Kawhi Leonard’s knee injuries and why he needs load management

LA Clippers superstar wing Kawhi Leonard has missed multiple games this season for “load management”, a strategy that Kawhi followed last season, to great success, by playing in only 60 regular season games under the guidance of the Raptors medical staff.

In this article, I’ll explain Kawhi’s ongoing knee problems and why “load management” is a critical piece for managing his health and fitness. If you prefer a video format, I have you covered.

The injuries

#1 – Right knee quadriceps tendinopathy

In the summer of 2017, Leonard developed what the Spurs medical staff diagnosed as “right quadriceps tendinopathy”. The injury caused Kawhi to miss all but nine games that year and led to the eventual fallout between Kawhi, his camp and the Spurs organization.

#2 – Right knee quadriceps hematoma

In addition to the tendinopathy, there were some reports – specifically based on the second opinion that Kawhi and his camp received from specialists in New York – that Kawhi also suffered a deep contusion or bruise in the right quad itself.

If a pool of blood forms a lump over that contusion (known as a hematoma), it can cause the development of hardened calcium deposits and possibly even bone growth at the site of injury (known as myositis ossificans). This can lead to impaired function and persistent pain and discomfort.

#3 – Left knee patellar tendinopathy

During the Raptors 2018-19’ eastern conference finals series vs the Bucks, Kawhi began limping on his left leg. It became obvious after this dunk in Game 6 where he landed awkwardly.

However, Kawhi was able to play through the issue and lead the Raptors to a championship; yet it continued to bother him over the summer.

The only thing we knew about the injury at the time was that – as reported by the The Athletic’s Sam Amick and Joe Vardon – it was a compensatory injury that developed in response to Kawhi favoring his right quad and leg.

Specifics of the injury became public early this season when Kawhi was held out for his second load management game and the NBA fined Doc Rivers for misleadingly saying Kawhi was healthy – possibly because the team or Kawhi didn’t want any injury news getting out, especially after all that he’s dealt with before – even though the Clippers were submitting evidence to the league to justify Kawhi’s need for missing games.

Accordingly, the league issued a clarifying statement that Leonard was dealing with left knee patellar tendinopathy and therefore had been approved for load management.

What is tendinopathy?

Tendinopathy literally means pathology of a tendon. The injury exists on a continuum, classically organized into three stages with increasing severity.

Stage 1

Stage 1 is called “reactive tendinopathy”. It’s a short-term adaptation of the tendon to a sudden increase in stress or direct impact to the tendon. The tendon will typically thicken, increase in stiffness, and then revert back to a normal tendon.

Stage 2

Stage 2 is called “tendon dysrepair”. It’s a progression from stage 1 that occurs when the tendon continues to take on an inappropriate level of load and is unable to revert back to its normal state. At this stage, disorganization of the tendon fibers and cell matrix is now visible on MRI and ultrasound scans, which is typically how it’s diagnosed.

Stage 3

The final stage on the spectrum, stage 3, is termed “degenerative tendinopathy”. It most typically occurs in athletes due to continued overloading of the tendon. At this stage, the changes in the tendon are characterized by cell death and general disorganization of tendon fibers. The changes are now considered irreversible and the prognosis is poor.

What stage does Kawhi have? 

We don’t know the specific stages of Kawhi’s tendinopathies and likely never will but here’s my hypothesis based on key indicators.

Right quadriceps tendon

Based on the long-standing nature of his right quad tendinopathy, the fact that Toronto and Kawhi’s camp felt the need to closely manage it last season, that it was still bothering Kawhi enough to cause compensation in the left leg over the course of last season and into the playoffs, and that his team reportedly made load management a key prerequisite during free agency meetings, it leads me to believe that Kawhi’s right quadriceps is firmly in stage 2, tendon dysrepair. 

Left patellar tendon

Considering the left patellar tendinopathy reportedly developed over the course of last season, the fact that Kawhi had to keep playing through it during the playoffs due to the high stakes and therefore couldn’t rest it, and how it remained an issue even after resting and rehabbing this summer, it leads me to believe that it’s in stage 1 possibly sliding towards stage 2.

Kawhi’s need for load management

Regardless of which hypothetical tendinopathy stage he’s at, what we know for certain is that the nature of his injury is such that it can become progressively worse without proactive, effective management of it.

A key part of that management is placing an appropriate amount of load through the tendon without overdoing it, hence “load management”. The right amount of stress will make a tendon adapt and become stronger whereas an inappropriate amount of stress leads to sliding down the tendinopathy scale.

Therefore, Kawhi is using load management to balance out activity and nip any worsening of the tendinopathies in the bud. This needs to be done consistently throughout the season – so no, it doesn’t matter that the season is still young – to maintain that appropriate tendon-load relationship.

That relationship can be very sensitive because once you fall behind a tendinopathy during the season, it can be extremely hard to play catch-up.

Two examples from last season

Josh Hart

Former Lakers guard Josh Hart began to develop right knee patellar tendinopathy during the 2018 summer league, continued to play, and eventually it blew up on him in late December to the point where he was basically unplayable in January. To combat it, he had a PRP injection in February but after that failed, underwent a season ending procedure – called an  “ultrasonic debridement of the tendon” – to remove damaged fibers.

Joel Embiid

The second example was Sixers big Joel Embiid who was held out of eight games after the All-Star break to reduce stress and undergo dedicated rehab on his left knee patellar tendinopathy. However, Joel continued to battle with it during the postseason, culminating in him missing game three of the Sixers first round series vs the Nets and playing relatively limited minutes throughout.

The tendinopathy was a key factor for Embid dropping 20 pounds this past summer and the Sixers continue to implement proactive load management with him this season.

All in all

Kawhi is dealing with bilateral knee-related tendinopathy that has to be effectively and proactively managed by modulating activity intensity and load, aka load management. It’s a very sensitive balance and tightrope of risk/reward. That tightrope and possibly ongoing discomfort may be reflected in Kawhi currently putting up some of the worst TS%’s of his career and a stark drop-off from last season, thus far.

It behooves Kawhi and the Clippers to be smart about his knees and sit out games as needed, especially when the alternative is playing a constant game of catch-up and potentially progressing towards or worsening a degenerative tendon. 

Kawhi’s already experienced what happens when he tries to push through the discomfort and that’s clearly not a lesson he’s forgotten, particularly now that he’s dealing with it on both knees. Frankly, not implementing load management at this stage would be irresponsible to his health and career.

That’s a wrap for this article. Thanks for reading. My goal is to provide you with in-depth, evidence based, narrative free analysis and you can always find me on IG and Twitter @3CBPerformance. Make sure to subscribe to the blog and to the YouTube channel for the latest updates. 3CB out.

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