Coming to an NBA team near you: better decisions about injuries.
|Jun 14||Public post|| 3|
BY HENRY ABBOTT
With 2:22 left in the third quarter, the last game of the NBA season stopped. Yet another wounded Warrior made yet another trip for emergency assessment under the stands. They have it down: The overworked team physiotherapist, Rick Celebrini, moves to the player’s side—it was Klay Thompson this time. GM Bob Myers trails, emitting worry.
Then it began to feel like, with the highest of stakes, the Warriors started shooting from the hip:
The broadcast crew, and every eighth-grade coach watching, knew that if Thompson didn’t shoot his free throws, he wouldn’t be allowed to return to the game at all. It might be a dumb rule, but it’s a famous one. Klay ran back to the court, shot his free throws, and ran back on defense.
Warriors center DeMarcus Cousins intentionally fouled to get Klay out of the game, even though Klay seemed to want to keep playing. Pascal Siakam hit two free throws, in a game the Warriors would trail by one with nine seconds left.
Thompson then ran back to the locker room, where ESPN’s Doris Burke reported that he told his dad he didn’t hear a pop, that Klay was able to jump, and then, shortly thereafter, that he wouldn’t play.
The Warriors had a few more herky-jerky decisions (their season ended by calling a timeout they didn’t have) and they lost the game, a title, and a chance at a three-peat.
Thompson left on crutches with a torn left ACL, with which he had been running, jumping, and starting to play defense.
All this came in the wake of a month of confusing signals about Kevin Durant and his injury. As a result of all of this, the Warriors will be moving into a brand-new billion-dollar stadium in San Francisco next fall, not as champions and favorites, but as a middling team that might set records for dollars paid to players too injured to take the court.
Lately there has been a massive, league-backed push to apply far more science to injury prevention and management. Injuries are personal and economic nightmares. A lot of the science boils down to playing players less, the most famously “load managed” player in league history, Kawhi Leonard, just won the title and the Finals MVP award.
The Warriors know a lot about this, having hired a succession of experts steeped in sports science. Coach Steve Kerr said, post-game: "It's like, 'You've got to be kidding me.' It just has to stop. ... I don't know if it's related to five straight seasons of playing 100-plus games and all the wear and tear, but it's, it's devastating."
But the league would also benefit from better applying emerging understanding of the complex ways humans move and what really drives soft tissue injuries. One of the leaders of that is P3’s Marcus Elliott, M.D. His Santa Barbara-based lab, P3, has worked with much of the league and has been assessing NBA draft prospects for several years, with significant results predicting injuries based on sophisticated assessments of movement patterns. Elliott says these key decisions, about whether or not to play Durant, or Thompson, are “mostly intuition, and it’s emotional.” But it could be different.
TrueHoop’s Dillon Shain identified 23 NBA players who have torn their Achilles. Most experienced a drop-off. Only Rudy Gay and Jeff Taylor returned to be more effective than before, as determined by the stat PER. You can count on one hand the number of players who, post-injury, surpassed the the PER of 15, marking league average. The good news, though, is that more recent injuries seem to have healed better; DeMarcus Cousins has the best post-injury PER of the bunch.
Achilles injuries can be subtle. (One question I heard asked: Was the MRI they used to examine Durant’s earlier calf injury high enough quality?) Another problem is that in many ways the Achilles is not subtle at all. It is nearly an inch thick, just beneath the skin, and defines the shape of the human heel. One of the ways it ruptures is by disappearing—it rolls right up into your calf.
Watch Durant’s hands in the seconds he sat on the court in Canada during Monday’s Game 5. He’s doing sports’ hardest calculus. He’s using his hand to assess whether or not he still has the same heel he had for the first 30 years of his life. He isn’t screaming about it. He’s deadly calm. It blows my mind how pragmatic professional athletes must be about their bodies. A minute later, the cameras catch Myers and Steph Curry stealing glances too. Is Durant’s Achilles still there?
They all know how serious it is. Elliott spells it out: “He may never be the same finisher at the rim again. He may never again be the kind of player who can get wherever he wants on the court. It’s a little bit of a tragedy. And it’s a cultural loss.”
I could barely watch
The recurring nightmare of my childhood was this: I’m asleep in my bed, face down, and somebody comes in the room with a chainsaw and just tidily—one little dip—slices right through both of my Achilles heels. (Gory, I apologize.)
The reason I had that nightmare is because my Achilles were usually searing with pain, starting around age 13, when I started running cross country. No matter where I was—math class, lunch—I was actively preoccupied by hopes that nobody would accidentally kick one, or touch it at all. Those years are thankfully behind me. The fix was recent, fascinating, unexpected, and surprisingly like stories from Curry’s past and—I’ll bet—Durant’s future.
‘Load his hips to unload his ankles.’
Do you remember when the story of Curry’s career was that he couldn’t stop hurting his ankles? (Fun fact, he also suffered, amid all those ankle sprains, a calf strain just like Durant.) Pablo Torre wrote an incredible story for ESPN about how that all ended, with the help of surgery and the Warriors’ trainer at the time—Keke Lyles.
Curry, Lyles believed, was already among the best in the world at changing direction. But the guard overwhelmingly relied on his ankles for speed and quickness. Those body parts appeared to be basketball's take on the mythical wings of Icarus: melting, as if made of wax, from overuse and ambition. But what if Curry could add another way to fly? "Shiftiness is an ankle strategy," Lyles explains, "but power comes from the hips. We wanted to teach Steph how to load his hips to help unload his ankles." … Curry swiftly perfected a yoga pose called the single-leg hip airplane, designed to build balance and core strength. He conquered the hip hinge, the fundamental movement of explosive lower-body exercises, in 10 minutes. He even mastered textbook trap-bar dead lifts, which amplify glutes and hamstrings, during his introductory session with Lyles. Other players typically need a week.
At first, a willowy Curry could deadlift a pitiable 200 to 225 pounds. But then the labor began: less a Rocky training montage, heaving with theatrical workouts, than a time-lapse video, comically dense with, well, time. "The man was always in the gym," teammate Klay Thompson says. "Steph just stuck with the routine. He works on his body just as much as he works on his jump shot." By Curry's second year in the program, his dead lifts could touch 400 pounds—more than twice his bodyweight and second most on the Warriors behind 6-foot-11, 265-pound center Festus Ezeli.
The fix for Curry’s ankle trouble turned out not to be in his ankles. People talk about kinetic chains, how this part of the body over here affects that part over there. Was that kind of insight available to protect Durant and Thompson?
“We are so bad at understanding the entire system,” Elliott says.
My Achilles heels are my Achilles heel
Foam roller, ice, heat, ibuprofen, analgesic rubs purchased at a British chemist’s, physical therapy, e-centric heel lowering, something called a “calf smash,” minimalist shoes, maximalist shoes, five-fingered shoes, landing mid-foot with a relaxed calf—I tried a lot of things to alleviate Achilles pain, which was variably diagnosed as tendinitis, tendinosis, or “bad Achilles.” I sought expertise in New York, Miami, Austin, Portland, and never found anything other than short-term relief. If I was running, and I love to run, those babies were going to be sore. By the time I was 35, I had just grown used to it.
On a steamy day in July 2012, my dad and I were lucky enough to spend a few hours in one of the country’s then-most advanced movement labs run by Jay Dicharry, at the University of Virginia. We ran on pressure-sensitive treadmills, sensors all over us, as cameras around the room picked up our movements from all angles and fed into live computer models.
By the time I walked into that lab, I knew that the best runners generated most of their power from the good ol’ gluteus maximus. After I got off the treadmill, I was excited to learn my score. Imagine my surprise when Dicharry told me I actually generated NEGATIVE power with my hips. That I moved forward at all was entirely the work of the other, smaller, less efficient muscles. Looking back, I now think my Achilles were objecting to that.
Dicharry prescribed a lot of exercises and drills, similar to what Lyles had Curry do. I did them alone, often while on the phone, but not religiously. Meanwhile, I got more serious about running generally, most of the year I was following a 12- or 16-week program to prepare for the next event. 20-mile training runs were not uncommon. Half marathons, marathons. I let Paul Flannery talk me into a relay team of older runners who crossed the 92 miles of New Jersey in 6-something minute miles.
Over time pain developed. At times shocking. It hurt when I sprinted, sneezed, kicked a ball, missed a step, slipped on ice, tried to sleep, ran on sand, sat on a plane, or a million other things. My Achilles became a total afterthought in light of this new pain that traveled through all of the muscles, front and back, that touched my hips.
I spent some time driving to see sports medicine experts, at physical therapy, googling this and that, and emailing experts like Dicharry. By the 2014 NBA Finals in Miami, the pain had grown so unbearable I stopped running. I talked about it at dinner. One of the guests—David Thorpe’s brother Mike—runs MRI clinics and told me to just come in. A few days later he called me with the news. I had four clear injuries: a back problem for which I should see a surgeon, a torn muscle in my pelvic floor for which I should see a different surgeon, a thing called osteitis pubis where your pelvic bones rub together in a way that often ends athletic careers, and a torn labrum. He guessed I had been in a major car accident.
Less than a year later, having struck out finding better care options I liked, I found myself in the hands of soft-tissue expert Eileen Cafferty Vazquez, who runs what might appear to be a regular high-intensity interval training class. But Cafferty Vazquez has a masters in Kinesiology, certifications in active release and functional movement, and has been addressing tough-to-solve sports injuries with very careful strength training for the better part of a decade.
As I lay on the turf to stretch during my first group class, Cafferty Vazquez noted the way my feet rested. My left foot aimed a lot more to the ceiling than my right one. She pointed at it, and said, “niiiiiiice.”
This all seemed just impossibly personal. I wanted to say that how my feet rested was kind of my business. But I’ve since learned, it’s totally her business.
Think about how a leg connects to a body. My foot resting at that “externally rotated” angle says to Cafferty Vazquez that something is happening up higher. The foot is attached to the leg, the leg is attached to the body. That angle is being determined in the hip. Thus began years of Cafferty Vazquez’s teaching a group of us the most persnickety things. Put your feet like this, no, not like that. Butt back to squat. Chest up. Feet weighted one way for this movement, that way for that. Push evenly on both sides of your body. Her mantra: each part of your body is connected to something else. Pain in one place is usually caused by an imbalance or weakness someplace else.
‘I built that ass.’
I also got special homework: “the hip workout.” It features all kinds of lunges and tapping the floor with a 20-pound dumbbell in each hand. For a while I did it in the basement, then we started doing it as a family in the kitchen and living room, usually to The Fugees. Much to my children’s horror, I’ve trotted it out in the driveway, on the beach, in friends’ driveways, and even in the snow.
Over time I came to understand and feel how a foot, thrown way out away from my body, is controlled by the mothership back at the hip. It makes perfect sense to me that Steph could use core strength to protect his ankles. The hip has to be strong if you want that foot, ankle, and lower leg to be protected. Six weeks after I started working out with Cafferty Vazquez, I had a moment, standing at the sink washing dishes. “Oh my God,” I remember thinking, “I’m not in pain!” We throw parties when good things start. We should throw bigger parties when bad things end.
By the time I got to Cafferty Vazquez, I had a scan showing four major injuries that threatened all kinds of trouble. I’m not sure I ever bothered to bring up the Achilles pain. But a funny thing happened: As soon as I got my hips strong, the Achilles pain went away. (I also haven’t sprained an ankle over that time.) I never even think about it anymore. And I never had any kind of surgery.
Just a scan
After Durant was hurt, I asked Cafferty Vazquez to watch the video with me. What did she see in how he moved? She thought he looked flat-footed, and knowing he had calf issues, was surprised he didn’t hurt himself on some earlier moves. But before we could get into all that she said, “I just … I am sure they looked at a scan.” Of course they did! They bragged about how many scans they took. Cafferty Vazquez understands what, in my experience even many doctors do not: that a lower leg beset by not one, but two injuries, was probably victimized by forces coming from elsewhere in the body.
She also noted that an externally rotated toe (the thing she called “niiiiiiiice,” facetiously, in our first class), can really load the Achilles. She pointed that out before we got to the part of the game where Durant got hurt, and he does appear to have his toe pointed out some.
Steph, we’re told, “loads his hips to unload his ankles.” The “hip workout” fixed a lot of issues for me including my Achilles issue. A prediction: Durant will find some elite trainer to whip him back into NBA shape. Some reporter will visit those workouts in the months to come, and get an earful about the importance of hips and glutes.
Looking at a scan of a calf muscle would never capture all that, how loads are shifting around a player’s body, causing problems.
It could be different
“I agree with Eileen!” said Elliott, later. “The scans don’t show you shit.” Right after an injury, he says, it can often tell you what is hurt. But as it heals, further scans, he says, are of little use. “Mostly they all look the same.”
Watching Durant, Elliott sees someone whose knees bend way far forward, “putting a lot of load on his ankles and calves.” And a sore calf might make anyone move strangely. “That injury,” meaning the Achilles tear, “is plausibly just because he’s loading differently” in the wake of the calf strain, says Elliott.
Elliott has first-hand contact with many NBA players and doctors, and believes there’s room for improvement. His prescription: Every NBA player could have a baseline assessment of their functional movement assiduously tracked, like my dad and I did on the treadmill, but more involved: Jumping off a box, shuttling across the floor. P3 has a standard set of drills they have done thousands of times by now, and it doesn’t have to take long. And then—here’s the genius part—when they’re banged up in a game, or on an off-day in the Finals, they could head to the locker room to do a carefully selected set of follow-ups to see, for instance, the degree to which Durant’s calf injury might be adding stress to his Achilles.
Are the Warriors doing all that? It’s hard to say. When Lyles ran the show there was talk of building a very sophisticated set of tools to assess fatigue and injury risk, collect data on each player, and compare it over time. It was in its early phases when he was lured away to the Hawks (the Warriors didn’t want to match the Hawks’ offer). Then Lachlan Penfold arrived with heavy scientific credentials, but reportedly wasn’t a hit with the players and didn’t last long. Next up was the revered Chelsea Lane, who, amazingly, also left for a sweetheart deal with the Hawks (who built their practice facility with insight from P3). Now the Warriors have Rick Celebrini, about whom Kerr has said the nicest things, but who is unlikely to be benefitting from whatever Lyles was starting to build all those years ago.
If I were a player, I could see seeking a team with better-than-average injury prevention.
Neither Cafferty Vazquez nor Elliott blames the Warriors’ doctors. “Nobody’s really at fault,” says Elliott, “and it’s mostly KD’s decision anyway.” But they both look forward to a time when the decisions take the whole body’s movement pattern into account.
“We could introduce some objective data,” Elliott says. “We could know if the force on his ankle is 30 percent bigger than when we last tested.” That kind of study would never replace human decisions, but he says “at least there is some objective data. It moves us close to some rational decision-making in times of stress.”
It keeps us, in other words, from shooting from the hip.
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