Top injuries to watch for 2013-14

The majority of injuries in the NBA are to the athlete's knee, both short-term (such as meniscus tears) and long-term (progressive injuries involving cartilage breakdown of the joint).

Anterior cruciate ligament tears have not typically been as common in the NBA as in other professional leagues, like the NFL, for instance, so there are fewer players for comparison. Yet it seems there have been more ACL injuries involving key NBA stars of late, making the injury more impactful now than perhaps it has ever been. The window for recovery is often listed as six to nine months, but the actual return time is based on multiple factors specific to the individual, including how he heals, his overall health and fitness, the nature of the activity to which he plans to return (in this case very high level in terms of directional change, rapid acceleration/deceleration and frequent pivoting/twisting/cutting) and confidence in his knee. On a positive note with regard to ACL injuries, the majority of NBA players who sustain one will return to action, and virtually all of them will do so within the following year.

A recent study published in the journal Sports Health highlights some interesting findings. Of 58 NBA players who underwent ACL reconstruction between 1975 and 2011, 50 returned to play in the NBA (seven returned to play internationally or in the D-League). Of those 50 who returned to the NBA, all but one did so within a year.

Perhaps more important than simply returning to the sport was how these athletes fared upon their return. After all, one of the big concerns following significant injury is whether there will be a decline in performance. According to the authors, performance upon return to sport following ACL reconstruction "was significantly declined in the following parameters (vs presurgery): mean games per season; minutes, points and rebounds per game; and field goal percentage. In addition, there were significantly fewer players selected for the All-Star team following ACL reconstruction (vs preinjury)."

The findings related to performance are at first glance somewhat alarming, to say the least. But they must be examined in the context of comparison to the study control group, which consisted of healthy NBA players matched based on age, sex, body mass index, position and years of experience in the NBA. Performance in the season following the index year in controls (the year comparable to the point in time when players post-ACL reconstruction were measured) significantly declined in virtually all of the same parameters. In other words, there is no significant difference in performance between NBA players following ACL reconstruction when compared to controls.

Another interesting finding by the authors was that nearly 40 percent of ACL tears occurred in the fourth quarter, something they suggest as potentially implicating fatigue in the timing of ACL injuries in the NBA. Since fatigue has long been implicated as one potential contributing factor in ACL injuries in general, this is not altogether surprising. While there is no way to completely combat fatigue, there is an awareness of how fatigue might contribute to injury, which may influence coaching decisions in certain game situations, particularly as the season progresses.

With those thoughts in mind, we take a look at some key players returning from injury as the 2013-14 NBA season gets underway, including several stars who are coming off ACL reconstruction.

The veterans

Derrick Rose, PG, Chicago Bulls
Injury: Torn (L) ACL
When It Happened: Rose tore his ACL on April 28, 2012. But Rose didn't set foot on the court in a game last season. After undergoing surgery on May 12, 2012, he spent the season rehabbing and preparing to return to basketball. The question for most coming into this season is, "Can he be the preinjury Derrick Rose?"

Status: It's interesting. The preinjury Rose is presumably the supremely talented All-Star before he tore his ACL in the playoff series against the Philadelphia 76ers. But even before he tore his ACL, Rose's 2011-12 season was marred by various annoying injuries. missing nearly 40 percent of the regular season prior to that one devastating exclamation point. Rose dealt with back, groin, ankle and foot injuries in 2011-12 before tearing his ACL. The point here is that the extended time off, while difficult to endure for eager fans and no doubt for Rose himself, likely granted his entire body a recovery period he has not enjoyed since his youth. And that time to get his entire body rested, rehabbed and ready to go may actually prove to be a difference maker in his overall career longevity.

As to the knee specifically, it has already been tested in competitive preseason play. Rose experienced a bout of knee soreness in early October, which sent a small shock wave through the basketball universe, but it resolved quickly and Rose has since resumed his impressive preseason display. All the training appears to have paid other dividends as Rose says his vertical jump has increased by five inches. "I think I'm way more explosive now," Rose told ESPNChicago.com. He says his knee feels normal and he has regained both his mental and physical confidence to the point where he is not holding anything back.

Maybe he even has a newfound love for the game after his extended absence. Said Rose, "I'm loving every moment." After a difficult year spent focused on rehabilitation and recovery, it seems Rose has indeed moved out of that phase and on to the next one, the one involving real opponents and competition. There are no plans for the team to restrict his minutes when the season opens, and for fantasy owners it would certainly appear that Rose and his knee are as good as new.

Kobe Bryant, SG, Los Angeles Lakers
Injury: Torn Achilles
When it Happened: April 2013

Status: The initial projection for Bryant's return was six to nine months, which would have him most likely playing competitively at some point in December. Following surgery, it is typically about six months before an athlete is cleared to return to basketball activity, with another four to six weeks generally required to return to competition. It is important to remember these timelines are always fluid. There is also a distinction between returning to "basketball activities" and returning to competitive game play. Once the biologic healing is satisfactory (in the case of an Achilles repair, that means enough time has passed to be satisfied that the tendon healing has taken place and the tendon has been gradually stressed through rehab to the point of being able to withstand a full load), the athlete is cleared to return to sport activity. Stressing the tendon to increasingly absorb load is critical for a basketball player who not only jumps and lands repeatedly but who also must explode off the leg from a stationary point, precisely the mechanism by which Bryant tore his Achilles this spring. For a basketball player to return to sports activity, that will include full-court drills, shooting and contact, all of which are resumed on a very gradual scale.

Return to play requires something else, however. Not only does the athlete need to be comfortable with all practice activities, he also needs to be in physical condition to play at game speed and at the intensity required to return to competition. Although an athlete can attempt to maintain physical conditioning while recovering from a major injury, the very nature of the injury itself prohibits the highest intensity activities and the sport simulations necessary to return to that particular sport. In essence, the only way to truly achieve game conditioning and performance readiness is to play in games. The final phase of recovery constitutes returning to play, gradually. As Bryant returns from this injury, he will understandably be eased back into competition, likely only playing predetermined minutes at first and increasing that time in a step-wise fashion, depending on how his body responds to the prior outing. Those close to Bryant know that limited time is not something to which he is accustomed. But he also seems to be very aware, based on his own tweets about his recovery throughout the process, that his best chance of returning at a high level lies in following the rehab plan outlined for him. Bryant recently spoke to reporters in Los Angeles and explained that he "scaled back" his activity when he felt some tightness in the Achilles after doing jogging and shooting drills while overseas with the team. He also acknowledged the risk of injury to another body part if he does not progress at an appropriate pace. "It's not about being 100 percent necessarily," Bryant said. "It's about making sure you're running with the proper gait and you're not putting stress on other areas that can cause problems down the road."

Perhaps Bryant's most telling comments came in a recent Sports Illustrated story when he acknowledged he didn't fully know what to expect when he returned. "I don't know how I'm going to come back from this injury ... but I'm going to stay with it until I figure it out." Many athletes coming off an Achilles repair will say they do not feel like themselves for up to a year. Typically they feel less explosive, less powerful, overall slightly less strong than they remember being preinjury. Most of those same athletes, however, will say that they still felt they were able to perform at a high level, and that the more they participated in their sport, the more they began to feel like themselves again. Bryant's experience is likely to be similar. The question is whether any differences he might feel will be visible to anyone but him. Working most in his favor are his work ethic and his mental toughness, which are equally important in overcoming a major injury as the physical rehabilitation itself. It may be a slow and gradual start to the season, but it's possible as the year unfolds that Bryant makes people forget how he left the court in April.

Russell Westbrook, PG, Oklahoma City Thunder
Injury: Torn right lateral meniscus
When it Happened: April 2013, surgery April 27 to repair meniscus, second surgery Oct. 1 to address persistent swelling

Status: After suffering a setback which required a second arthroscopic procedure, it appeared Westbrook would miss the first month of the season, perhaps longer. But his progress since that second surgery has been solid, as evidenced by him participating in portions of practice by late October. An on-time start to the season is not expected, but it is possible Westbrook's absence could be shorter than originally thought. When he does return, it's likely his playing time will be controlled early on, but if his knee responds well (no pain, swelling), those minutes could increase fairly swiftly.

If it seems like a lengthy recovery time for an athlete following meniscus surgery, it's important to note that Russell's meniscus was repaired, not resected or debrided (where the torn flap of fibrocartilage material is either removed or trimmed down). A repair requires a lengthier rehabilitation process since the tissue must be protected in the early phases to ensure proper healing of the repair. The meniscus does not have a great blood supply and repairs are only possible in certain cases. But given the role of the two menisci in providing cushion and stability for the knee joint (between the thigh bone and the shin bone), preservation of that cushion is desirable when possible. In fact, it is particularly desirable on the lateral or outer side of the knee joint, especially in a younger player since the risk of arthritic changes in the knee increases when the lateral meniscus (or a portion of it) is removed. The decision to repair Westbrook's meniscus made sense. Unfortunately, he was having persistent swelling and irritation in the knee associated with the stitch, a not altogether uncommon consequence. A second surgery to clean up the area was required and Westbrook is now back on track with his rehab, perhaps even a bit ahead of where the team thought he might be after the most recent procedure. Even if the second procedure results in a brief delay to start the season, not doing it might have meant chronic swelling and poor performance well into the season. As long as Westbrook is at full strength when he returns, the repair should help ensure the health of his knee and, ultimately, the longevity of his career.

Rajon Rondo, PG, Boston Celtics
Injury: Torn (R) ACL
When it Happened: January 2013, surgery Feb. 13, 2013

Status: Rondo is still working his way back toward readiness to play, something that won't happen by the time the season kicks off. But in late October he gave reporters a remarkably specific assessment of just how far along he is with his reconstructed knee. "It's getting stronger," Rondo said. "[The leg] is probably about 87 percent depending on how my day goes." Sure, there might have been a hint of playing with the media when assigning that particular number to his recovery, but based on how he described the improvement in his knee, that estimate may be fairly accurate. He seems to have the proper perspective when it comes to gauging his readiness to return. "I'm taking it one week at a time," Rondo said. "I know it's getting stronger each week and whenever I'm able to jump off my right leg and probably dunk, that's when I'll be back to play."

The good news is that Rondo's progress has been fairly uneventful, at least so far. As he embarks on a progression of increasing contact, resuming practice and working toward game minutes, his progress will be closely monitored and his activity adjusted, as necessary. He says he wants to come back without limitations, including minutes restrictions, but he may not have the final say in that regard. It's safe to say he won't be on the floor for the season opener, but it's looking like he could make his debut before the new year.

Al Jefferson, PF/C, Charlotte Bobcats
Injury: Sprained ankle
When it Happened: Oct. 11, 2013
Status: The team feared the worst when Jefferson's ankle swelled and he was placed on crutches and in a walking boot. X-rays were negative, however, and the swelling has since subsided. Fairly soon after the injury, Jefferson expressed optimism that he would be able to play in the season opener and he appears to be on track. As the Charlotte Observer notes, Jefferson participated in walkthroughs even though he could not formally practice to help with his mental reps. He says his ankle is doing "great" and he anticipates being ready for the first game of the regular season.


Nerlens Noel, C, Philadelphia 76ers
Injury: Torn (L) ACL
When it Happened: February 2013

Status: The 76ers announced a week before the season opener that they did not expect Noel to participate in games this season. Days later, it sounded as if they were modifying those remarks to leave the door open for a possible appearance. The bottom line is that Noel has been focused on rehabbing his reconstructed knee with no particular return date set in stone, and that everyone expected his debut would be delayed as he returned to full health. Ultimately, the team's goal is and should be the long-term health of their draft investment. Not rushing him back is an important part of that equation. Arbitrarily excluding him from the season, however, is not the answer, either.

There has been no evidence of a setback, and based on his progress leading up to the draft, there is every reason to believe Noel will make a full recovery. The timeline for his debut, however, is wide open at this point, which could be as far as a year removed from this season, and fantasy owners will not want to invest in uncertainty of this magnitude.

Trey Burke, PG, Utah Jazz
Injury: Fractured right index finger
When It Happened: October 12, 2013

Status: Burke underwent surgery to insert pins to stabilize the fracture in his finger on Oct. 15. He was placed in a splint and, according to the team's official website, will be in that splint for approximately three weeks and then will be re-evaluated. The key will be how well the bone healing is progressing. Based on the healing and how quickly he regains motion and strength in his finger, Burke will then gradually be returned to basketball activities. He will need to get comfortable with ballhandling and shooting before moving to contact drills and scrimmaging. A return to actual game competition will depend on how Burke moves through these various phases of rehab, but fantasy owners should plan on at least a month's absence.

C.J. McCollum, G, Portland Trailblazers
Injury: Fractured left fifth metatarsal
When it Happened: Oct. 5, 2013

Status: McCollum suffered the same injury in January while a senior at Lehigh University. The fifth metatarsal is the long bone of the forefoot that connects the pinkie toe to the midfoot. While it is not uncommon for athletes to sustain repeat fractures at this site, if the bone fails to heal, it can become a chronic source of pain. McCollum had surgery to insert a screw to stabilize the fracture in January but, according to The Oregonian, opted after this second fracture to undergo a procedure with renowned foot and ankle specialist Dr. Bob Anderson. On Oct. 16, McCollum was treated with extracorporeal shockwave therapy (essentially high-pressure sound waves) in an effort to help the bone heal. Currently he is off crutches and walking with the foot in a boot. McCollum will be re-evaluated six weeks from the procedure date, at which point the next steps will be determined, based on the healing progression of the bone. It is too soon to say when his return to play date will be, given that his activity level is predicated on the results of his recent treatment, but clearly it will not be before December.