A fractured knee, Kyrie Irving and a lesson learned

Let’s start from the beginning. Midway through overtime in Game 1 of the 2015 NBA Finals — his debut on the NBA’s grandest stage — Kyrie Irving tried taking Klay Thompson off the dribble, driving to the right elbow, where he collapsed in pain (and still made the right pass).

“I tried to stop on a dime,” he said days later, recounting the injury. “I’ve done it thousands of times. I tried to get out of it with my knee. I tried to stop myself, and all my force went to that knee, and I believe Klay hit it in the right spot at the right time, and it fractured my kneecap.”

Fast forward to 2018, and Irving aggravated the same knee in the Celtics’ March 3 loss to Houston. He missed the next game with what the team termed left knee soreness, returned to torch Minnesota three nights later, and then left at halftime of Sunday’s loss to Indiana, citing the same issue. Afterwards, Irving insinuated he would require multiple games of rest.

In an effort to better understand the challenges Irving has faced, currently faces and will face, I reached out to the leading experts at Tufts Medical Center, Boston Medical Center and Beth Israel Deaconess Medical Center — none of whom have direct knowledge of Irving’s case, all of whom are orthopedic surgeons with extensive experience treating knee injuries.

That disclaimer again: These guys don’t know the Celtics star or his knee; they just know a whole heck of a lot about fractured kneecaps. Still, there’s a lot to learn about the issues Irving’s faces this year and beyond.

There is some question as to whether Irving’s Finals debut really was the beginning. Eighteen months earlier, on New Year’s Eve 2013, he suffered what at first appeared like a similar injury on a drive against Indiana.

“I thought the worst happened,” Irving said, before missing three games with what the Cavs called a knee bruise. “I felt something pop in my knee. When I came back in, my left knee is pretty weak right now. I was falling all over the place. I didn’t have my legs under me. It was a painful experience.”

Again, in December 2014, he bumped knees with Russell Westbrook, tried playing through it, and then sat two games with another left knee bruise.

“I definitely felt something buckle,” Irving said then. “I was just really scared, but … the biggest thing when something happens like that, is opening up your eyes and just realizing everything is going to be all right, no matter what the verdict is. So I just had to get my bearings together. It was a scary play. I still don’t want to look at it. I won’t look at it. I’ll be all right, though.”

Irving battled patellar tendinitis in the first few rounds of the 2015 playoffs, enough to visit with the famed Dr. James Andrews between tweaking the knee again in Game 1 of the East finals and sitting out Games 2 and 3. Irving played 22 minutes of a closeout Game 4 blowout of Atlanta, and then 44 minutes of Game 1 against the Warriors before the kneecap cracked.

“It was a little bit different than what I had been experiencing,” Irving said after the game and before the season-ending diagnosis. “[Before,] there was a quick pinch, but I could still feel what was going on in my knee. This time, I kind of knew it was a little bit different [from] the other times.”

If Thompson did “hit it in the right spot,” it wasn’t with much force.

“Most of the time when you fracture your kneecap, usually it’s from some sort of direct trauma involved right on your knee,” Dr. Christopher Geary, Chief of Sports Medicine at Tufts Medical Center, told Parquet Post. “In his case, I think he basically completed a stress fracture in his knee.”

Such injuries can result from one or more stress reactions that progress to a fracture, from overuse, or from an individual’s predisposition anatomically. Or some combination of all those things. Kneecaps can fracture in myriad ways, the simplest of which is a transverse break upon which the bone splits in two, and that’s generally the easiest such injury to repair and restore.

“Once the bone heals [in 10-12 weeks], you can expect it to function fairly normally, as long as the articular surface underneath is not damaged badly,” Dr. Paul Tornetta, Boston Medical Center’s chief of orthopedic surgery, told Parquet Post. “Now, there are other types of breaks that are a little more difficult, that are almost like a tendon rupture than they are like a break.”

Greater concern comes with damage to the cartilage on which the patella slides, or to the patellar tendon that connects the kneecap to the tibia.

“If you were to land really hard with enough force that was stronger than your ligament, you might rip that patellar tendon right off the patella,” added Dr. Tornetta, “and there are variations of that.”

The patellar tendon can rip bone with it, too, which sounds as bad as it is. Long story short, there are degrees to which one can fracture a kneecap, none of which we know for sure Irving suffered. But the more damage to the bone and the soft tissue around it, and the closer it occurred to the foot than the hip, the less likely it is to heal properly and the longer the recovery.

“There’s another whole subset of fractures where you may have significant trauma to the knee or the bone quality may not be great where it breaks into a number of pieces, and some of those fractures require treatment as well,” said Dr. Arun J. Ramappa, Chief of Sports Medicine at Beth Israel Deaconess Medical Center. “There are different surgical ways to fix each of these.

“Usually, people do relatively well with this. They heal up, and it takes in general three to six months to recover, but to achieve higher-level activities such as professional basketball it may take longer.”

Irving returned on Dec. 20, 2015, almost two months into his next season and a little more than six months after suffering the fractured kneecap.

Irving rested twice between his first five games back and thrice more during the final 10 games of the 2015-16 season. He then played all 21 playoff games, culminating in his series-winning shot over Warriors guard Stephen Curry in Game 7 of the Finals. Kyrie Irving, it seemed, was a man in full.

He played 60 of his first 67 games in Cleveland’s title defense, with rest days surrounding missed games for right hamstring and right quadriceps issues.

Then came Irving’s first public acknowledgement of left knee soreness.

In mid-March 2017, Irving said his left knee felt sore in the days leading up to a game against Utah and tightened up in the fourth quarter, almost identical symptoms at an almost identical point of the season as his current ailment.

He missed the following game, played the next 12, and then sat out the final two games of the regular season, when his knee felt “terrible” and the Cavs conceded the No. 1 seed to Boston. “Sometimes it’s going to hurt,” Irving conceded at the time. “And I’ve got to be able to deal with it.”

There are people with surgically repaired kneecaps who forget which knee they had the procedure on, because it heals without a hiccup, most likely after a clean break. For others, especially someone meeting the activity demands of NBA basketball, residual pain is normal, and there are all sorts of reasons for post-surgery soreness and inflammation in that knee.

“When you break the bone, a lot of times there’s some damage to the cartilage on the other side,” said Dr. Geary. “And that’s the kind of thing that can give patients problems moving forward.”

It’s normal to experience activity-related pain if, say, there’s even an iota of “cartilage death” from the injury or the bruising that contributed to it, or if the patellar tendon pulled some bone with it and didn’t heal to the patella properly, or even if there’s no structural damage to the knee at all.

“Someone like him I’m sure rehabbed great, but in general your femoral strength — the strength of your quadriceps, your hamstrings, how stretched you are, the muscle balance around the knee — really contributes to that femoral joint functioning well and the knee functioning well,” said Dr. Tornetta. “So, there’s a lot of other things that can come into play. There’s weakness that might make you have more sort of anterior or front knee pain, even though there may not be anything wrong with that joint, because it’s seeing more stress, because it’s not balanced in the way that it moves. Trying to speculate on any one person’s problem is really tough.”

You’ll notice a theme. It’s impossible to diagnose a patient without having seen his MRI. All three doctors will remind you of that repeatedly. There are orthopedic surgeons who dedicate their entire careers to patellofemoral joint. It’s complicated. Yet, there’s still more we can learn here.

This time last year, Irving had five days to rest his sore left knee before the 2017 playoffs. Sweeps over Indiana and Toronto in the first two rounds and a five-game series win over the C’s in the conference finals provided a total of 21 days of additional rest between series. He didn’t miss a playoff game, averaging 29 points in 40 minutes over five games against the Warriors.

Now, after sitting the second half of Sunday’s game against Indiana, Irving suggested he could use a similar pre-playoff sabbatical. He sat Wednesday’s loss to Washington, and he’s “unlikely” to play Friday in Orlando.

Dreams of capturing the No. 1 seed took a death blow over the past week for a variety of reasons — Toronto snapping Houston’s win streak and the Celtics suffering injuries to roughly half the roster chief among them. With the C’s all but locked in to the two-seed now, there will be ample opportunities for rest down the stretch, and that’s good news for Irving.

If you’ll recall, Irving suffered from tendinitis prior to his fracture kneecap in 2015. According to ESPN’s Adrian Wojnarowski, “there’s confidence” Irving’s current “left knee soreness is no more than tendinitis and that he will not need to miss significant time.” The fear, at least from my limited perspective, is that one might lead to the other again, but in reality that’s not the case.

It’s “highly unlikely” Irving suffers another kneecap fracture or ligament injury as a result of the residual pain he’s experiencing, per Dr. Geary. “If he pushed it, and it flares up a lot, then it’s more like, ‘OK, what can we play through?’” he said. “Anything’s possible, but it’s not something that sticks out on my radar like, ‘Oh, geez, he’s going to injure this other thing.’”

“Activity modification is always the most conservative and safest thing to do,” added Dr. Tornetta. “Very few things get worse by holding off.”

In other words, rest might be the best medicine. For now. If what once subsided after two or three days of rest now takes a week or more, that isn’t always cause for greater concern. Playing through the playoffs on some combination of physical therapy, pain management and even a cortisone shot before readdressing the injury in the offseason isn’t a significant risk.

“That’s not unreasonable,” said Dr. Tornetta. “If he had, for instance, some cartilage injury, maybe one day it’s inflamed and rest allows it to settle down. … There’s a lot of stuff that could be treated with rest and conservative measures, maybe some bracing, that would be reasonable to wait and watch. And maybe it would be better the next time around if it had a real long time to rest.”

As injuries to the rest of the Celtics roster mount and the Raptors establish themselves as the clear favorite with each passing game, that “real long time to rest” may come sooner rather than later, and the “This was always about next year anyways” mantra becomes clearer. What that means for Irving, as you may have guessed by now, may take many forms this offseason.

Per Cleveland.com’s Joe Vardon, “Irving needs minor knee surgery as a follow to the procedure he underwent during the 2015 Finals to repair his broken kneecap. It’s not pressing … but the procedure would ease some of the swelling and day-to-day pain he feels.” Irving reportedly used this as leverage to leave Cleveland, threatening to undergo surgery and miss the season if the team did not fulfill his trade request, Vardon’s sources said.

Irving denied the second part of that report in January. As for the part about potentially needing surgery, he added, “It sounds like a HIPAA violation.”

Concern about Irving’s knee only grew with the recent news of his left knee soreness and Celtics president of basketball operations Danny Ainge’s revelation on 98.5 The Sports Hub last Thursday that, “I think that it’s something that he’ll have to manage the rest of his career.”

Ainge followed this Thursday by adding, “He has some surgery that may need to happen, but maybe not this summer, maybe the following summer, or maybe the summer after that. I think he could probably do it any time he wanted, but I’m not sure that it’s needed at this moment.”

Irving is 25 years old, a five-time All-Star, and the future of the franchise. Eyebrows were raised. So, we asked all three of our experts on orthopedic surgery how customary follow-up procedures are on fractured kneecaps.

“It is not so uncommon to require additional procedures after this kind of injury,” said Dr. Ramappa, clarifying he knew nothing of Irving’s history.

“When I hear that I’m not like, ‘Oh, wow, that’s really weird,’” added Dr. Geary. “I would say it’s not common, but it’s not uncommon.”

“A follow-up treatment plan, yes [that’s normal],” said Dr. Tornetta. “A follow-up surgery would be a little bit abnormal, but you’re talking about someone who’s functioning at the 99th percentile of people. If this were you or me with the same thing, would we have a problem with whatever is going on in that person’s knee at a normal activity level? Maybe not. It’d be hard for me to speculate on what would be the norm for a professional athlete.”

It may sound strange when Ainge says Irving’s secondary surgery, should he require one, could be postponed beyond this summer, but it’s actually not.

“If a secondary procedure is needed, it doesn’t change it much,” said Dr. Tornetta. “If your bone didn’t heal bone-to-bone and healed with scar tissue, for instance, and you can modify your activities to get by, you can get years out of that and maybe it eventually heals. On the other hand, if it just continues to get worse, it’s the same injury, so a lot of things can be waited on very successfully.”

Once again, there are a variety of reasons why someone would require a follow-up procedure. For the most part, they fall into two categories. Some — like a patch of rough cartilage that can be smoothed to allow the joint to move free from obstruction — only require arthroscopic surgery.

“It’s an outpatient procedure,” said Dr. Geary. “Most patients are on crutches for a day or two days afterwards. For getting back to something like high-level NBA basketball, it’s probably more like a month, maybe longer, contingent on how extensive it is and how you recover.”

It seems unlikely (my speculation, not theirs) that Irving wouldn’tundergo a similar surgery this summer, if it only costs him a month and he could be symptom-free by the start of next season.

Other procedures — like, say, the bone didn’t heal properly, the cartilage behind it eroded, the soft tissue sleeve around it needs repairing, the patellar tendon either partly healed or didn’t heal to the kneecap — require revision surgery. Or what amounts to a redo. And that’s not great.

“In general, it’s at least as bad as the first, if it’s one of those major problems,” said Dr. Tornetta, who has treated a number of these instances. “Revision surgeries for fracture care and healing generally are a little bit worse off than the original one. The first one goes best if it goes best.”

Red Sox second baseman Dustin Pedroia, for example, tore the meniscus in his left knee, underwent surgery to repair that cartilage last offseason, and then required a more significant cartilage-restoration procedure this past October that is likely to keep him out seven months.

There are some other procedures that present an entirely different set of obstacles. “If they’re just tracking issues, the way the kneecap tracks on the femur or the way that it sits or the way that it’s moving,” added Dr. Tornetta, “that can be a bit more nuanced and challenging to solve.”

If Irving might require a more serious surgery down the line, you can understand why he and the Celtics would want to continue the rest-and-recovery route that has gotten him through the last two seasons at an All-Star level playing 85 percent of the regular season and into the playoffs.

Asked after sitting the second half of Sunday’s loss to Indiana if he’ll need another surgery in the future, Irving said, “I don’t know. I hope not. I’ve been down that road before. I’ve had a fractured kneecap already. So I think taking games like this, being smart about it probably will put me in a better position not to be out for a long period of time. That’s the last thing I want to do.”

“It’s a normal way of dealing with it, in that you’re going to give it more time off if it’s feeling worse,” said Dr. Geary, “but if you’re getting to a point where you’re playing two or three games and you have to take off two weeks, you’re trending in the direction of needing an operation for it.”

Irving is traveling with the team this weekend and could return Sunday in New Orleans. That would be six days of rest. He has not missed two weeks or more than three straight games since returning from surgery in December 2015. Here’s hoping he doesn’t ever have to go back to the beginning.

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