IT's A Vivrant Thing: Understanding Isaiah Thomas's Hip Injury

Isaiah Thomas was recently declared out for the post-season after suffering a re-aggravation of a prior hip injury, specifically “re-aggravation of a femoral acetabular impingement (FAI) with labral tear”. 

The injury originally occurred on March 15th against Minnesota and he missed the next 2 games.  He then seriously aggravated it sometime during game 6 against Washington –I’d wager he was dealing with it to some extent ever since the original injury. 

Behind the scenes in Boston, there was some question as to whether or not he could actually play in game 7.  Those questions alone should give some insight into how painful of an injury this can be.

After gritting out that game 7, he did his best to play in the Cleveland series - although it can be argued no Celtics player actually played the 1st two games – but got to the point where he was in too much pain and it wasn’t worth risking greater damage when down 41 points at half in essentially a must-win game 2.

*quick aside, I’ve heard some talk saying that IT “quit”.  That talk is unfounded and frankly ridiculous to me.  Playing through injury should be a cost-benefit analysis – his injury has the risk of becoming much worse + the team is clearly outmatched in the series = obvious answer

Additionally, IT has been playing through the sudden death of his little sister and dental surgery on multiple teeth – if anyone, ever, deserved some benefit of the doubt, it’s him.  All I can say to his detractors is CMON*

So what exactly is FAI and labral tear? Let’s start with the anatomy.

The Anatomy

The hip joint

The hip joint is comprised of the head of the femur (the upper leg bone) and acetabulum (socket of the pelvis).  The head of the femur fits into the acetabulum, often referred to as a “ball and socket” joint.  Here’s a picture: 

 

The labrum

The labrum is a peripheral ring of fibrocartilage that nearly encircles the acetabulum and acts to grasp the head of the femur, increasing joint stability.  A visual representation:

FAI and Labral Tear

FAI has 3 different types:  Pincer, Cam, and mixed

- Pincer occurs when the acetabular socket is too deep or sticks out too far which approximates the labrum too closely to the neck of the femur.  The neck of the femur impinges onto the labrum and acetabulum. 

- CAM occurs when there is excessive bone growth on the head of the femur.  This excess growth impinges onto the labrum and acetabulum. 

- Mixed is a combination of the two and certain reports state that upwards of 80% of symptomatic individuals have this type of FAI.

With repetitive or forceful movements, the labrum can tear and acetabular cartilage can be damaged.  Here's a nice comparison of all 3 types:

The following video does a great job of explaining FAI and how it interacts with the labrum and hip cartilage (and it’s short, a little over 2 minutes):

For these reasons, FAI and labral tears are very commonly found together – as in IT’s case.

So what causes these anatomical changes?

 The cause of FAI remains “controversial” – there is no conclusive evidence to one specific theory.  Two competing theories abound:

1 -  genetic factors leading to deformity

2 – repetitive stress to the area during a critical period of adolescence

In recent years, research has tended to favor #2 particularly in the case of Cam deformities.

All that being said, I don’t want to scare you and have you running to your PCP asking for an x-ray. Having these anatomical changes doesn’t mean you will have pain – it’s only an issue if you are symptomatic.  Like IT.

IT’s Case

There’s no way to know what type of FAI that Isaiah may have without seeing further imaging.  What we do know is that basketball is an activity that significantly loads the hip and requires constant and repetitive hip movement. 

At some point during the Minnesota game, there was a movement that broke the camel’s back .

Additionally, when you factor in IT’s specific style of play and his usage with Coach Steven’s offense, it becomes clear that he’s constantly loading his hips with a high level of force.

Due to his height differential, IT has to use his strengths of pace, agility, and body control to create more space to get his shot off.  He relies heavily on change of pace (“start-stop”) and change of direction to create space and angles for himself. 

Whether it be 1v1 or off actions like PnR or DHO – 2 key staples in Stevens’ offense- IT will often utilize a hard jump-stop, step-back, or pull-up off a hard downhill dribble. 

This is one of my favorite examples - it's a 1v1 iso at the end of the game vs Atlanta but showcases his change of pace, hard dribble, and step-back:

If he’s overplayed, he will attack downhill into the paint, using his pace with sharp angles to knife through driving windows.  When finishing in traffic, he uses his body extremely well to shield defenders but this also means he is often taking contact in the air and landing at different angles – therefore heavily loading the hip at different angles.

Here's a solid breakdown of how IT attacks downhill:

All things considered, it’s no surprise that he re-aggravated the injury nor that Boston is being cautious. Hip labrum and cartilage tears can get progressively worse with additional stress, increasing pain and further de-stabilizing the hip joint…which, you guessed it, further increases the possibility of further tears and de-stabilization.

It’s a vicious cycle that can lead to a degenerative joint if not taken care of appropriately.

Timeline and Rehab

The Celtics haven’t released any detailed information as to how severe the labral tear is.  According to both Brad Stevens and Danny Ainge, IT will be visiting with multiple consults and then will make a decision – whether to try conservative therapy first or to immediately get surgery.

The timeline on the former option varies profusely depending on the person and the goals.  With surgery, the individual will be involved in physical therapy from day 1 post-surgery and can tolerate full weight-bearing commonly within 3 weeks.

Regardless of what is chosen, the focus of rehabilitation is the same.  Increasing mobility of the hip joint while strengthening all stabilizing musculature in the kinetic chain – from his upper back to his core to his hips to his legs and feet.  

We will soon find out what route he takes and I wish him the best.  I hope you enjoyed the piece and thanks for reading.  Until next time.

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