Like other diehard NBA fans, I groan when I hear about “load management” or see “DNP-Rest” in a box score. We whine about it in my NBA group chat. I think that most fans, fantasy basketball players, TV partners, and sports bettors feel the same way. So would some of the best NBA players. Remember the story of PJ O’Byrne, the 10-year-old girl that went to Ball Arena decked out in Warriors gear with her “MVP Steph Curry” sign in hand, only to learn Stephen was spending the game at home on his couch? He’d been ruled out to rest his body. As a sports medicine physician, I found myself wondering: Is it all worth it? The answer may surprise you.
“I think it’s apparent [that] injuries are not declining,” says Jeff Stotts, ATC and owner of the popular injury-tracking website In Street Clothes. “The number of games lost to injury or illness in the NBA were at an all-time high last season.” When I spoke with Stotts earlier this week, he noted that total games lost to injury were even higher through the first portion of the 2022-23 season. Through November 29, two of the stars we were hoping to see this year after they missed most of last season—Kawhi Leonard and Damian Lillard—had played in only 24 percent and 55 percent of their teams’ games so far, respectively.
So what’s going wrong? “It’s impossible to identify one specific thing influencing the growing rates as it’s likely multiple factors,” says Stotts. “While the treatment and approach to sports medicine has evolved, and continues to evolve, the game has also changed in the process. Players are asked to do more and cover more ground as the game has expanded to the three-point line and beyond, resulting in more stress and load applied to each athlete.”
Over the past decade, general “pace of play” changes such as the 8-second rule and 14-second shot-clock reset have created a faster game, favoring more athletic players. Changes to defensive rules and position-less lineups have fostered an era of constant switching on defense, which has resulted in players moving laterally more often during game play. Players are running faster and covering more mileage in today’s game than ever before.
Looking at this question through a medical lens: are we, as a sports medicine community, doing an inadequate job with load management and biomechanical evaluations? Or is today’s game so different that our interventions have helped players adjust to a completely different game than what was being played 15 years ago? Are we nearing the biological limit of what players can do with their bodies?
To try and answer these questions, I spoke with Dr. Marcus Elliott, a sports scientist and founder of the Peak Performance Project (P3). P3 has been studying athlete biomechanics for over 15 years and has been working closely with NBA athletes throughout that time. Every athlete at the NBA rookie combine undergoes a biomechanical assessment by P3, and as of the start of the 2022-23 season, 64 percent of NBA opening day roster athletes have been evaluated by P3. Dr. Elliott sees P3 as “an academic research project embedded in professional sport.”
As I sat at my laptop on a typical frigid November day in Detroit, Dr. Elliott logged onto our Teams chat from his facility in Santa Barbara. At the time of our call, my hometown team’s star and SLAM 238 cover star Cade Cunningham was on his way to P3 to be evaluated. I was glad to see both the Pistons and Cade’s personal team were taking this step to protect his short-term and long-term health. He had missed a few games with shin pain, which may seem unalarming to the casual fan. But when I see an athlete experiencing shin pain in the office, one concern I must rule out is a stress fracture. This diagnosis was first mentioned by Shams Charania on November 19.
“Thankfully we have baseline data on Cade from when he entered the League and was healthy,” Dr. Elliott said. “How we move has significant implications around what happens to us in the future, both in terms of injury and performance advantages/disadvantages. We can assess his motion to find any imbalances or compensation patterns that have developed and may have led to this injury. Then, we can recommend exercises to correct these patterns and prevent continued strain on this area. The baseline testing allows us to create a very granular return-to-play (RTP) protocol.”
P3 started off using a variety of tools and medical tests to assess athletes, including EMG (electromyography to assess muscle and nerve function), EEG (electroencephalography to assess brain wave patterns), and accelerometers (to measure acceleration and deceleration of player movement). But it wasn’t long before they gave up all that fancy stuff. “We realized early on that the keys were in biomechanical assessment,” said Dr. Elliott. “We got huge amounts of useful input relative to the other tools.”
Sometimes, injuries occur and not much can be done to prevent them. Chet Holmgren was the No. 2 pick in the 2022 NBA Draft and fans everywhere were excited for his debut. However, this summer he suffered a Lisfranc injury in a pickup game, keeping him out for the entire 2022-23 season. “With Chet, he is an example of someone who was moving very well on his initial assessment, and then experienced an incredibly atypical injury for his sport,” said Dr. Elliott. “So we expect a full recovery for him, and we can use his baseline to create his RTP protocol resulting in a return to his usual movements. We do not expect to see an overuse or compensation-related injury based on his movements.”
“It’s a player-driven league, and it’s on us to make an athlete’s life better by preventing injuries and extending careers,” said Dr. Elliott. A study of 400 NBA athletes shows that, based on biomechanical assessment, P3 is able to predict a knee injury with 75 percent accuracy. This is groundbreaking work—the ability to assess and predict injury while an athlete is healthy! Talking with Dr. Elliott, my mind jumped immediately to the athletes—what if teams got hold of this data and used it to influence their draft decision-making or to leverage player contracts? Dr. Elliott nodded, understanding this concern.
“We hear this concern and are ultimately here for the athlete. We give the data directly to the players, who are welcome to share it with someone they trust. Nowadays it is more accepted to undergo this type of assessment. Not only are we building a means of helping players, but the players really seem to appreciate the opportunity to contribute to the health and longevity of those who come after them.”
Understanding that Dr. Elliott is clearly on the cutting edge of sports science, what does he think of the load management movement? What does the future hold?
“The systems of an athlete are overloaded, which leads to an overuse injury. But frequent rest results in ‘de-training.’ Despite the tools and technology currently available, load management is still distributed somewhat evenly across the 15-man roster. Load management is completely overcooked right now. The best load management requires objective assessments with a significant subjective component. Machine learning is also key for the future.
“These technologies that allow us to estimate loads, when not in the hands of a skilled operator, are actually taking teams further into the weeds versus serving them, leading to players becoming less robust and more vulnerable,” he added. “Load management is missing the other big piece of the equation, specifically how [each athlete is] vulnerable mechanically (and to a lesser extent metabolically). What is the [quality of their movement] and do they do things mechanically that are specifically increasing risk?”
Understanding this is key to measuring how much a player’s body can be loaded (playing time, practice time, workouts) based on the current state of the player’s individual biomechanics. Furthermore, loads can be increased when a player’s biomechanics are optimized.
He also sees a future where P3 will be utilized by the entire NBA in a similar way as SportsVU. SportsVU provides the arena-mounted camera systems and proprietary software that tracks player movement. Once a luxury for a select few teams, SportsVU is now standard in every arena and data is shared for the benefit of the entire league. Dr. Elliott’s hope (and mine as well) is that P3 will follow a similar path. The Spurs and Jazz franchises were the early adopters, and the plan is for P3 to provide assessment and recommendations to every single NBA athlete in the near future.
And for amateur 37-year-old athletes like myself?
“We hope to democratize this in the future. Right now, you do what you love until something hurts. You go to see an orthopedic doctor that tells you to stop doing the thing you love,” said Dr. Elliott. This is admittedly an accurate description of both my own experience and how I typically first meet patients. In the world Dr. Elliott envisions, I could have had an assessment and worked on correcting my running gait to prevent the smattering of issues I’ve dealt with. I would jump at the opportunity to provide that kind of tool for my patients. I’m sure it makes more economical sense for players who have $100 million contracts and jobs requiring them to maintain their athletic prowess—but I anxiously await the day when this technology is available to everyone.
For now, let’s hope that the NBA and all professional athletes will adopt these methods. They can play, we can watch, and your favorite players are able to log a few more games at full strength for fans to enjoy. Everybody wins.
Danny Seidman is a sports medicine physician, NBA fanatic, and lifelong Pistons fan. This is his first article for SLAM. He can be found on Twitter and LinkedIn.