San Antonio Spurs star forward and perennial MVP candidate Kawhi Leonard has missed a significant amount of time with a mysterious right leg injury. Officially diagnosed with right quadriceps tendinopathy, Leonard has missed all but nine games thus far this season and a report filed by ESPN’s Adrian Wojnarowski this past Thursday would seem to indicate that his return is anything but imminent.
So what’s going on?
For starters, tendinopathy injuries are much more complex than one may assume at first glance.
“Tendinopathy” is an umbrella term that, if broken down into its component parts, is straightforward, yet vague. The tendin- preface indicates that the injury is affecting a tendon, the connective tissue structure that attaches muscle to bone, whereas the -opathy suffix simply refers to a diseased/disordered state.
A widely known tendinopathy is tendinitis. Tendinitis is, as outlined by the -itis suffix, an acute injury and involves active inflammation and irritability of the tissue.
While it is a common diagnosis in sport, rarely is an athlete’s injury truly a tendinitis. Most often, the athlete’s injury is more chronic in nature, meaning that symptoms have been present for at least three months, at which point a more accurate diagnosis would be a tendinosis (-osis means chronic).
Only one major component is needed in order for an athlete to be diagnosed with a tendinopathy injury: pain. Studies have shown that tendon degenerative changes, a term used to indicate that the tendinous tissue has become more irregular in nature, are common even in athlete’s who aren’t experiencing pain. Therefore, unless pain is present, the tendinopathy diagnosis can’t be given.
The main mechanisms that drive pain in athlete’s with tendinopathies are neural growth as well as what’s known as neovascularization. In neovascularization, new blood vessels and nerves grow into the tendon, causing it to become more sensitive and painful.
Tendinopathies typically arise in professional athletes for at least one of two reasons: a sudden increase in muscle loading (i.e. beginning the season after the off-season) or heavy chronic loading across the athlete’s career (i.e. playing heavy minutes over a long period of time).
The difficult thing with tendinopathies, however, is that the research isn’t clear as to how they can be prevented if they can at all, or what the best course of treatment is.
Eccentric (strengthening the muscle as it lengthens) exercises have been a staple of treatment for tendinopathies for some time now. Research has shown that eccentric exercises can decrease neovascularization and decrease pain in as little as 4-to-6 weeks, but recent research also suggests that heavy and slow concentric (strengthening the muscle as it shortens) may be just as effective.
Corticosteroid (i.e. Cortisone) injections are often used to help dull the pain caused by a tendinopathy, but they only provide short-term relief. Platelet-rich plasma injections are also commonly utilized, but the efficacy of this treatment is constantly in debate. Other treatments such as dry needling (a Western medicine version of acupuncture) are beginning to be researched, with promising results.
However, tendinopathies don’t only affect the muscle tendon, they also affect the brain.
Central sensitization is the concept that the brain and nervous system become more sensitive after prolonged exposure to pain, thus making the pain more severe and/or producible with lighter stimuli.
With Leonard reportedly experiencing tendinopathic pain since last season’s playoffs, it would be fair to assume that he is likely experiencing central sensitization to some degree.
But the main question surrounding Leonard is when will he return to play?
As Wojnarowski reported, he’s already been cleared to play, but the onus is on him to decide when he wants to return. Tendinopathies are typically slow to heal because, even though the treatments stated above seem to be effective, properly addressing tissue loading may not be possible until the offseason.
Athletes often require “controlled rest”, or rehab in combination with decreasing the load placed on their bodies (i.e. cutting down on practice, games, travel, high-intensity workouts, etc.), to recovery properly from tendinopathy injuries.
It can take upwards of six months of proper loading and treatment for an athlete to reduce their pain tolerable or non-existent levels, though everyone heals at different rates.
At the end of the day, and as Wojnarowski reports, it’s up to Leonard to determine if he is able to, or even wants to, play with pain.
There is some evidence to suggest that playing with a tendinopathy places the athlete at a greater risk for rupture and high levels of play can have a deleterious effect on performance. It would not be a negative reflection on Leonard if he ultimately decides to not resume play for the rest of the season.
Tendinopathies are complex injuries with a complex presentation and a complex treatment. They aren’t a type of injury where surgical intervention is a cure or even appropriate. The best ways to treat them is with proper loading, eccentric exercises, and potentially with techniques like dry needling.
Leonard will step foot on the court again, but as to when will remain up in the air for the foreseeable future.
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