Understanding Marcus Smart’s Tibiofibular Subluxation

NBA injury reports can be maddening. Some teams elect to carefully guard their injury information and provide the public with vague descriptions that often involve non-specific regions of the body. Others are more transparent and provide details that accurately and vividly describe an injury. Fortunately the Celtics were the latter regarding Marcus Smart’s leg injury, revealing the second year guard recently suffered a subluxation of the proximal tibiofibular (tib-fib) joint.

The description of the injury provides details regarding the extent of the damage and precisely where it occurred. The term subluxation means the involved joint temporarily shifted from its normal alignment. A subluxation is often described as a partial dislocation. The dislocation is considered incomplete, meaning the neighboring ligaments and musculature often force the joint back into alignment and medical assistant to re-align the area is not usually warranted. However the shift can result in damage to the involved soft tissue structures like muscles of ligaments. It appears any associated damage in Smart’s case is minimal, as surgery will not be needed.

The specific joint Smart injured is the tibiofibular joint, an articulation formed by the two lower leg bones, the tibia and fibula. The inclusion of the word proximal indicates the injury occurred at the area closest to the knee where a bony rim of the tibia touches the round head of the fibula. The area is fortified with multiple ligaments to insure stability.


Fortunately for Smart the proximal tib-fib joint is not a major weight-bearing joint. Instead its primary responsibilities include the dispersion of forces applied to the ankle, particularly with a pulling or tensile load. It also helps absorb forces applied to the outside portion of the leg, which could explain how the injury occurred following Smart’s collision with Brooklyn’s Thomas Robinson.

Moving forward Ed Lacerte and the Celtics medical staff will first focus on controlling the associated symptoms like pain and swelling. They will then shift their attention to insuring any sprained ligaments appropriately heal. Doing so will prevent any chronic instability from developing and help prevent a shift in Smart’s overall biomechanics. This is particularly important given his history of lower leg injuries. Fortunately the blood supply to the area is strong, and barring a complication with the nearby peroneal nerve, a complete recovery is very possible.

However the necessary time needed to rest and rehab remains in flux. The initial timeline provided by Boston suggests Smart will miss at least two weeks, though that would easily be a best-case scenario. Unfortunately the rarity of the injury makes it hard to find a comparison and a four-to-six week recovery is a safer estimate.

The Celtics currently sit a half game out of the Eastern Conference playoff picture and play six of their next eight away from TD Garden, including a five game road trip. Their return to Boston will be anything but easy with home games against the Bulls and Warriors scheduled. In the meantime, Avery Bradley and Isaiah Thomas will be leaned on heavily with Evan Turner expected to see an increase in responsibilities. Still Smart’s absence will be felt on the defensive end and determining how to minimize that impact could go a long way to shaping Boston’s long-term success.

Understanding Jonas Valanciunas’ Broken Fourth Metacarpal

The Toronto Raptors have bounced back from last season’s postseason disappointment and once again find themselves in the early season playoff picture. Unfortunately maintaining their position in an improved Eastern Conference got significantly harder with center Jonas Valanciunas suffering a fractured hand in Friday’s win over the Lakers.

Valanciunas’ exact injury is a fractured fourth metacarpal bone in his left hand. Metacarpal fractures are common in the NBA and have been profiled multiple times here on InStreetClothes.com but let’s review.

Five metacarpal bones form the bulk of the hand and link the tiny carpal bones of the wrist and the long bones of the fingers.  The distal ends of the metacarpals form the knuckles of the hand. This positioning makes the metacarpals vulnerable to breaking especially following a direct blow or an axial load. For this reason metacarpal fractures are often known as a Boxer’s fracture.

Last season multiple players, including Rajon Rondo, Russell Westbrook, and Robin Lopez suffered fractured metacarpals. Other players to suffer the injury include Anthony Davis, Kawhi Leonard, and Kevin Love.

The necessary recovery time normally depends on multiple factors, including the specific metacarpal fractured. Breaks to the second and third metacarpals, located below the pointer and middle fingers, are easier to manage as they are anchored to the bones of the wrist and as a result are largely immobile. The fourth and the fifth metacarpals, located beneath the ring and pinkie fingers respectively, are more mobile in order to allow motion at the wrist and pinkie. The mobility here often necessitates additional healing time.

The other major factor influencing recovery time is the nature of the break. If the fragmented pieces of bone remain aligned, it is considered a non-displaced fracture. Non-displaced fractures are often treated conservatively and the effected individual can avoid surgery.

If the position of the broken bone or bones shifts upon injury, the break is considered displaced. These types of injuries are often treated surgically to insure a proper union of the bone. The InStreetClothes.com database reveals that on average players who need surgery for a metacarpal fracture miss five more games than those who avoid going under the knife.

Unfortunately for Valanciunas that gap is negligible when isolated fourth metacarpal injuries are examined. The difference between surgical and non-surgical treatments isn’t significant and the average number of missed games for these injuries is 17 games. Raptors fans looking for an even better comparison are in luck as this marks the second metacarpal fracture for Valanciunas. During the 2012-13 season, Valanciunas suffered a fractured fourth metacarpal in his opposite hand. He would not require surgery and miss 18 games recovering.

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Regardless of treatment options, the setback for Toronto remains considerable. Valanciunas is averaging 12.7 points and 9.3 rebounds through the first 14 games of the season, both career-highs for the Lithuanian center. His ability to secure rebounds will be particularly missed, as he is an integral part of the team’s top three rebounding five-man lineups. Furthermore, as Daniel Hackett of Raptors HQ recently detailed, Valanciunas’ individual impact on the teams offense and defense is crucial to the team’s on-court success.

Sustained health has been a key component of the Raptors recent return to relevancy. The team’s top ranked medical staff will now be tasked with getting Valanciunas back as quickly as possible while maintaining the health of the other members of the team. Having the previously injured DeMarre Carroll and Terrence Ross back in the lineup will help but how the team performs during Valanciunas’ prolonged absence will be critical in shaping the remainder of their season.

Understanding Hip Labrum Injuries in the NBA

The Washington Wizards announced Tuesday that forward Martell Webster will undergo surgery on a partial tear in the labrum of his right hip and miss the remainder of the season. The news comes less than a week after Yahoo’s Adrian Wojnarowski reported forward Wilson Chandler would also miss the season due to a torn hip labrum. The surgeries for Webster and Chandler mark the fourth and fifth hip surgeries needed by NBA players since July, the highest occurrence rate over the last 10 seasons.

NBA fans are more familiar with labrum tears of the shoulder. Cleveland’s Kevin Love infamously tore the labrum of his glenohumeral joint during last year’s postseason, joining a long list of players to suffer the injury including Carmelo Anthony, Dwyane Wade, and Dwight Howard. Similarly, the hip is stabilized by its own fibrocartilage labrum but, like its shoulder counterpart, it is susceptible to injury.

The primary joint in the hip is known as the acetabulofemoral (AF) joint. The AF joint is what most people refer to as the hip socket and for good reason. The joint is classified as a ball-and-socket joint, just like the shoulder. Ball-and-socket joints resemble a golf ball on a tee. In the AF joint, the head of the large upper leg bone known as the femur (the golf ball) sits in the acetabulum of the pelvis (the tee). The ball (head of the femur) can freely pivot on the tee (acetabulum) allowing for a large amount of mobility. This high degree of freedom comes at the cost of stability, which is where the labrum comes into play. The labrum deepens the acetabulum without overly restricting motion at the area. The surrounding musculature and numerous ligaments work with the labrum to further stabilize the hip. Unfortunately a violent collision or excessive repetitive motion can cause the labrum to fray or tear. Anatomical variance in the head of the femur can also contribute to the problem, resulting in an impingement of the labrum. These injuries are very painful and often result in limited mobility. If left untreated chronic instability in the hip can develop.


Surgery remains the most proactive approach to treatment. The exact procedure depends on the root of the problem. An acute tear can be repaired or smoothed down, similar to the way a meniscus injury is addressed. If an impingement issue is the problem, the defect or bone spur will be trimmed or removed in a debridement. A microfracture procedure may even be performed to help stimulate cartilage repair. Those with congenital problems, like Portland’s Gerald Henderson, may ultimately require surgery on both hips.


The sudden increase in hip surgeries is a bit alarming given the severity of the injury and the extended treatment time associated with surgery. Part of the reason for the sudden increase in diagnoses may simply be medical professionals are more keenly aware of femoroacetabular impingement and other congenital problems. However identifying any other contributing factors could go along way in preventing any additional hip labrum cases before they occur.

Early Season Injury Woes Grounding the Pelicans

The 2015-16 NBA season is only 11 days old but injuries are already shaping the playoff landscape. Four teams have yet to lose a game to injury, including familiar faces like the Spurs and Raptors, last year’s injury ravaged Thunder, and the Clippers. As of November 6, the combined record of these four squads sits at 15-7. On the opposite end of the spectrum sits the Pelicans and 76ers. Both teams sport 0-5 records and have missed 24 and 25 games to injury respectively, the two highest totals in the league.

The injuries numbers for the 76ers were anticipated with centers Joel Embiid and Carl Landry both recovering from offseason surgeries and guards Tony Wroten and Kendall Marshall working their way back from ACL repairs. However, with the exception of Quincy Pondexter’s knee surgery, the majority of the injury woes for the Pelicans happened unexpectedly during the preseason or in the first five games of the year. One week before the season opener against the Warriors, starting guard Tyreke Evans underwent a debridement surgery on his right knee, his third such procedure since the 2014 offseason. His absence has been particularly impactful as the team continues to limit the early season minutes of his backcourt mate Jrue Holiday and Norris Cole remains sidelined with a high-ankle sprain suffered in mid-October.

The frontcourt has been equally decimated by injury. Centers Omer Asik and Alexis Ajinca, who both spent the summer playing for their home countries in international play, have nursed lower extremity injuries throughout the start of the year and Asik remains out with a nagging calf strain. Things have only gotten worse as Yahoo’s Adrian Wojnarowski reported Friday that veteran center Kendrick Perkins is expected to miss three months with his pectoral injury.

The pectoral muscles compromise the upper portion of the chest and are most often associated with pushing exercises like the bench press. However in addition to its attachments to the sternum (breastbone) and ribcage, the pectoralis major extends across the chest and ultimately connects to the upper arm bone, the humerus. As a result the pec is able to help flex and extend the upper arm while also pulling the arm toward the body in a motion known as adduction. It also plays a part in rotating the arm.

Significant pectoral injuries are relatively uncommon in the NBA though big men appear particularly prone to the injury. Atlanta’s Al Horford has twice needed surgery to repair a torn pec and Darrell Arthur and Kwame Brown also missed extended stretches with high-grade pectoral injuries. Overall the average number of missed games for these injuries was 53 games, although each injury did require surgical intervention. As of now surgery has not been discussed with Perkins.

The rash of injuries is an unfortunate setback for a team looking to ascend into the upper echelon of the Western Conference. The problems are further frustrating as they come on the heels of a top-10 finish for fewest games missed to injury in head athletic trainer Duane Brooks’ first year on the job. For comparison’s sake, last year’s Pelicans squad didn’t lose 24 total games to injury until December 21, a total this year’s team has matched in 22 fewer outings.

The Pelicans will look to become the fifth team since the 1999-2000 season to start off 0-5 and still make the postseason. While the presence and play of Anthony Davis gives New Orleans reason for optimism, the team’s success for the remainder of the year hinges on a turnaround in overall health. Unfortunately a turning point remains difficult to envision with multiple Pelicans players still without firm recovery timelines.

Breaking Down Derrick Rose’s Facial Fracture and Iman Shumpert’s Wrist Injury

NBA teams are just days into training camp and the injuries for the 2015-16 season have already begun. Two Eastern Conference contenders were hit hard with ailments that will require surgery for key backcourt players. In Chicago, Bulls guard Derrick Rose is slated for surgery after suffering a facial fracture during practice while Cleveland swingman Iman Shumpert is out after undergoing wrist surgery.

Rose’s injury is fairly common in the NBA as multiple players have suffered fractures to the face and skull. Last season alone guards Victor Oladipo, Russell Westbrook, Rajon Rondo, and Mike Conley all missed time recovering from various facial fractures. InStreetClothes.com has previously looked into the trends of these injuries but let’s so a quick review.

The skull is made up of two primary parts, the area that surrounds the brain and the facial skeleton. The facial skeleton is comprised of 14 fused bones that serve as anchors for the various muscles of the face. Of these 14 bones, the two nasal bones are the most frequently broken while the eye socket, or orbit, is also susceptible to injury.

The orbit is made up from bones of the face and the neurocranium and surrounds and protects the eyeball. Injuries to the area are particularly complicated as the eye can be damaged and vision problems can arise. The severity of the fractures depends on the bones involved, whether or not they shift, size of the actual fracture, and any soft tissue and/or muscle damage. Surgery is often performed if the damage is severe and a bone has displaced. Any considerable damage to the eyeball would also warrant surgical intervention.

Multiple factors help shape an individual’s return to play. To start any concussion-related symptoms have to dissipate. Second, if surgery is required then the length of time missed is often extended. Finally the bone or bones involved also shape a potential recovery window. Nasal fractures and cheekbones often heal quickly as was the case last year when Westbrook missed just one game due to a zygomatic arch fracture. However this fracture is away from the eye socket and any associated vision issues are avoided. Orbital fractures that require a trip to the operating table have forced NBA players to miss an average of 13.6 game or roughly three to four weeks.

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The Bulls have yet to release a firm timetable for Rose’s expected to recovery though history suggests he has a realistic chance of being ready for the regular season opener on October 27 when Chicago hosts Cleveland. Last season, Oladipo suffered an orbital fracture during the preseason and was back in action 20 days after his surgery.

ECUWhile Rose’s availability remains in the air, Shumpert will not be in uniform as he is expected to miss three months recovering from wrist surgery. The former first-round pick sustained a rupture of the sheath that surrounds the tendon of the extensor carpi ulnaris (ECU). The ECU sits on the pinkie side of the lower arm and is responsible for extending the wrist and performing a motion known as adduction (similar to a karate chop). Fluid motion is dependent on arm position and to aid in stability the tendon of the muscle is anchored down by a sheath of connective tissue. The sheath is vulnerable to injury, particularly following repetitive motion like those performed by golfers and tennis players. However the sheath can be injured following an isolated high-stress episode, like slamming your wrist on the rim during a dunk. While ruptures are rare, surgery remains the best option and has a high success rate.

Comparable injuries in the NBA are hard to come by. Rashard Lewis suffered a tendon sheath tear in his right hand that caused him to miss 52 days and 22 games. Shumpert’s current teammate James Jones suffered a more extensive injury in a similar area when he tore the tendon of the extensor muscle during the 2008-09 season. Jones returned to action 86 days (2 months and 25 days) later after missing 36 games for the Heat. While the sample size is small, these examples suggest the current timeline released by the Cavaliers is reasonable and perhaps a bit conservative. However it seems likely that Shumpert sits for the first 20 to 25 games of the regular season.

Last year’s NBA season was dominated by injury and unfortunately this year isn’t off to the best of starts. Fortunately neither one of the injuries can be considered season-ending and both players should be able to help their respective team contend for the Eastern Conference crown.