Kawhi Leonard's quad injury (diagnosed as a quadriceps tendinopathy) has become a bit dramatic for the buttoned-up Spurs franchise. There have been multiple changes in his timetable for return and Coach Pop has openly been stumped about when he will actually return. Since his initial injury in last season's Western Conference Finals, the Spurs have made it a task to understand Leonard's injury.
Let's go through the general timeline and updates of Kawhi's quad injury:
- 9/30/17 – Coach Pop reveals that Kawhi has a quad injury, will miss the pre-season, with no timetable for return
- 10/13/17 – Spurs confirm that Kawhi's quad injury will keep him out of the regular season opener
- 11/7/17 – Coach Pop comments that Kawhi's quad rehab is coming along slower than expected
- 11/15/17 – When asked, Coach Pop states that Kawhi should be back sooner rather than later
- 11/28/17 – Tony Parker returns from quad tendon rupture (over a month earlier than he expected)
- 12/2/17 – Kawhi returns and plays nine games, averaging up 16, five, and two. He doesn't play in back to back games.
- 1/17/18 – The Spurs list Kawhi as being out indefinitely because the quad tendon didn't respond the way the team wanted
- 1/23/18 – Rumors of a potential rift between the Spurs and Kawhi
- 2/7/18 to 2/17/18 – Kawhi spends 10 days in NY with a quad injury specialist for a second opinion
- 2/21/18 – Coach Pop says that he would be surprised if Kawhi returns this season
- 2/2118 – News that Kawhi has been medically cleared but choosing not to play
- 2/26/28 – Reports come out that Kawhi has begun working out with the team again, is eyeing a March return
Clearly, there's been a lot of uncertainty with Kawhi's timeline and rehab which naturally leads to a lot of hand-wringing.
So what exactly is going on?
Is Kawhi's quad injury worse than the staff is letting on? Is Kawhi just pissed off at the Spurs and doing this to spite them? Did Tony Parker sabotage Kawhi's rehab to prove that age doesn't matter? Is Kawhi's uncle to blame? Does Leonard just need to update his OS?
Or are there valid reasons for Kawhi's ongoing uncertainty of return?
Yes. Three reasons specifically – the diagnosis itself, the neuroscience of pain, and the Spurs medical staff.
I. Kawhi's quad injury diagnosis
Before I get into the actual diagnosis, lets quickly review the quadriceps tendon.
A. The quad tendon
The quadriceps tendon is an extremely important and powerful tendon. It's the convergence point of all four of your quads:
The quad tendon is involved in basically all upright activity and heavily stressed during dynamic movements such as running, jumping, moving laterally, starting & stopping, etc.
Due to this high level of demand, rehab is generally going to take longer and be more conservative because it's imperative that the tendon is at or very close to 100%.
B. The diagnosis – quadriceps tendinopathy
Quad tendinopathy is a general catch-all term for a tendon injury. It simply means that there is a disorder in the tendon.
A tendinopathy generally falls into 4 different phases, from least to most severe :
- Phase 1 – Reactive tendinopathy
- Normal healing process
- Excellent prognosis with normal recovery
- Normal rehab
- Phase 2 – Tendon dysrepair
- Mildly abnormal healing processs
- The tissue deterioration rate is greater than the repair rate
- Good prognosis as the tissue is attempting to heal
- Rehab
- The goal of rehab is to prevent further deterioration of the tissue so the repair rate becomes greater than the deterioration rate
- If deterioration continues, this can lead to phase 3
- Mildly abnormal healing processs
- Phase 3 – Degenerative tendinopathy
- Permanent cell and tissue death
- Poor prognosis as the cells are giving up on repairing
- Phase 4 – Tendon tear or rupture
- Severe tissue breakdown resulting in a tear or complete rupture (grade III tear)
- Results in a loss of function
- Very poor prognosis
- Surgery is often the only option
As you can now see, there's a huge spectrum on the healing process, rehab process, and timeline for return based on the phase. We have no idea which phase Kawhi's quad tendinopathy is in.
The Spurs medical staff haven't given any specific information and a delayed return or poor response to activity doesn't necessarily indicate that Kawhi's quad injury is getting worse.
II. The neuroscience of pain
So we've established that the diagnosis itself doesn't provide an established timeline. Additionally, understanding how pain works gives additional insight into why Kawhi's return has been so variable (I also touched upon this in my piece about Lonzo Ball's MCL injury).
A. How pain works
Pain is an output from the brain. The brain's key role is to survive and keep it's vessel – the body – functioning and alive. It does that by constantly assessing threat and when it senses danger, it sends out pain as a signal of “don't do that! It's dangerous!”.
Here's a basic overview of that process:
This is a key tenet of understanding chronic pain and why pain can exist far after a tissue is healed and medically cleared. An analogy I like to use (full credit to Seth Oberst, I heard him explain this multiple times during my rotation with him) is this:
Think of your body as a car and the brain as the car's alarm system.
If you're living in a dangerous neighborhood that has a lot of car theft, you want the car alarm to be really sensitive and aware of potential threats.
However, you move a to a much safer area with no car theft, but the car alarm continues to be really sensitive. It's now perceiving innocuous things as threatening and goes off constantly.
This parallels what happens with the brain and pain. The brain, even after the acute injury and tissue are healed, continues to perceive that body region as threatened, resulting in a constant pain “alarm” going off.
When you continue to push through pain for a prolonged period of time, your brain begins to anticipate having pain with those movements (it's almost like Pavlonian conditioning of pain ).
Additionally, increased stress, frustration, anger, etc (each of which up-regulate your sympathetic nervous system aka “fight or flight” system) increases your perception of pain, sensitivity to pain, and generally is not conducive to a healing environment.
Check out a visual of this vicious cycle:
So how does this all apply to Kawhi?
B. Kawhi's quad injury pain saga
We know Kawhi has constantly been dealing with soreness and irritation of his quad tendon throughout his rehab process. Coach Pop has commented on it multiple times. This now long-term pain serves to reinforce that movement is painful and threatening.
Adding to that is the fact Kawhi did come back for nine games and he experienced residual soreness and pain throughout, eventually getting shut down because the quad tendon didn't respond the way the medical staff wanted it to.
Even though it was just nine games, playing through pain again reinforces the expectation of pain. There's the possibility that previously pain free movements are now painful because the brain is on high alert (the car alarm is going off whether it's a four-year-old toddler crawling by or anyone else).
Now, let's think about the level of stress, frustration, and likely anger that Kawhi has felt throughout this process.
- He's a 25 year old kid at the height of his career who just came off a season where he was arguably the best 2-way player in the league and the face of the Spurs franchise. He wanted redemption after getting taken out by Zaza with his team up double figures in game 1 of the western conference finals vs the Warriors.
- He gets hurt over the summer and is originally told that he will be back by the start of the regular season. Ok, no big deal.
- Regular season rolls around and there's still no timeline. He's still dealing with constant soreness and pain. Setback.
- Rehab continues to go slower than expected, and then he sees his teammate – Tony Parker who suffered a full quad tear, a relatively rare but far more serious injury of the same tendon, at the age of 34 with nearly 17 seasons of wear & tear on his body – come back before he does. Man, what the heck?
- Comes back for nine games but his quad injury continues to be very sore and he's eventually shut down indefinitely.
- Seeks an outside medical opinion in New York.
- Still no timeline on his return, with Coach Pop saying that he might not even return this season
Just reading all this makes me angry and frustrated – and that's even with my detailed understanding of the injury and pain science. Imagine how he feels!
He's had basketball taken away from him, is a franchise player but can't help his team, and isn't sure if he'll even return this season.
Both Coach Pop and GM RC Buford have touched on Kawhi's emotional state:
Pop, according to Jeff McDonald of San Antonio Express-News: “He's given it a shot. He’s frustrated as hell. He wants to play badly”.
“This has been difficult for everyone…it's been difficult for Kawhi. He's an elite-level player. It's been difficult for the team, because they want to play with a great teammate. And it's been difficult for our staff. Historically we've been able to successfully manage injuries. This rehab hasn't been simple, and it hasn't gone in a linear fashion…we sought outside expertise with the best tendon experts in the world…it worked beautifully for Tony [Parker], but it hasn't worked the same for Kawhi.”
As RC Buford noted, there's frustration amongst the entire organization and it's only natural to believe that at some point Kawhi is going to become frustrated with the medical staff and organization as his own anger builds – leading to the reports of possible discord between him and the Spurs.
Like I touched upon above, this stress, anger and frustration all plays into and affects how Kawhi perceives his injury, how sensitive he is to pain, and the general healing environment.
Kawhi's neuro-cognitive pain and high stress and frusration adds another layer of complexity and haziness to his timeline for return.
III. Kawhi's quad injury prognosis
The reality with Kawhi's quad injury and his specific context is that there are too many variables and grey to put a finite timeline on it.
A tendinopathy diagnosis already exists on a spectrum and the added layers of pain neuroscience convolute that even more.
That being said, there are two huge positives for Kawhi.
A. Spurs medical staff
There's no medical staff or organization that I trust more than the Spurs. The track record of their medical team speaks for itself:
- Least amount of player games missed since 05-06
- Were the first team to strategically rest players
- Very forward thinking, proactive, and understand risk/reward very well
Their medical staff understands that Kawhi's quad injury and tendon need to be at or near 100% so the tendinopathy doesn't progress.
This is especially true for Kawhi because in addition to the huge stress that NBA movements put on the quad tendon, Kawhi is a two-way franchise player. This means more minutes, often guarding the opponent's best player, generally having an increased role on both ends, playing during the most intense stretches of the game, etc. All this adds up to increased stress on Kawhi's quad tendon compared to the average player.
Additionally, if any team understands pain neuroscience intimately and how it affects healing, I'd wager it's the Spurs. They are so forward thinking and ahead of the curve.
The medical staff utilizes incremental rehab progressions & protocols that mitigate chronic pain tendencies. We've seen these protocols throughout the entire process including shutting Kawhi down after 9 games when the quad injury didn't respond appropriately.
Further, the medical staff and organization have been fully supportive of Kawhi. Even when he spent 10 days in New York for a second opinion, the Spurs training staff was there working out with him.
Lastly, the medical staff has a clear understanding of risk/reward. Kawhi is only 25 and even though the Spurs are the third seed, they understand there's too much risk here to rush him back.
We already have clear examples, involving Kawhi, of just how cautious the Spurs medical staff is.
- In last year's western conference semi-finals vs the Rockets, Kawhi sprained his ankle in Game 5 and then wasn't cleared for Game 6.
- When Kawhi again sprained his ankle in Game 1 of the western conference finals, they held him out the rest of the series.
These decisions were made even though there was everything to play for. The Spurs staff doesn't play when it comes to injury risk and it's one of the things I respect most about them.
B. Coach Pop and GM RC Buford
There's not a better coach and GM duo in the league. No one is as connected to their players, handles disagreements, or player issues quite like these two.
Let's use LaMarcus Aldridge's situation as an example. On how many other teams – Kyrie in Cleveland comes to mind – does LMA's discontent blow up into something huge to the point of no return. Instead, we didn't even find out about LMA's trade request until months after the fact.
I have no doubt that Pop and Buford are extremely connected to Kawhi, the medical team, and are in constant communication with both. These two are the best in the business when it comes to organizational and player relations, bar none.
C. All in All
Taking everything into account:
- The tendinopathy diagnosis making it difficult to establish a timeline for return
- The pain neuroscience factors stemming from Kawhi's extended duration of soreness and pain and stress/frustration adding more haziness to a timeline for return
- Spurs medical staff being ultra conservative yet very effective
- Spurs organization being unrivaled in regards to player relationships and conflict resolution
This long variable process, although not ideal, doesn't worry me. I'm confident that Kawhi's quad injury will be resolved and we'll see him back at 100%.
When? That I can't tell you. However, I'll trust the judgement of the Spurs medical staff and organization every time.
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