How freaky was Kyrie Irving’s knee injury?

Posted on June 22, 2015

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Late May to early June is my favorite time of year sports wise. I barely watch regular season hockey or basketball, but I always get into the playoffs.

Playoff hockey has to be the best sport to watch. It’s fast, minimal timeouts, violent, glorifies beer and beards, and damn is it intense.

Playoff basketball has some similar qualities, particularly once the finals rolls around. Unfortunately, the last five years has meant I have to deal with watching Lebron James cry every other night. Go Spurs!

What playoff sports also gives is an opportunity to watch how athletes at the highest level are managed. It’s kind of incredible every year there are standout examples of what not to do. Examples I think everyone can take something from. Professional athlete or not.

Last year it was Lebron James’ cramping. (I also wrote about the United States national soccer team’s hamstring issues.) This year it’ll be Kyrie Irving’s knee. Irving had been suffering from tendinitis in his left knee for a while, eventually fracturing his left knee cap. Something his team calls a freak incident. That the tendinitis had nothing to do with the patellar fracture. Let’s see if we can figure out how freaky this thing was.

Of course, I’m not on the Cleveland Cavaliers. I have to go by media reports, what the players say to reporters (rarely tell the whole story), etc. This inevitably leads to some conjecture on my part. But it’s a fun post to write, and I still think we can learn something.

Background on Irving’s knee

The playoffs started April 18th. Up until that point, Irving’s left knee had only one (public) issue, although it looked pretty bad. This was back in December (video is only a minute):

This was said to be a “knee contusion.” The fact that’s all it was is amazing. That’s the type of stuff that sends you into the operating room. Something worth keeping in mind later.

Beyond this, his knee seemed (publicly) good up until the playoffs.

He had to sit out with a back injury right after he returned from the contusion. Something he felt was unrelated to the knee issue he just had. Yet he never had a back issue before.

-> If your knee is banged up, you’re not going to move it like you typically do. When you don’t move a limb like normal, you get that movement somewhere, often the lower back. He may think it wasn’t at all related, but that’s unlikely. (Back problems are common after knee surgery. It hurts to bend your knee -> You bend your back instead.) Particularly because Irving’s back tightened up like crazy. The exact thing you’d expect in a back suddenly working more than it’s used to. We’ll keep this in mind for later as well.

After this, he had some issues with his left shoulder.

Right before the playoffs, early April, he had to miss time for a few games with a hip issue.

On May 6th, Irving told reporters he had issues with fatigue, after playing 44 minutes against Chicago. Our third thing to keep in mind for later.

By May 8th, we find out Irving had been playing with a strained foot for a few weeks.

By May 11th, we find out he has also been diagnosed with tendinitis in his left knee.

Background to the background

Let’s step back even more. This is Irving’s fourth season. His first two seasons, he played 51 and 59 games. A NBA season is 82 games, not including playoffs. So, he missed a lot of games.

His third season, he got that up to 71 games.

Minutes wise, according to Basketball Reference:

  • First season ~1500
  • Second season ~2000
  • Third season ~2500

Those are pretty big bumps. 30% jump one season, 25% the next. But what about before the NBA? For his one season at Duke, he only played eleven games due to a big toe ligament injury.

  • Duke season ~302.5 minutes

So, we can see a significant ramp in minutes each year.

Before we talk about the most recent season, we need to mention Kyrie played international ball in the summer of 2014. That, and he played more minutes this most recent season:

  • 2014 (fourth season) ~2700

Not a huge bump from his third season, but it’s a worth mentioning bump considering he didn’t have an offseason.

He did have a good amount of injuries the first few years, but a lot of them were traumatic type injuries. A contusion, concussion, the types of things that are shit happens oriented. Up until season four, he seems to have handled the extra work fairly well.

In 2014 though, things change. A “sore” back, hip, foot, and knee. He also missed time with a shoulder injury that was a bit weird. It may have just been the right angle, but it didn’t look like much was needed to tick the arm off. He’s had issues with this shoulder in the past, making me think he may have been having problems during the season (privately), where it didn’t take much to flare it up.

This seems to be what was going on with Kobe’s most recent shoulder injury. He had been having issues, and finally it hit a tipping point. This seems quite common with athlete injuries. You don’t find out it’s been a problem until it’s really a problem. Nobody wants to give the other team advantageous information.

“Oh, Kyrie’s left shoulder is bothering him? Guess we’ll be doing a few extra screens to his left side tonight.”

These are the types of things where training and game volume (minutes) needs to be carefully looked at. Because a hip, foot, and knee issue all in ~five weeks isn’t “shit happens,” or “it’s less likely shit happened,” kind of stuff. Having issues with fatigue at 44 minutes, in a 23 year old guard, is also unusual. (This may have been an injury bothering him that he didn’t want to mention; instead using fatigue as a facade.)

You don’t get knee tendinitis out of nowhere. Either he was relying on that left leg more due to the right foot, or he had been suddenly overworked. Or both. I use suddenly loosely, as he was having issues on and off all season, in a season where he already played more minutes than ever, in conjunction with having no offseason. By April, his body was way, way more worked than it had ever been.

Way more overworked and going into an environment where he would be playing harder than ever (playoffs), and adding more minutes than ever.

1) He never played international ball before

2) He never played ~2700 minutes in a season before

3) He never played in the playoffs before

4) He never played over 36 minutes per game before, yet out of nowhere starts playing 41 once the playoffs start. (A ~14% jump in volume for an elite athlete, over night, is a gigantic leap.)

5) Not only is he playing more minutes, he’s playing more intense minutes. Things get ratcheted up in the playoffs.

His offseason was shorter / non-existent, his in-season consisted of more minutes, his season is months longer than ever before and more intense than ever before. And he played in the all-star game, so he didn’t even get that break.

Ineptitude / Ignorance / Tradition / Whatever you want to call it?

Last year I covered the highly questionable advice Lebron was getting in the playoffs. Long story short: He was obsessing over hydration, yet hydration has little, if anything, to do with cramping.

Fast forward to this year, and you can see a perfect example of continued questionable advice, even with regards to cramping again. Matt Dellavedova had to go to the hospital after game three to help his cramping. Because of this, he said he’d be giving up coffee in game four. He drank it before the game, at halftime, and sometimes during. He’d be giving it up due to fear of dehydration.

1) Dehydration does not cause cramping.

2) If you’re not thirsty, you’re not dehydrated.

3) Coffee does not cause dehydration!

Alan Aragon ran a nice review of 3) in his research review. Yes, you pee more when you’re drinking coffee. But that’s because you’re drinking more water. Overall, it doesn’t affect total body water.

To be fair, Alan Aragon is a little more of an underground name. Although, I believe he’s done work with the Lakers in some capacity. But it’s not like he’s NPR, or the Huffington Post, or the MayoClinic, or RunnersWorld, or BBC…who all have articles, some from the same month (January 2014), mentioning coffee / caffeine is not a dehydrator.

Coffee links no dehydration

This matters because:

1) A player shouldn’t all of a sudden be changing their pregame / ingame routine. That’s panicking. Especially when what you’ve been doing has been working so well for you.

This is even more true with caffeine. As anyone who drinks a lot of coffee can tell you, all of a sudden drinking a lot less, or none, is a great way to feel terrible. You don’t want to be going into a NBA Finals game with the dreaded caffeine-withdrawal-headache.

2) It’s a sign whoever is helping him probably doesn’t know what they’re doing, at least in certain areas (and probably others).

Dellavedova played great game three, but crappy game four, and the rest of the series. No, coffee isn’t the only reason for this. A more likely explanation was the guy went from 20.5 minutes per game in the regular season, to 40.5 minutes per game in the playoffs. He actually took himself out of game four at one point, as he started cramping again. Never mind the research, the Cavs have their own case study “With coffee -> cramped. Without coffee -> cramped.” “Exhausted -> cramped. Exhausted -> cramped.” I wouldn’t be surprised if after the first few games he was never fully recovered the rest of the series.

Up next, David Blatt.

“That’s the coach’s decision if he decides he wants to go deeper in the bench,” James said. “We haven’t played many guys throughout this playoff run. I think it would help some of the guys that are playing some high minutes, for sure. Just give guys a couple minutes here, a couple minutes there. But I think the coaching staff will try to do what’s best to help us be physically and mentally prepared for Sunday.”

Translating Lebron James,

“I’M DYING! For fuck’s sake, we’re only playing seven guys here. Golden State has like 15 people rotating in and out. No, we can’t keep this going. I don’t know what the hell coach is thinking…I mean, I tend to make all the decisions anyways, so I guess this is actually my fault. I’m actually scrapping plays and calling my own, and telling which guys to sub in. I don’t listen to a word Blatt says when we have a timeout. But I’m ‘Bron ‘Bron. I get all the credit when things go well; coach gets all the blame when it doesn’t. #Team”

Yet, here is David Blatt (bolding mine):

“[It] was the third game in five days, including the trip back from the West Coast, and it seemed to have an impact on us,” Blatt said after the 19-point Game 4 loss. “We’re thinner now than we were, but that’s not an excuse. We haven’t used it as an excuse yet, and we won’t start now. We’ve just all got to pick it up.”

Maybe Blatt is trying to be rah-rah all while knowing they’re screwed, because there is no picking it up. This is physiology, not willpower. Your star player is saying the way minutes have been managed isn’t working. I find it silly to say, “We just got to pick it up” as a solution. The press already knows it’s influencing you.

And you can’t say, “Maybe it was gamesmanship. He didn’t want to reveal their plans,” because he kept the same strategy the entire time. Throw Shawn Marion in there for a few minutes at least, and have him hack Iguodola a few times in a row. It may not affect the scoreboard much, but Lebron could be getting a breather in the meantime. Lebron is a once in a generation type athlete, but he is known to gas out.

-> After winning MVP, Iguodola said James has no weaknesses. He does, and his conditioning is it. Yes, he’s big, and that makes it harder. That’s the point. You don’t beat him one on one, because nobody on your team will match him physically. But your team can wear him out.

If I were coaching against him, I’d be trying to make him run non-stop, all game. I hate seeing him walk the ball up the court. I’d go full court press, constant screens, constant ball movement. Hack him so when he goes to the rim his ass goes on the floor:

1) He expends more energy bitching at the refs than he does improving his free throw shooting

2) His free throw shooting hasn’t improved in over a decade (.754 rookie year & .710 this year). No matter how much he tells you he works on his craft, his craft is being 6’8″ and a lean ~260lbs. This so big, even a car “fit for a king,” can’t actually fit him:

Lebron James Kia Fit for King

Continuing the mismanagement, when watching game four, I took a note when the announcers said,

“Talking to Lebron James before the game, he said he hadn’t been getting much sleep.”

I’m thinking this is because he’s staying up late thinking about the games, excited, etc. Why hasn’t he been sleeping?

“He said the Cavaliers staff has been performing treatments on him ’round the clock; limiting his ability to sleep.”

Wow. Let’s take away the best recovery modality we have -sleep- and instead keep this guy up doing who knows what. You are not beating sleep. I don’t care whether it’s TENS machines, ice baths, massage, stretching -all things he’s apparently doing- it does not matter. Lebron having an ice tank in his house, does not matter. Ice tanks unequivocally accomplish two things: Misery and Shrinkage.

-Ice futility here

Shockwave futility here

-Massage futility here

-Drugs futility here

-Tech in general futility here

If you play with an injury, you ARE more at risk for an injury

From here:

“However, he [Irving] said doctors told him the tendinitis did not make him more susceptible to other injuries and he wanted to play.”

I don’t know how someone could possibly give this advice. First, let’s say you couldn’t make the knee worse. That doesn’t mean you can’t make other areas worse. If you’re in pain, you’re going to be compensating. Remember his back earlier in the year?

Second, you can make the knee worse. By the time the finals roll around, Irving is at least a month into this “tendinitis” issue. After that long, it’s tendinosis. -Itis and you’re talking a more acute, inflammatory condition. -Osis and things are breaking down. For most tendons, -Osis is the problem. (Again, even if cryothearpy had some amazing anti-inflammatory powers, icing a non-inflammatory condition makes as much sense as J.R. Smith’s decision making.)

-> I mentioned before knee tendinitis does not randomly come about. That Irving was either compensating out of nowhere, or was suddenly overworked. Which is really the same thing.

The third option here is he was chronically overworked, but that would be more tendinosis. Based on how often this gets confused, I wouldn’t be surprised if Irving never had tendinitis, that it was always tendinosis.

He did go see James Andrews, an esteemed surgeon (someone I’ve found a lot of great information from), so I can’t imagine he’d get that wrong. But the other things going on around Irving, that really look like less than ideal care, makes me think it could have easily been misinterpreted. Andrews was only a consult; not the primary person(s) handling him.

Or, something else happened, like the media misinterpreted it. Or someone in his camp went, “Look, the media doesn’t know what tendinosis is. Just call it tendinitis.” OR, the Cavs didn’t want to say, “Irving has a condition where his knee is breaking down.”

Something goes on with this distinction though, because I just can’t ever recall an injury report saying “tendinosis.” Yet you hear all the time about tendinitis. But we know tendinosis is the more common ailment.

There are rates of repair and disrepair the body is always going through. This is one of the most crucial elements of managing any athlete or client: Keeping these rates from getting too asymmetrical. More specifically: Keeping the rate of disrepair never too far from the rate of repair.

If the rate of breaking down gets too far ahead the rate of building up, problems start arising. If a building is breaking down faster than it’s being maintained, it starts crumbling. Things start getting weaker, or more susceptible to injury. The body can’t keep up.

This is what happens when a stress fracture occurs in a runner. The bone has been breaking down more than it’s building up. Eventually it cracks = you’re in a boot for six weeks. Who do you see these types of injuries the most in? People who suddenly ramp up their volume. What other types of injuries do you see in people who suddenly ramp up their volume? Tendon issues. This is not a coincidence as the rate of turnover for things like bone and tendons seem to be much, much slower than things like muscle.

When astronauts come back from being in a microgravity environment, bone health takes, by far, the longest to come back:

Notice in the above graph how at the “Point of Adaptation,” which is six weeks after returning from space, most things have hit their baseline. After this mark, they stay relatively unchanged. Yet at six months, bone and calcium metabolism is still increasing.

robert frost microgravity graph with extra line

Think lifting weights. If you go into the weight room and do an amount of work you’re not used to, you usually end up pretty sore. Such as after a lay off. The body is telling you, “We need time to repair. Don’t do anything to compromise that.” It tries to limit movement range of motion and or speed, through yelling at you every time you sit on the toilet, or go down some stairs. Things have been broken down -> injury risk is higher until it’s built back up -> don’t fuck around until things are built back up.

If you ignore this and keep going, lift intensely again the next day, and the next, etc. You start asking for it. Initially, the muscles may recover, but the bone takes longer. Eventually, odd sorenesses, aches, and pains start coming about. Eventually, you crack your foot, rip a tendon, something really bad happens.

-> Another analogy here is sunlight. If you go out in the sun after being pale all winter, you understand you’re more at risk to get burnt. If you then get burnt, you know you should avoid the sun for a while while you heal. If you ignore this and go right back out in the sun 1) You know you’ll be in pain 2) You know that can’t be healthy, and that things will only get worse, like blistering.

You know who knew this? Kyrie Irving. The full quote (bolding mine):

“However, he said doctors told him the tendinitis did not make him more susceptible to other injuries and he wanted to play. […] ‘Obviously, there was a risk going out there playing anyway, no matter what,’ he said

Maybe Kyrie gave the training staff the middle finger, that he was playing no matter what, and he wants to make sure nobody gets fired for this. Because he knew the risk was elevated.

What was especially troubling about this was David Blatt and Lebron James -who is more dramatic than Riley Curry- both publicly made statements about pain tolerance. Blatt saying Irving’s condition was one of pain tolerance, James saying not everyone has the same pain tolerance. That he holds himself to a higher standard. This is publicly saying to your teammate, “I mean, you know, I don’t want to say you’re a pussy, but I feel like you’re one, but I understand that maybe you’re not, even if I say you are.”

Blatt also told the public Irving’s recovery was going “slower than expected.” You can see Irving asked about this, and the facial expression tells a lot. I’m not trying to go all voo-doo body reading here, but the moment he’s asked the question, his face changes. The discomfort is palpable. Video herebetween the one and two minute marks.

I bet he’s either thinking things being slower is his fault, or “Thanks for the support coach!”

While I actually expect worse things from Lebron -except the progress of his jumpshot, which I’m betting will improve after he loses his 10th finals- you hope better from the coach. You’re publicly saying you don’t really care about his leg. He then followed up with managing Irving in a way that’s tough to defend.

Kyrie Irving minutes

On the left is the game; on the right is Kyrie’s minutes. After the “tendinitis” announcement May 11th, he still played 40 minutes May 12th. After this, It starts to get the better of him, and his minutes drop dramatically against Atlanta, to where he barely plays.

Now, I don’t know exactly what he was doing in practice, but it’s likely they were doing a lot to calm down his leg. Meaning he wasn’t doing anything similar to what a game entails.

Yet on June 4th Irving played 44 minutes. He did this after likely having a week or two of not doing much. (By much I mean game oriented playing. Not that he wasn’t doing treatments, etc.) He certainly didn’t play many minutes against Atlanta, because they were trying to get the leg to calm down.

After three and half weeks of barely playing, he played more minutes than his average. The same amount he complained of fatigue after playing against Chicago. An amount he hadn’t played in nearly five weeks! You already have a baseline of what’s too much for this guy. Any iota past that baseline and you’re asking for problems. Just like metal has an exact breaking stress, so does bone. Yet he was pushed to this limit, and in the NBA Finals, in overtime, meaning the minutes were even more intense.

“But the game he got hurt he was playing great. Moving around well. He looked fine.”

First, talk to people who’ve had a stress fracture. A lot of them are completely fine, then one extra step and bam, their foot is broken.

Second, there are these things called drugs. They work. And nobody ever reports how much they’re used before games. Some guys in the NFL take epidurals before games.  But cortisone shots are (I believe still) the most common. Cortisone, which can weaken tendon. If you don’t think someone would inject cortisone to decrease pain for a tendon issue, because of the known issues cortisone has with tendons, you’re morally optimistic, and delusional at the same time. I, as a teenager, found an orthopedist willing to do that exact thing, so I could play in a high school football game. (It happened to be the patellar tendon too!)

Plus the adrenaline of being in the finals. Just because you can’t feel it though, doesn’t mean bad shit isn’t going on. Remember our earlier graph. Bone is the thing that takes the longest to come back. Just because his pain had perhaps significantly subsided, doesn’t mean his body had caught up repair wise.

If you watch when he goes lame in other games, he looks fine too. Then all of a sudden, one particular move, and he can’t walk. 1:30 mark of this video, when playing Atlanta.

Whether he felt fine or not is irrelevant though. You don’t take someone who has been really hurting –they’ve been having trouble walking- then out of nowhere have them perform way more volume than they’ve performed the last month. An amount you know they’ve had trouble with recently (44 minutes). All in a more intense setting. That’s about as close a definition I can think of for “Cause of injury.”

It is not an athlete’s responsibility to properly manage themselves. That’s impossible. The athlete’s mindset is no pain, no gain. They don’t stop unless their body stops them. This is why we have coaches, trainers, doctors. To help the athlete. Not to publicly say they need to suck it up.

“The Cavs are saying it was a freak thing, from colliding with Klay Thompson.”

After the injury, Irving didn’t say a word about “colliding” with Klay Thompson’s knee. He said he had been used to feeling a severe “pinch” in the knee, but this time it “felt different.” Don’t you think he would state it was different because “you know, I collided into some guy’s leg”?

Somehow this didn’t break his knee cap:

Kyrie Irving Russell Westbrook Knee Injury

But this did?

Kyrie Irving Klay Thompson Knee Injury

First, the Westbrook instance (top) looks worse. There is the pure look of it, the fact he’s landing out of a jump and gets his knee nailed backwards, and you can actually see his knee gets hit twice. First by Westbrook’s left leg, then again by his right leg. Knee on knee:

Kyrie Knee Injury 6

Alright, maybe he was somehow hit perfectly with Thompson. I guess you can’t completely take this off the table, even if Irving didn’t mention it, even if it barely looks like his knee cap was touched, even if Klay Thompson was completely fine but the other guy’s patella fractured, even if Irving doesn’t even know if their knees touched (bolding mine):

“Irving said the left-to-right move he tried was something he had done “a thousand times.” He attempted to stop and believes he made contact with Warriors forward Klay Thompson.”

(It looks like he was attempting to go right to left, but the Irving quote is accurate, in this video.)

But you also can’t take off the table nobody from the Cavs wants to go out and say, “Look, we played him too much. It’s our fault. The guy has been injured essentially non-stop since December, and hasn’t had an extended break from basketball in two years.” No, they want to chalk it up to a “freak incident.” Tell that to his father, who was apparently livid at the way they managed his minutes. (Dad likely knew better than anybody how much pain he was in.)

This is a broken leg we’re talking about, in an elite, 23 year old athlete. It takes some serious force to do this…unless things have been breaking down.

What’s more likely is the guy’s leg was degenerating. we already know this, but it was probably more significant than anyone was letting on. He had been limping throughout the playoffs. When “tendinitis” is making you limp, it’s really bad.

Based on his 2013-2015 schedule, where he played basketball non-stop from the fall of 2013 to the summer of 2015, it makes sense for this to happen. To where his leg was degenerating to such a degree, it made a stress fracture more likely, or a tendon ripping off part of the patella more likely. Especially when trying to fully decelerate, where the leg would be put in a position of deep knee flexion, and having to come out of that. Necessitating about as much work as the patellar tendon can engage in.

Or, if it truly was the contact, the degeneration was to such a degree it made a minimal level of trauma cause his bone to break.

But again, this doesn’t look like contact to the knee cap:

Kyrie Irving knee contact

Kyrie Irving knee contact 3

That’d have to be the most superior-lateral patella I’ve ever seen. (It looks like Thompson’s kneecap made more contact than Irving’s.)

Maybe the contact made it so he had to suddenly generate even more force on the leg, because it does look like the contact pushed his knee further forward, which would cause deeper knee flexion and more force on the patella. That I’ll buy, but that is not a freak incident. Who knows how many times these guys bang their knees every game? Either into one another, or the floor. It’s why so many of them wear knee pads.

In this case though, we’re saying some not-unusual running caused his kneecap to fracture. That’s only a freak thing if you don’t consider the context in which it happened. Playing for at least a month on a leg you’re having trouble walking on IS a way to make the leg worse.

It doesn’t matter if Kyrie says it was his decision to play. That’s never his decision. The coaches and training staff are responsible for pulling the athlete back. Especially a young guy, who will have more chances at a championship. Because more often than not, the athlete is going to play if given the green light. Especially if you question their pain tolerance. Especially if you tell them you can’t make it worse, which you always can.

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