Trying to Make Sense of Jimmy Butler’s Knee Injury

The Chicago Bulls entered the season with hopes of threatening the Cleveland Cavaliers for Eastern Conference dominance. Unfortunately things haven’t gone has planned as the team has struggled to find an identity under first year coach Fred Hoiberg and injuries have prevented the team from establishing any continuity. The problems began just days before camp opened when veteran forward Mike Dunleavy Jr. underwent surgery to address a herniated disc in his lower back. Former MVP Derrick Rose was unable to participate in training camp after breaking the orbital bone in his face in the team’s first practice. Center Joakim Noah managed lingering soreness in his surgically addressed knee and missed nine games after spraining his left shoulder. His return to the lineup was brief after Noah re-injured the shoulder, this time dislocating the joint so severely that season-ending surgery was ultimately needed.

Now as the season moves past the All-Star Break, the Bulls will be forced to play without All-Star guard Jimmy Butler after he suffered a knee injury in a loss to the Nuggets. The team remained tight-lipped on the specifics of the injury, initially calling the injury a hyperextended knee. Additional testing revealed all ligaments intact and the Bulls changed their diagnosis to a non-descriptive strain.

These details explain how the injury occurred and suggest the injury is muscular in nature but remain vague. Unfortunately the tendon or muscle involved remains unreported, with the hamstring, quadriceps, and several other small muscle all possibilities. However in a recent interview at this weekend’s All-Star media session in Toronto, Butler provided a bit more insight to his injury revealing he injured the joint capsule in his knee.

“I was scared, ‘Please don’t let anything be wrong.’ I was asking, ‘Do I have to have surgery? How long do I have to be out? ‘Can I play in the All-Star game? Things like that because I didn’t want it to be over with,” Butler recalled. “I was scared. Obviously knowing the history with the knees, please don’t let it be something too serious.

“Yeah (I heard a pop),” he said. “Something did, but luckily, they said it was the capsule around my knee. I don’t know (what that means). I’m not the doctor.”

To clear things up for Butler, the articular capsule of the knee is a double-layered envelope that surrounds the knee joint and provides stabilization while aiding in movement. The capsule engulfs multiple structures of the knee joint including the menisci, kneecap, bursa, and the stabilizing ligaments of the area.

The capsule is strongest in the posterior aspect of the knee and is vulnerable to injury in the areas where a tendon enters the capsule. A forced hyperextension is a common mechanism of injury and would be in line with previous information used to describe Butler’s injury.

ess_knee1340490219761

Capsule injuries often occur in conjunction with a more significant injury, like in the case of Shaquille O’Neal. During the 1996-97 season Shaq hyperextended his left knee and suffered a capsule tear, as well as a partially torn lateral collateral ligament (LCL) and fracture. Isolated capsule injuries are fairly uncommon though Kings forward Rudy Gay did miss a lone game last season with a lateral capsule injury.

With this new information, the three-to-four week recovery timeline provided by the Bulls makes much more sense. Insuring the capsule is fully healed is crucial in insuring the long-term stability of Butler’s knee and will help reduce the odds of him suffering a more severe injury upon his return. After what transpired with Noah, it wouldn’t be surprising to see the Bulls handle Butler extremely conservatively. In the meantime, the team will look to stay relevant in the playoff picture without their leading scorer and the Hornets and Pistons breathing down their neck.

Trying to Make Sense of Manu Ginobili’s Testicular Injury

Manu Ginobili has endured plenty of injuries throughout his professional career including broken bones, sprained ankles, and countless muscle strains. Ginobili haphazardly throws his body around so often that former teammate Brent Barry dubbed him “El Contusione.” However the injury he sustained Wednesday against the Pelicans is easily the most cringe worthy on his laundry list of ailments.

Ginobili suffered a significant testicular injury following an apparent knee to the groin from Pelicans forward Ryan Anderson. Ginobili was escorted to the locker room and his teammates’ somber mood in postgame interviews hinted the injury was severe. Late Thursday afternoon their fears were confirmed when it was revealed Ginobili would need surgery to repair the testicular damage he sustained.

Given the sensitive nature of the injury, it’s not surprising to see the Spurs limit the particular information surrounding Ginobili’s injury. However following this type of incident several possibilities exist. In most cases a simple scrotal contusion occurs that includes pain in the area and occasionally nausea, though this appears more serious. In more severe cases, a traumatic hydrocele can develop if excessive fluid builds up in the scrotum. If the swelling is caused by damage to the main veins in the testicles it is known as a varicocele. Even worse, a hematocele can occur if the bundle of veins ruptures and blood quickly accumulates in the area.

Another common testicular injury is possible if the impact affected the spermatic cord. Testicular torsion can occur if the testicle rotates, twisting the spermatic cord. As the cord twists, the blood supply to the area becomes restricted and the area swells. If the ischemia is prolonged the affected individual runs the risk of losing the testicle.

Finally testicular rupture is also a possibility. Like the other aforementioned injuries, a rupture presents with scrotal swelling but also includes the contents of the testicles protruding out due to breaks in the surrounding connective tissue.

Surgery is a treatment option in most traumatic testicular injuries and recovery often takes multiple weeks.

Ginobili isn’t the first testicular injury in the NBA, though the number of reported cases is surprisingly low. Former Sonics forward Detlef Schrempf missed three games during the 1996-97 season following “testicular trauma.” Mavericks’ big man Shawn Bradley also missed three games with testicular trauma during the 1997-98 season but his injury accompanied a groin strain. John Stark missed two playoffs games during the 2001 postseason following an episode of testicular torsion though its development wasn’t basketball-related. Unfortunately none of these injuries seem to be on the same level as Ginobili’s.

Regardless of specifics, it is clear the Spurs will proceed without Ginobili for the immediate future. The team expects him to miss four weeks recovering though it would be understandable if he needed longer to completely heal. The All-Star break will help minimize the games he misses but the injury is a painful setback for a team who only lost 11 games to injury through the first half of the season.

NBA Injury Report at the Midway Point of the 2015-16 Season

After a promising first quarter that saw NBA games missed due to injury drop by 12% when compared to the previous season, the 2015-16 season continues to be marked by an overall drop in injuries. After 41 games played the 30 NBA teams have combined to lose 1,968 games as the result of injury, 282 games less than last season’s midseason total and 351 less than the 2013-14 season.

Significant turnarounds for two of the league’s most storied franchises has helped as the Los Angeles Lakers and New York Knicks find themselves in a much healthier position this season. Last year the Lakers endured injury after injury including the career-ending nerve issues for veteran point guard Steve Nash and season-ending injuries to Kobe Bryant and Xavier Henry. Now with a younger roster and a renewed commitment to health, the Lakers sit third in the league with just 19 games missed.

In New York, the improved health of Carmelo Anthony has been a major factor for the Knicks’ turnaround. After limping through the early months of the 2014-15 season, Anthony underwent a patellar tendon debridement procedure that appears to have gotten him back on track. The offseason pieces brought in by the organization, including Robin Lopez, Kevin Seraphin, and Arron Afflalo, have been reliable additions that have done an admirable job of staying out of the training room. This is dramatic departure from New York’s previous track record of overspending on medically risky players including Amar’e Stoudemire, Eddy Curry, and others. In fact, the Knicks’ overall numbers would be even better if not for the gunshot wound sustained by Cleanthony Early in his unfortunate late night robbery.

The Thunder medical team, led by head athletic trainer Joe Sharpe, is also in the middle of a bounce back season and leads the league in fewest games missed to injury. Just two years after missing 26 total games to injury, Oklahoma City endured an injury-riddled 2014-15 season that ended with 224 total games lost. Kevin Durant and his Jones fracture was the primary culprit behind the elevated total but Russell Westbrook and Serge Ibaka also contributed to the problem missing a combined 33 games. However the Thunder lost just one game to injury during the second quarter of this season. It will be difficult to match their 2014-15 pace given the recent injuries to Steven Adams and Andre Roberson, but it’s nice to Oklahoma City put together an extended run of good health after last season.

Games

Not every team has avoided the injury bug as the Washington Wizards have been hit hard by injuries over the past 20 games. Prolonged absences from veterans Drew Gooden, Kris Humphries, and Nene decimated the frontcourt while starting shooting guard Bradley Beal missed 16 games with the fourth reoccurrence of his stress-related fibula injury. While team leader John Wall has yet to miss a game this season, he too is ailing and playing through an assortment of injuries including a knee sprain and painful quadriceps contusion.

Joel Embiid’s foot injury has kept the Sixers’ injury total high and the Pelicans and Nuggets are both feeling the impact of players already lost for the season. In New Orleans, forward Quincy Pondexter is expected to miss the remainder of the year after undergoing a second surgery to address a cartilage injury in his left knee while Nuggets forward Wilson Chandler saw his season prematurely end in the preseason after a hip labrum tear.

A surprise team in the bottom 10 for games lost to injury is the reigning champion Golden State Warriors. Despite winning at a record pace, the team has lost 87 games to injury so far, 16 more than they missed all last season. Rookie Kevon Looney made up a substantial portion of the total as he recovered from offseason hip surgery but Harrison Barnes also sat for 16 games with an ankle sprain and both Steph Curry and Klay Thompson missed a pair of games with injuries of their own. In fact, All-Star snub Draymond Green is the only Golden State starter to not miss at least two games due to injury.

$$

League wide a major reason for the drop in injury totals appears to be the decline in bone-related injuries. 272 games of this year’s midseason total can be attributed to fractures or bone contusions. While that total may seem high, it’s a stark contrast from the previous two seasons when the league lost 589 (2013-14) and 489 (2014-15) games to bone issues. Notable players to miss time over the past two seasons with bone-related problems include the aforementioned Durant, Embiid, and Beal as well as Paul George, Julius Randle, and Kobe Bryant. Nutrition is a widely speculated contributor to the problem and perhaps a renewed commitment to addressing players’ diets is making an impact on the reduction in bone injuries.

As mentioned in the first quarter report, it is too early to tell if league-wide schedule changes and other extrinsic factors are a reason for the decline in games lost to injury. However with the drop in games lost carrying over into the second half of the season, there is at last some reason for optimism.

Making Sense of Joakim Noah’s Shoulder Injury

Bulls center Joakim Noah sprinted off the court Friday in clear agony after suffering his second shoulder injury of the season. As the game progressed confusion about the specifics of the injury had many people scratching their heads as they attempted to determine what it could mean for the Bulls and their energetic center’s future with the franchise. Shortly after leaving the court it was reported that Noah has separated his left shoulder and would not be available for return.

However just minutes later the injury classification was amended and a dislocated shoulder was reported.

The confusion would continue, as the classification of the injury would vacillate between a dislocation and a separation until a dislocation would be the agreed upon final diagnosis.

While this wording may seem inconsequential, the difference between a separated shoulder and dislocated shoulder is significant. The shoulder is comprised of multiple joints and articulations. It starts where the clavicle (collarbone) connects to the sternum at the sternoclavicular (SC) joint. The collarbone than extends away from the midline of the body and attaches to the scapula (shoulder blade) to form the acromioclavicular (AC) joint. The AC joint acts like a strut, allowing the arm to be raised overhead. When the ligaments that stabilize this area are injured, it is referred to as a shoulder separation. AC sprains have a very specific grading scale that depends on the severity of the damage to the ligaments and surrounding structures. In recent seasons, NBA players including Kyrie Irving, Chris Paul, and Anthony Davis have missed time with AC joint sprains.

The joint most people associate with the shoulder is the ball-and-socket joint of the shoulder, medically referred to as the glenohumeral joint. The glenohumeral joint is formed from the proximal end of the humerus and the glenoid of the shoulder blade.

Anterior shoulder final

Together these structures loosely resemble a golf ball sitting on a tee. The head of the humerus acts as the golf ball while the glenoid serves as the tee. The ball (head of the humerus) can freely pivot on the tee (glenoid) allowing for a large degree of motion. To reinforce the area and insure the ball remains on the tee, a cartilage ring known as the labrum stabilizes the glenohumeral joint. Additional musculature, connective tissue, and soft tissue also provide additional stability to the area.

Unfortunately this alignment can be disrupted in varying degrees following repetitive force or more commonly direct trauma. If the displacement is minor and the shoulder joint slips out but naturally returns to its normal position, the injury is considered a subluxation or partial dislocation. A total dislocation occurs when the displacement of the joint is complete. Following an injury of this severity, the joint must often be realigned by medical personnel and is considered a much more serious injury.

Noah’s previous injury may have played in a role in his latest ailment. Noah suffered what was described as left shoulder sprain earlier this season and would miss nine games recovering. However Noah admitted he felt the shoulder come out of place and, in an interview following a MRI, the injury was described as a “slight tear.” Though the location of the tear was never revealed, damage to either a ligament or the labrum would result in an instability and make it easier for a true dislocation to occur.

As previously detailed following Kevin Love’s shoulder injury, the return to play time following a shoulder dislocation is often dependent on the severity of damage accrued by the neighboring structures, particularly the labrum. A significant labrum tear, like the one suffered by Love, would be a devastating injury for Noah as surgery could be a necessary option. Love spent months recovering from his surgery though the timing of the injury makes it a difficult comparison. The InStreetClothes.com injury database previously uncovered 18 in-season injuries classified as complete dislocations with varying recovery times.

Screen Shot 2015-04-26 at 5.49.27 PM

Given Noah’s previous injury and the state of the locker room following the team’s loss to Dallas, it appears the Bulls are preparing to be without their “emotional leader” for a prolonged period of time. The impending MRI will provide a final diagnosis and help shape the course of treatment and Noah’s future with the Bulls.

UPDATE: The Bulls have announced Noah will undergo surgery and be out four-to-six months.

Understanding Blake Griffin’s Partial Quad Tear

Clippers forward Blake Griffin will miss an extended period of time after suffering a left knee injury in the first quarter of the team’s win over the Lakers on Christmas day. Late Saturday, the team announced a MRI taken on the area revealed a partial quadriceps tendon tear and Griffin would be unavailable for the next two weeks.

Griffin’s injury is a significant setback for the All-Star forward who is currently averaging a team-best 23.2 points per game. To start the quadriceps is a dynamic muscle group that plays a role in multiple joint motions. The four quadriceps muscles, the rectus femoris, the vastus lateralis, vastus medialis, and vastus intermedius, work in unison to carry out knee extension (straightening of the leg). The rectus femoris also attaches at the hip and aids in hip flexion (bending the hip). As a result extra care must be given during the rehab process to prevent a troublesome muscle imbalance from developing.

Knee

Furthermore, Griffin’s past injuries will play a role in his recovery and could delay his return to the court. The patella (kneecap) is a sesamoid bone embedded within the quadriceps tendon. The portion of the tendon above the kneecap is referred to as the quadriceps tendon. The inferior portion that connects the muscle to the tibia is known as the patellar tendon. As the knee is bent or straightened, the patella moves to modify the mechanics of the quadriceps muscle. Correspondingly, the vastus medialis of the quad stabilizes the kneecap throughout this process.

A partially torn quad tendon could easily disrupt the biomechanics of the area and put undue stress on the kneecap, a major issue for a player that missed the first season of his career with a patella stress fracture. Griffin also tore the lateral meniscus in his left knee during the summer of 2012, another injury that will have to be considered during his recovery.

Finding a recent NBA comparison of Griffin’s specific injury is difficult. A majority of the quadriceps injuries in the league occur in the muscle belly and not the tendon, though Carlos Boozer missed 44 games of the 2008-09 season with a quad tendon strain that ultimately needed surgery. Several players, including Randy Foye and Luke Ridnour, have missed substantial amounts of time with Grade 2 quadriceps strains though their injuries were to the muscle belly and not the tendon itself.

Partial quadriceps tendon tears may be relatively uncommon but multiple players have endured comparable patellar tendon injuries in recent seasons. Last year New York Knicks forward Carmelo Anthony limped through a majority of the season with a partially torn patellar tendon before ultimately opting for surgery. Miami Heat guard Dwyane Wade has also previously undergone surgery to address an incomplete patellar tendon issue. Even if surgery isn’t needed to repair the tendon itself, a debridement is often necessary to clean out scar tissue and other resulting debris.

The Clippers will reevaluate Griffin’s injury after two weeks of treatment but that doesn’t guarantee he will be back in action at that time. While every injury responds differently, the recoveries of players with similar injuries do not establish an encouraging precedent for Griffin. Los Angeles responded well last season collecting nine wins when Griffin was sidelined 15 games with a staph infection. However this year’s squad isn’t performing at the same level and will miss Griffin’s scoring and rebounding ability. Josh Smith started in Griffin’s place on Saturday but played just under five minutes as Doc Rivers turned to Paul Pierce in a win over the Jazz.