.

“Cumulative microtrauma from further repetitive activity ultimately causes clinical injury. In chronic or recurrent cases, continued loading produces degenerative changes leading to weakness, loss of flexibility, and chronic pain”.
“Thus, in overuse injuries the problem is often not acute tissue inflammation, but chronic degeneration (ie, tendinosis instead of tendinitis).” 10. 11.

Joints, tendons and ligaments can only take so much overuse. “Clinicians must emphasize that more is not always better and explain that overtraining precipitates injury and causes fatigue and decreased performance. Athletes should be encouraged to follow basic training principles of progression and periodization, which imply gradual increases in workload and training cycles that emphasize programmed rest.” 12.

“Complex knee injuries are common, often resulting from multiple forces: varus, valgus, hyperextension, hyperflexion, internal rotation, external rotation, anterior or posterior translation, and axial load. Certain combinations of forces are known to cause specific injury patterns. After a review of the literature, the authors developed a mechanism-based classification system based on patterns of bone marrow edema and ligament injury for complex knee injuries depicted at magnetic resonance imaging. The classification system takes into account knee position and forces and recognition of patterns of bone injury and complementary soft-tissue injury. Ten mechanism-based injury patterns were recognized:”

(a) pure hyperextension,
(b) hyperextension with varus,
(c) hyperextension with valgus,
(d) pure valgus,
(e) pure varus,
(f) flexion with valgus and external rotation,
(g) flexion with varus and internal rotation,
(h) flexion with posterior tibial translation,
(i) patellar dislocation (flexion, valgus, and internal rotation of femur on fixed tibia), and
(j) direct trauma. Recognition of these patterns may help assess the full extent of knee injury, particularly at the posterolateral and posteromedial corners of the knee. 13.

To date, the goal of sport scientists has been to better understand the mechanisms of noncontact ACL injuries in order to learn which elements might be modifiable. This will aid in reducing other serious knee injuries such as PF dislocations. Such research is happening both in Minnesota and around the world. The hope is to provide a safer environment for all athletes in regard to reducing the risk of serious knee injury.

Anterior cruciate ligament (ACL) injury prevention programs reveal that little information exists regarding whether a program designed for an individual’s
movements may be effective or how baseline movements may affect outcomes.

A program designed to change specific movements would be more effective than a “one-size-fits-all” program. Players with the greatest amount of movement errors experienced the most improvement. 14.

Most ACL injuries involve minimal to no contact. Female athletes sustain a two- to eightfold greater rate of injury than do their male counterparts. Recent videotape analyses demonstrate significant differences in average leg and trunk positions during injury compared with control subjects. These findings as well as those of cadaveric and MRI studies indicate that axial compressive forces are a critical component in noncontact ACL injury. 15.

Increase in peak internal rotation moments has the potential to increase the risk of ACL injury. 16.

Sidestep cutting technique has a significant effect on loads experienced at the knee. The techniques that produced higher valgus and internal rotation moments at the knee, such as foot wide, torso leaning in the opposite direction to the cut and torso rotating in the opposite direction to the cut, may place an athlete at higher risk of injury because these knee loads have been shown to increase the strain on the anterior cruciate ligament. Training athletes to avoid such body positions may result in a reduced risk of non-contact anterior cruciate ligament injures. 17.

Whole body sidestep cutting technique modification resulted in reduced knee loading. 18.

With the passage of Title IX in 1972, competitive sports for girls and women in the U.S. changed forever. In fact, from 1972 to 2006, the number of females participating in high school sports grew from 300,000 to an estimated 3 million, an increase of almost 1,000 percent. 20.

The knee joint is the site of the highest injury rates among female athletes.
Women have considerably higher rates of knee injury. Women suffer ACL tears at a four to six times greater rate than males in the same sport. Every year 1 of 10 college female athletes and 1 of 100 high school female athletes will sustain a serious knee injury.

About 70 percent of ACL injuries are NON-CONTACT in nature, occurring in sports that involve jumping and landing, quick stopping, cutting and directional changes.
Knee injuries to the menisci, other ligaments, joint cartilage and the underlying bone structure also occur frequently which occur in almost 50 % of injuries.

Factors that contribute to the discrepancy between male and female knee injury rates

I. Structural and Anatomical Differences: Women have wider pelvis, coupled with shorter bones that increases the Q-angle between the quadriceps muscle on the front of the thigh and the patellar tendon. And a narrower femoral notch that may cause a “shearing” effect on the ACL by the femur during cutting and jumping movements.

Pronation at the foot causes internal rotation of the tibia coupled with a greater degree of rotation at the femur, which increases stresses along the ACL.
Smaller ligaments and bone surfaces for ligament attachment.
II. Hormonal Differences

The ACL contains receptors for both estrogen and progesterone and some researchers suggest that increases in one or both of these hormones may loosen the ACL and heighten its potential for injury. A woman’s ligaments exhibit greater laxity during pregnancy due to changing hormonal levels, which may also explain why the risks for injury may vary within the menstrual cycle (e.g., higher during the ovulatory phase of the menstrual cycle).

The use of oral contraceptives, which alter hormonal levels of estrogen.
Estrogen directly and indirectly affects the female neuromuscular system and may alter neuromuscular response activity.

III. Gender, Skill and Training Differences

Women have less neuromuscular coordination when compared to males and lower abilities and skills, inferior technique and often receive less coaching, all of which contribute to a higher incidence of knee injuries.

IV. Inadequate strength and slower muscle-reaction times.

When landing biomechanics and muscle utilization patterns have been studied, males show higher hamstrings and gastrocnemius use during jump-landing, while females favor quadriceps action to control anterior tibial translation, especially during the first 40 degrees of knee flexion. The hamstrings are an ACL agonist, lengthening eccentrically during this hip-flexion/knee-flexion phase. This reduces the strain placed upon the ACL as they help hold the tibia close to the femur, controlling or minimizing anterior tibial translation. indicating an eccentric load that helps unload the ACL. Quadriceps contraction during this phase of knee flexion (where injury most often occurs) increases strain upon the ACL due to increased shearing forces as the quadriceps attempt to control anterior tibial translation. 19.

REFERENCES

1. [A SIMPLE MODEL OF ENERGY EXPENDITURE IN HUMAN LOCOMOTION Revista Brasileira de Ensino de F¶³sica, v. 31, n. 4, 4306 (2009) F. Romeo Dipartimento di Fisica “E. R. Caianiello”, Università degli Studi di SalernoI-84081 Baronissi (SA) , Italy]

2. [Encyclopedia, zoology]

3. [Wikipedia]
4. [“How Running Made Us Human – Endurance Running Let Us Evolve to Look the Way We Do” by Lee Siegel, a news release about the article by biologist Dennis Bramble and Harvard University anthropologist Daniel Lieberman, November 18, 2004 issue of the journal “Nature”).]

5. [Strength and Conditioning Journal, Overuse Injuries in
Young Athletes: Cause and PreventionJames H. Johnson, PhD
Exercise and Sport Studies, Smith College, Northampton, Massachusetts]
6. [PowerBasketball, Movement Skills, ACL Injuries and Coach Education. by Brian McCormick]
7. [De. Squatt, weight lifting trainer]

8. [ Knee Disorders, Frank R. Noyes, M.D. ]

9. [Epidemiologic Patterns Overuse Injuries,The Physician and Sportsmedicine , May 1997, Nirschl Orthopaedic Center for Sports Medicine and Joint Reconstruction Arlington, Virginia]

10. [Overuse Injuries in Children and Adolescents John P. DiFiori, MD THE PHYSICIAN AND SPORTSMEDICINE – VOL 27 – NO. 1 – JANUARY 1999]
11. 11. [Baquie and Bruckner BrJ Sports Med 1997;31:2-4 Overuse injuries: where to now?]

12. [Epidemiologic Patterns Overuse Injuries,The Physician and Sportsmedicine , May 1997, Nirschl Orthopaedic Center for Sports Medicine and Joint Reconstruction Arlington, Virginia]

13. [October 2000 RadioGraphics, 20, S121-S134, Mechanism-based Pattern Approach to Classification of Complex Injuries of the Knee Depicted at MR Imaging, Curtis W. Hayes, MD, Monica K. Brigido, MD, David A. Jamadar, MB and Tim Propeck, MD
From the Department of Radiology, University of Michigan Health System]

14. Musculoskeletal Injuries of the Knee, Are Females at Greater Risk?, By Elizabeth Anne Arendt, M.D., June 2007 Minnesota Medicine

15. J Am Acad Orthop Surg, Vol 18, No 9, September 2010, 520-527. Noncontact Anterior Cruciate Ligament Injuries: Mechanisms and Risk Factors Barry P. Boden, MD, Frances T. Sheehan, PhD, Joseph S. Torg, MD and Timothy E. Hewett, PhD

16.Papers in Sport Biomechanics, Can Technique Modification Training Reduce Knee Moments in a Landing Task? by Alasdair Dempsey

17. Papers in Sport Biomechanics, The Effect of Technique Change on Knee Loads During Sidestep Cutting by Alasdair Dempsey

18. Papers in Sport Biomechanics, Changing Sidestep Cutting Technique Reduces Knee Valgus Loading by Alasdair Dempsey

19. When it Comes to Knee Injuries, Are Women Really the Weaker Sex? By FABIO COMANA, M.A., M.S.
20. Lal and Hoch, 2007; Giugliano and Solomon, 2007.

____________________________________________________________________________________________________________

J Orthop Sports Phvs Ther.Volume 31 .Number 10-October 2001, Dynamic Knee Stability: Current Theory and, Implications for clinicians and scientists, Glenn N. Williams, PT; SCS1, Terese Chmielewski, MA, PT; SCS1, Katherine S. Rudolph, PhD, PP
Thomas S. Buchanan, PhD3, Lynn Snyder-Mackler, ScD, PT; SCS, ATC4

CONCLUSION
Dynamic knee stability is the result of several factors, including articular geometry, soft tissue restraints, and the loads applied to the joint from weight-bearing and muscle action. In this paper we have focused on the contribution made by the neuromuscular system because this is the only component of dynamic knee stability that can be addressed with therapeutic interventions. The neuromuscular system utilizes a complex motor control system that consists of prestructured motor programs and a distributed network of reflex pathways mediated throughout the CNS to produce movement that is defined by coordinated muscle activity (neuromuscular control). The neuromuscular control system is believed to utilize both feedback and feed-forward control mechanisms. Descending control signals from the brain (eg, motor programs and responses to visual and vestibular feedback), ensemble feedback from muscle, joint and cutaneous receptors, and the ongoing neural control process for locomotion are involved in a complex interaction through which the neuromuscular system produces coordinated movement. The concept of muscle stiffness modulation is put forth as a key mechanism by which dynamic knee stability may be maintained. Muscle stiffness is the result of 3 factors: (1) the intrinsic properties of the muscle (nonreflex stiffness), (2) force feedback provided by ensembles of GTOs, and (3) length feedback from ensembles of muscle spindles. Most challenges to knee joint stability alter the force and length feedback of several muscles in the lower limb. As a result, muscle activity patterns are altered in an attempt to maintain stiffness and, indirectly, joint stability. Our understanding of the neuromuscular control system, however, remains somewhat theoretical.

____________________________________________________________________

Over 4 million emergency-room visits were analyzed for pediatric and adolescent basketball injuries over an 11-year period (1997 to 2007).
Key facts:

•Average number of basketball-related injuries per year: 375,000.
•Most common injury: strain or sprain to the lower extremities, especially the ankle.
•Boys were more likely sustain lacerations and fractures or dislocations.
•Girls were more likely to sustain TBIs and knee injuries.
•Teens (ages 15-19) were 3 times more likely to injure the lower extremities.
•Younger kids (age 5-10) were more likely to injure the upper extremities (especially fingers) and to sustain TBIs, fractures, or dislocations.
[PEDIATRICS Accepted Jun 21, 2010 Charles Randazzo, Center for Injury Research and Policy, Research Institute at Nationwide Children’s Hospital, Columbus, Ohio]

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