In the past two years, ACL tears—one of the most common and sudden setbacks in the NBA—have gotten the most attention of any injury afflicting NBA players, as Derrick Rose, Rajon Rondo, Ricky Rubio, David West, Danilo Gallinari, Lou Williams, Iman Shumpert and Brandon Rush all have gone through the process of recovering from an ACL injury.
It's much rarer to read about a player undergoing a knee treatment based on a chronic ailment, such as arthritis, which can shut down an older player's career.
Occasionally, you'll hear about a knee treatment—typically a major arthroscopic operation—but a team management’s general preference is to share as few details as possible about any medical procedure, which makes accurate reporting on injuries one of the toughest jobs for a beat writer.
Keep in mind, too, that a player himself sometimes won't disclose a nagging problem to his team, to protect himself for a bigger salary in the future, especially in a contract year. In addition, players will sometimes stay hush-hush about an ongoing problem if it's the playoffs or a key stretch during the season to be there for their team, or to earn the respect from their veteran teammates for their toughness and ability to play through pain. Locker rooms in the NBA are not ones for complaining.
One unique circumstance regarding knee treatments came late last week with news of Kobe Bryant visiting Germany to receive regenokine—not platelet-rich plasma therapy (PRP) as some media outlets reported. For one, word broke because it's Kobe Bryant, one of the greatest players ever, and two, the extremely expensive treatment—which is for serious arthritis—requires travel out of the country.
Bryant is just one of many players around the league fighting to keep his career alive while battling knee issues. Just ask Dr. Harlan Selesnick, M.D., the orthopedic surgeon for the two-time defending NBA champion Miami Heat, who has been with the team since its inception in 1988.
For the past 20 years, he has been facilitating preseason MRI scans on both knees for each player. The Heat were actually the first team in pro sports to do that, according to Selesnick, and the Cleveland Cavaliers are the only other NBA team currently doing it. And he says he's seen remarkably few "normal knees" in those exams. Three in all.
Selesnick also said during the course of a season, nearly every player gets treated for knee tendonitis on a daily basis. Also, during the season, 50 percent of players have a treatment at some point on one of their knees, and that teams with older players typically might have six guys undergoing routine treatments.
But even with all of the pounding during a potentially 117-game season (from preseason through every game of the postseason), a player’s longevity and recovery from injury have improved, thanks to doctors like Selesnick and the advancements in knee treatments. Because of these developments, he said he's seen a decrease over the years in surgeries per season—only two on average nowadays—and some don't even involve the knee.
In fact, Selesnick said with the success of the preseason MRI scans—also known as baseline MRIs—he's helped eight Heat players avoid knee surgery through the years. He also said team-administered exit physicals after the season—some involving MRI scans—help with developing strategic summer medical and training programs.
Selesnick, a former NBA Team Physician of the Year who has previously worked on two Olympic men's basketball teams and in three All-Star Games, said the biggest innovation in surgical procedures is that they're less invasive. That has helped reduce arthritis further along in a player's career.
"If you think 20 years ago, if someone had an ACL tear, it was probably a career-ending injury," said Selesnick, who helped perform Michael Jordan's first-ever NBA physical in 1984. "Now if you do an ACL surgery and they don't come back, you think you screwed up the surgery. So things have changed dramatically. Years ago, we used to remove the torn meniscal cartilage, or we would remove part of the cartilage which was torn.
"Now, in many circumstances, we're able to sew back and save the entire meniscus. That cuts down on arthritic risk down the road, so there are a lot of things that have improved dramatically technology-wise. And recovery rates are much better and the success rates are much better, and longevity of players in the league is better."
Looking ahead, will the other 28 NBA franchises outside Miami and Cleveland consider adding preseason knee MRI scans to their fall physicals, which already include league-mandated cardiac and neurological testing? Selesnick said he presented his findings to the other teams' doctors, and there was a positive response. For now, many teams only conduct a knee MRI scan when there's a specific need for one, typically after a sudden injury.
"I think they thought it was good and I think a lot of them would like to do it," he said. "But a lot of it comes down to the teams and the expenses, and whether the team's management thinks it's cost effective to do. To me, it's a no-brainer. If you have 15 guys, you do 30 MRI scans and maybe that costs $30,000."
Will Carroll, who specializes in the coverage of medical issues for Bleacher Report, agreed with Selesnick on the expansion of preseason knee MRI scans. He also offered some other reasons as to why teams might shy away from them.
"I like the idea," Carroll said. "There's some pushback even from players, who are always worried that their medical information will be used against them at contract time. The biggest worry that I've heard from doctors is that in most cases there's a normal level of wear and tear in the knee, and with a totally asymptomatic athlete, introducing any sort of doubt can be counterproductive.
"Dr. James Andrews, M.D., (a highly sought-after orthopedic surgeon who has operated on many high-profile athletes), often says that if a surgeon wants to do surgery, he should just get an MRI. I wish baseline MRIs wouldn't be considered a negative by some since it's great data."
What's also important to Selesnick is making sure Heat players are protected in the offseason when they're working with personalized trainers. With more and more players seeking out advanced workout methods to gain an edge, Selesnick said it's always critical that their medical histories are first evaluated.
"That is a problem that these guys all hire personal trainers and they'll get their agents to send them to someone. Players also hear from other players," he said. "If that's the case, we get in touch with that trainer, so they at least know the medical condition of the player, his limitations and what deficiencies to work on. Things can be made worse if they don't know what they're doing, so we try and at least monitor that as much as we can."
If you're one of many aspiring basketball players out there hoping to make it to the NBA, keep in mind this: Prepare for a possible needle, or more, in your knees. But with the advancements in treatments—and doctors taking more precautionary measures—they might help you play better for a longer time.
Here's a closer look at common knee treatments players receive during the season (all quotes via Selesnick):
Physical therapy or anti-inflammatories
What it's for: "The most common problem we see in basketball players is jumpers knee based on overuse, and that's either patella or quad tendonitis. And most players with patella tendonitis—probably 95 percent—can get better with just the usual treatments of anti-inflammatories or physical therapy. Most guys will have jumpers knee at some point during their career."
How it works: Physical therapy includes flexibility, stretching, strengthening the muscle and increasing range of motion, as well as stimulation or cold laser therapy. "With a lot of guys, we work on flexibility and stretching to cut down on injuries, as well as strengthening their quads and trying to develop a balance for the quads. For example, the inside quad sometimes needs to be strengthened more than the outside quad, depending on the way the kneecap sits."
Anti-inflammatories (prescription or over the counter) include Advil, Aleve, Celebrex, Mobic and Motrin, or a cortisone shot. Also, ice postgame is prevalent around the league.
Is it effective? They often are very effective, but in some cases more extensive treatment is needed.
Cost of treatment: Physical therapy is usually more than $100. Anti-inflammatory drugs are usually less than $100.
Back to playing: Usually one day to a week.
What it's for: "We use this a fair amount on athletes who have early arthritis. What happens is, in joint fluid when you have arthritis, there's a low concentration of hyaluronan (which cushions the knee joint). Someone in Europe, like 25 years ago, figured out you could harvest hyaluronan from the red part of the rooster comb."
How it works: It's a one-time injection-based lubricant into the knee joint. "It cuts down on the wear and tear, and cuts down on the pain in 75 percent of people with arthritis. We've actually done a study showing that it's pretty effective in professional athletes. I know a lot of the NFL teams use it, NBA teams use it, pro tennis. There are different forms of it, but the one that I use most commonly is the one injection shot."
Is it effective? "Compared to PRP and regenokine [see below], the hyaluronan has been around for the longest, so it's been studied and it's shown to be effective. It's not very effective with people with bad arthritis. But in the younger, athletic population, it seems to be quite helpful."
Cost of treatment: About $2,000 per knee.
Back to playing: Usually a day or two.
What it's for: "A very small percentage have chronic patellar tendonitis, and sometimes even some partial tearing of the tendon. In those circumstances, there are other treatments that could be tried—some of which are off-label—such as PRP."
How it works: "A patient's own blood is spun down to the plasma part of the blood that has growth factors, and it is injected into the injured area one time."
Is it effective? "In many circumstances, it can help the athlete, but it's still controversial how well that works. The PRP hasn't been studied enough compared to placebo to know how effective it is. Clinical trials still need to be done to determine if the PRP is more effective than the placebo. Although we're using it and some people believe it's effective for some of the tendonitis—and some people even use it for arthritis—there haven't been enough scientific studies."
Cost of treatment: About $500 to $2,000 per knee.
Back to playing: Usually a week.
What it's for: Regenokine—which was invented by German Dr. Peter Wehling and is known as orthokine overseas—treats more serious arthritis, joint pain and some muscle and tendon issues.
How it works: Anti-inflammatory proteins are drawn and reinjected into the problem joint to block inflammation receptors. It involves six injections over six days. "It's similar in some ways to the PRP, but they add other growth factors and enzymes and stuff that they believe will help cut down on inflammation, and allow players with significant arthritis to be able to come back to play."
"It is not FDA approved in this country. They do certain things with the blood that is not approved here. How they get around to it here I don't know. Dr. Christian Renna does it in L.A. and there's one doctor in New York."
Is it effective? "I have seen a few athletes that it's helped with, and we sent a couple players to have it done. Most of the time, teams don't tell you that they send guys to get it done. Dr. Wehling has used it on many players in the league, and Kobe swears by it, but other guys have had mixed results.
"I think it acts in some way as an anti-inflammatory to decrease the inflammation in the synovium, where a lot of the pain and swelling comes from. But that has not been scientifically studied. Most of (the studies) are anecdotal things. The important thing that Wehling has showed is that it doesn't hurt anybody."
Cost of treatment: About $20,000 to $30,000 per knee. Selesnick said usually the player covers the cost.
"It depends on the league, but under the player's contract, they have to at least notify you of what treatments they're going to get or else it's a violation of the contract. And then the team can say whether it's something that's worth trying or not worth trying. If it's agreed upon, then the team doesn't have to pay for it. Generally, it's not really an issue because the one thing that Wehling has shown is that it doesn't appear that you're endangering anyone or making them worse."
Back to playing: Usually a week.
What it's for: "Another thing that you can use, which is also off-label, is something called orthotripsy. The company that made that is with OssaTron, and that is similar to lithotripsy, which they use to break up kidney stones. In some patients, the tendon attached to the bone doesn't have a good microcirculation. It's got nothing to do with age. You can be 15, you can be 50. Some people just don't have the ability to heal something."
How it works: "The orthopedic surgeon determines that high-energy shock waves produce microfractures of the bone just to simulate a soft tissue healing response by having blood vessels grow into the tissue, and it heals."
Is it effective? "It's approved by the FDA. It's for plantar fasciitis and it can be used off-label in other areas of the body, such as the knee, with some success."
Cost of treatment: About $3,000 to $4,000 per knee.
Back to playing: Usually one to two months.
What it's for: Topaz, considered an alternative to standard invasive surgical procedures, aims to treat common tendon disorders.
How it works: "It's almost like a laser treatment with a tiny incision to remove unhealthy issue in the same type of thing for some chronic patellar tendonitis or quad tendonitis. There's the guy who just died in L.A., Dr. Lewis Yocum, who was the pioneer of the treatment. He worked with Dr. Frank Jobe, who performed the first-ever Tommy John surgery."
Is it effective? "There is some literature on it. I have not used it to be able to tell you personally how it works. The reason why I haven't used it yet is there really aren't many scientific studies, and there are other things that I've found to be effective that are non-surgical."
Cost of treatment: About $2,000 to $4,000 per knee.
Back to playing: Usually two months.
What it's for: Arthroscopies correct problems inside the joint, involving the ligament (such as the ACL) or cartilage (to remove/sew it back or clean it out through a debridement procedure), or to perform a microfracture, in which the doctor cuts into the end of the bone to increase blood flow into the knee joint to improve its function.
"Arthroscopies can be a very simple little procedure where you're taking out a little piece of cartilage, or (they) can be an extensive procedure where you're trying to regrow cartilage and the player is out for a year. And it's all done arthroscopically in the same three little holes. So that's why sometimes you'll see a player back in three weeks playing and another player in a year. It's not that the surgery was screwed up; it's just that the problem was totally different. That stuff the public doesn't quite understand."
How it works: It's a minimally invasive surgical procedure that uses an arthroscope, which is inserted into the joint through a small incision. This gives the surgeon an excellent view of the inside of the affected joint.
Is it effective? Overall, they are effective, but recovery time varies. Regarding microfracture, "If you look at the studies of it, only 40 percent of the pro athletes come back to be the way they were before the microfracture. So those aren't great odds, and 20 percent don't come back at all. Remember, at this level a guy at 95 percent can be the difference between a star and not being in the league. It's not like an average person."
Cost of treatment: Usually in the thousands.
Back to playing: Usually three weeks to a year (depending on the arthroscopy).