Contact Tracing: The Curious Case Of Soft Tissue Injuries In The NBA

Contact Tracing is a three-part series examining the decisions the NBA has made in a year since the 2019-20 season was suspended due to COVID-19.

Part 1: What We Can Learn From The Challenges And Pitfalls Of Remote Sports Media
Part 3: The NBA Has Spent This Season Caught Between Its Moral And Business Compass

It was barely a week into the season when Spencer Dinwiddie went down. Ten minutes into the third quarter against the Hornets, Dinwiddie drove into the paint and crumpled, his hands jerking to his right knee as he rolled protectively onto his back. At first it looked like a contusion for how he’d knocked knees with Bismack Biyombo, but as Dinwiddie’s right leg continued to reach out and down toward hardwood in his lengthened stride, there’s an almost imperceptible bulge and wobble at his knee when his foot plants and his weight shifts over entirely from left leg to right.

It went almost identically for Markelle Fultz a week after that. Fultz, going full-tilt, cut to center court. As his left leg planted on his first stride into the paint, the knee contorts, shifting in, and Fultz instantly dropped. There was no contact, the Cavs’ Isaac Okoro had already lifted into the air for an anticipated block as Fultz fell and rolled into a fetal position, hands cupping his knee. Four days later and Thomas Bryant, tangled up for a rebound, landed on his left leg with no more force than usual, only the leg bowed out, his knee popping like a hip would. As Bryant’s right leg kicked out at the shock, he fell to the floor, one arm wrapped around his injured knee while the other reaches out, pleading for help.

All three suffered season-ending ACL tears on what were practiced plays in routine, early-season games typically meant to gradually ramp players back up to a consistent level of performance. They wouldn’t be the only ones. It was during practice in Chicago that Marquese Chriss broke his leg, and in a preseason game where Chris Clemons tore his right Achilles tendon, putting him out of his second season in the league before it officially started. Chriss, in a late-January scrum a month after his injury, recalled that it had been a “lighter” practice meant to help players with their conditioning, something that might have traditionally been achieved throughout a regular preseason.

Within the NBA’s first month of the 2020-21 season, four injuries had players officially out for the season and seven were serious enough that players were forecast to return sometime in mid-March, if they weren’t then reevaluated and declared out for longer. It’s a noticeable shift not only in the number of season-ending injuries compared to the same window of the 2019-2020 season — Gerald Green broke his foot in an October 2019 preseason game and Al-Farouq Aminu tore his meniscus in November — but in the nature of the injuries.

Unlike other pro leagues, where injuries spike in training camp and within the first month of a season, the NBA tends to see injury events trending upwards as the season progresses, peaking in March. Factor in fatigue and players pushing themselves to secure playoff contention and the spike makes sense, as players return from the offseason and months away from high-impact and high-load levels of performance there is a greater risk of soft tissue injury — things like sprains, muscle pulls, and bruises. Because of this, one thing is top of mind all season long among those whose jobs are helping athletes navigate a grueling regular season.

“It’s the soft tissue mobility,” explains Dr. Michael Gordon, orthopedic physician for the Milwaukee Bucks from 2005-2015. “It’s working on flexibility, it’s trying to minimize risk for a lot of soft tissue injuries, being muscle strains, muscle pulls. Things that are traumatic stuff. The contact injuries, you get knocked over and you break something, those are hard to prevent. But the non-contact, you plant your leg and you cut hard and your knee shifts, that’s a non-contact ACL injury. Those things we can’t prevent, but we try to mitigate those risks by focusing on muscle balance, landing mechanics, strength balance, things like that.”

But if mitigating risk can be challenging enough for professionals in a typical season, how hard would it be in a season that saw its start date bumped forward by a month, its 71-day offseason the shortest of any pro league in history? Where players fresh from deep playoff runs, for whom the downtime would feel more like a flash of respite, and those who hadn’t had access to training facilities since before the Orlando Bubble, would meet again as perceived equals on a steeply lopsided floor?

“In this situation, it’s unprecedented,” Dr. Martino Franchi, an assistant professor in skeletal muscle physiology at Padova University, says. “It’s not a bed rest, it’s not a unilateral limb suspension, it’s not something called tapering — which is basically the willingness to reduce the amount of load during a season, but it’s controlled, but it’s not that. It’s not detraining, purely, because we are not studying, ‘I’m training, and now I stop,’ and that’s it. So it’s a mixture of all these things. And what we wanted to say was: be careful.”

Franchi, who previously worked as head of sport science and an athletic trainer with the Nottingham Wildcats Basketball Club, and is a faculty member at the Football Science Institute, contributed to a study last April concerned with the sudden physiological changes athletes faced due to the home confinement and training restrictions of coronavirus.

“We are based in Italy, so we are probably one of the first who experienced the lockdown situation,” Franchi recalls. “Also we are big soccer fans, so we asked ourselves, all these athletes that are used to high-impact and high-load, and used to receive load stimulation during every training session. If you train on the court, or the pitch or field, you get some sort of stimuli on soft tissue. So tendons, muscles.”

None of the examples that existed to researchers like Franchi prior to COVID-19 fit with the circumstances athletes were facing. There are studies that focus on prolonged bedrest campaigns of athletes in recovery, periods of up to 60 or even 90 days in bed, or unilateral lower limb suspension, where focus is directed on the muscular and tendon stiffness decline when a limb is suspended for days or weeks at a time.

Getty Image

But they were good starting points. As Franchi points out, “What we know from these studies, they shock the system pretty badly. There’s reduction in muscle mass, reduction in force that is produced by the muscle, a reduction of the stiffness of tendon.”

Tendons are crucial for athletes exerting high amounts of pressure and strain on their muscles because, Franchi explains, “the tendon is what transduces the force from a muscle to the tendon the bone.” In early lockdown, NBA trainers made sure players stuck at home had access to portable equipment as possible. But when the pandemic and its lockdown measures continued and players, scattered across states with varying restrictions that continued into the offseason, were unable to recoup meaningful full-court training time, there was a pronounced lack of stimuli on these crucial muscles and tendons.

“[The] Achilles tendon, or patella tendon, are so important because they pick up the stress. And if they are a little bit slacker, that might lead to risks but also to different adaptations, or maladaptations,” Franchi says.

It’s these kinds of soft tissue and tendon-based injuries that are currently proliferating in the league.

“We don’t have a model of adaptation for lockdown. There was no model in science, at least not a perfect model of this. And I’m not sure that, it’s too little time right now, to make a conclusion,” Franchi stresses. Like any researcher mired in the science, he can’t speak in absolutes, there just isn’t enough hard data yet for a season still underway. But as someone with a concentrated background in studying the impacts sports like basketball and soccer have on the body, and who witnessed the effects of lockdown on athletes in Italy months before players in the NBA would experience the same, it’s caution he circles back to throughout our conversation.All we can say is that yes, probably the preseason was short.”

While Franchi is adamant that NBA team trainers and doctors are aware of the dangers a season like this one presents, he stresses the need to proceed with caution, “The risk is out there because the science tells us that if you practice unloading, there is a risk.”

There was one example that continued to come up in conversations with experts as being the closest possible comparative study for the current rapid deconditioning concerns the pandemic has produced, for two reasons. During the NFL’s 2011 lockout, players were barred from training facilities for three months. It wasn’t as lengthy as the prolonged conditions COVID-19 has forced, but it was just as sudden. The first similarity is upon return to play: There was a substantial increase in Achilles ruptures, with 12 Achilles tendon ruptures occurring in the first 29 days post-lockout when compared to the total amount in the two seasons prior of six and ten Achilles ruptures, respectively.

The second is rhythm. Whether referred to as routine, a grind, or putting in work, athletes have a rhythm. Everything from training to diet to travel and sleep schedule supports it, and even during the offseason, it exists as an underlying metronome. In the NFL lockout study, there was no noticeable uptick in hard injuries, only injuries traditionally related to conditioning that came via a player’s rhythm being thrown out of whack.

“Everyone’s routines are different right now, from the athletes just to our daily routines. I think that that definitely needs to be considered,” Dr. Gordon says. “But I would certainly be concerned that the change in the offseason regimen and routine, that most players have pretty consistent plans, has been thrown off. They have to adjust to the new normal and I would be concerned that could lead to more injuries, particularly the soft tissue injuries.”

Routine exists on court, too, and it’s possible that the injuries that have resulted so far this season are beginning to have a much more permeating effect.

When Chriss was injured, Warriors rookie James Wiseman and Kevon Looney split his minutes in the starting rotation. On Jan. 30, in a game against the Pistons, Wiseman sprained his left wrist catching a lob from Draymond Green. Three days later, Looney sprained his left ankle sliding into the key to catch a baseline pass from Steph Curry. This season, without Summer League, regular training camp, and the standard docket of preseason games, NBA rookies had just 34 days between Draft day and season start to get themselves up to competitive speed when compared to the class a year ahead of them who had 123 days.

But Wiseman didn’t even have that. He’d tested positive for COVID-19 in the days leading up to Warriors training camp and missed it completely due to his resulting quarantine.

It would be impossible to examine the potential increase in injuries this season without factoring in the effects of the pandemic. Fatigue, which has run ravenously parallel to the relentless drive of the product the NBA pushes, has found a deeper notch this year. The anxious fatigue of COVID-19, along with the additional time testing, distanced practices and pre and post-game treatments, media, and travel takes, whittle down what little rest players might have been able to squeeze in previously during game and off days. Joining J.J. Redick on his podcast, The Old Man & the 3, Steven Adams outlined how this season “screws up your sleep cycle,” especially after games when Adams said players, too wide awake to sleep sometimes until 4 a.m., are up again at 7 a.m. for testing.

Even in a shortened season of 72 games, there are a slew of back-to-backs, with teams averaging seven in the first half of the schedule and some playing as many as 11 in the second half. Moreover, postponed games stacking up due to health and safety protocols will need to be made up, crammed somewhere on the other side of what’s already a compact season. And while resting procedures for players have relaxed slightly, the rules are still dictated by the broadcast schedule, with teams potentially incurring $100,000 fines for resting star players during high-profile, nationally televised games. In recent weeks, Anthony Davis, Kevin Durant, LeBron James, Kyrie Irving, and Kawhi Leonard have all sat due to injury.

Getty Image

Exhaustion has not been limited to players, with the league’s new COVID-19 protocols the start of the season saw a request to teams that one staff member be designated a protocol compliance officer. This person would be responsible for fielding and implementing the daily memos and oft-changing procedures in the NBA’s response to the virus. It’s also been a job that’s fallen largely to team trainers.

In an ESPN story on the NBA’s health protocols, a league “health source” shared the following quote: “What scares me — and I know it’s happening — is that their normal job of doing health care on players [is impaired]. I’ve had some trainers tell me, ‘I haven’t touched a player in two weeks because I’ve been so busy doing all this logistics and testing and all that.’” A head trainer went on to admit that there would be “some decline in player health care” this season, as if the current precarious state of things without knowing the strain team trainers and doctors are under isn’t difficult enough.

While Dr. Gordon and Dr. Franchi both admit it is too early this season to make a definitive call on whether any increase in soft tissue injuries is firmly indicative of shortened camps, longer absences of conditioning and the strain of a rapid return to regular gameplay, both urged caution and close attention to the next portion of the season in order to frame a larger picture.

Within the NBA, there has been a gradual trend upward of player injuries season-over-season. Looking as far back as 1998 when the conclusion of a ten year study in the changing nature of the game and its impacts on player’s health determined a 12.4 percent increase in game-related injuries. In the modern era, some of the blame for the upward trend has been placed on the league’s scheduling of games, with calls for a shortened regular season coming from stars and the NBPA, while others look to factors inherent in the way the game is played. Pace, for example, has seen a steady increase for the last six seasons. When paired with the fatigue of travel catering to a packed game schedule influenced by broadcast opportunities, a shift in how the game is packaged, pushed and consumed could also lend to more injuries over time.

The reality is that as the game and its demands have changed, injuries have too. That there are increasingly more factors to consider when looking at the number of players getting hurt each season, including going from rapid deconditioning to the sudden high-impact, high-loading of muscles that experts are concerned about specific to this season, only underscores the rise overall, even if they can’t be explained by one, leading reason.

As far as solutions that address the same concern, Dr. Gordon pointed out the prevalence of load management now compared to even two seasons ago. It was a method he admitted to “never really liking” but has since “come to grips with more” as a tool.

“In watching,” Dr. Gordon says, “you can kind of see when things are starting to change, the moving patterns are different. I think that the really experienced trainers are great at picking up on that. The load management type stuff now gives you numerical justification for some of the decisions you’re making. You say hey, look, we’ve gotta pull this person back. We know when you hit this threshold that the risk of injury goes up X-fold. So I think that’s going to be a big part of it. I think a lot of it’s going to be the soft tissue work right now.”

That more games will be lost to illness this season than any other seems like the rock, the steady increase in injuries per season the hard place, and the league, stuck between the two with potentially more damaging data of injuries due to lockdown, with nowhere to responsibly go. The best hope is that the numbers this season prove an anomaly, that players did not succumb to more than average soft tissue injuries typically mitigated, or at least better prepared against, in the ramping up to a regular season. But that still squares the NBA to the sharp reality that more of its players are, by the existing data, getting hurt every season.

As we wait with our breath held and fingers crossed for a healthy second half of the season and a better overall picture of what happened within it, we can remind ourselves not to lose the gruesome shock of a muscle unraveling, or the agony in someone collapsing to the floor only weeks after they set a confident foot on it for the first time. To remember that the league is a structure only as strong as the bodies supporting it, like tendons fixed to bone until it breaks.