What do we really know about LaMarcus' injury?

I was on a break at work on Saturday morning when I checked a message sent to me from the NBA Game Time app about 5 minutes before.  It stated simply:

"LaMarcus Aldridge (ligament tear left thumb) puts surgery on hold; will play tonight versus Washington"

Like many people, I was initially dumbstruck, and not just by the app’s apt use of a semi-colon or tone-deaf delivery. My mind was trying to process so much opposing information and emotion that it stopped functioning effectively. Surprise, elation, concern, and admiration swirled together, causing me to read the message several more times (as if it would reveal something new), while repeatedly checking that it was indeed Jerry West’s silhouette next to the message, assuring its authenticity.

After about two minutes of making mumbled pronouncements to myself such as "What? WHAT?!?" "Like a boss..." "This can’t be good for his thumb…" "Throwback style…." I came to, and realized that this needed to be posted on Bedge. I went to the site as fast as my thumbs could carry me, and two people had already beaten me to it.

At this point I retreated again to my fog of wonder, and tried to look up any other news I could find in what remained of my break. The rest of the day, I brought it up to anyone who I thought might be interested – I got to be the person to break the news to several people of various levels of fandom, whose excitement level rose exponentially with each second passing from my words hitting their ears. Pretty heady stuff, having the power to change people’s day like that. The many others who had already heard it still seemed equally as incredulous, if more calm.

As excited as I was, I was still left with the question, "How can this be okay for his thumb?" I mean, these opposable digits are one of the things that makes us so fabulous a life form in the first place. What if playing through messed up LA’s thumb, like permanently? Yeah, it’s his off hand, but still! Could he some day in the future get a monkey thumb sewn on as a replacement?

No matter how hard (or bizarrely) my curiosity strove, answers would have to wait.

It ended up being a kind of rough day to drive a taxi (my day job), but I got off in plenty of time to walk across the Broadway Bridge and get to the arena in time for introductions. The crowd showed its appreciation for LaMarcus' courage by reserving a level of volume for him that hadn’t been heard in intros since last year’s playoffs.

As tip off neared and the players gathered around mid-court, I stared at the brace on LaMarcus’ hand and couldn’t help but be a bit nervous for him.

LaMarcus missed his first shot, and it looked like he was aware of his hand when shooting, though it did look pretty close to his regular shot, which gave me heart. He also missed his second shot, but the form looked better.

Coming out of a timeout with the Blazers down 13-2, LaMarcus promptly drilled two jumpers in a row, on his way to a 5 of 6 stretch. He was himself the rest of the way offensively, except for his two left-handed shot attempts, which went really, really badly - aesthetically and from a scoring perspective, anyway…but no further injury!

When getting down the floor on defense, before the opponent had set up their offense, he would massage or squeeze his thumb – a routine familiar to anyone who has ‘messed up’ a finger in athletic play. He actively avoided using his left hand whenever possible. Other than that, his performance stood as pretty compelling support for his decision to play.

It was great to see a win after losing 4 of the last 5, and I figured LaMarcus would only get better at knowing how to operate within his new limitations as the season wore on – but the nagging question persisted: At what cost?

Sometimes I’m okay with operating in a sea of uncertainty and can roll with the waves; other times I get obsessive-compulsive and won’t rest until I get answers. This was a matter of the latter variety.

The soundbites that we’ve been getting from doctors regarding LA’s situation have been wholly unsatisfying. I had the need to understand what was going on.

You know that unsettling and frustrating feeling when someone gently coos at you "It’s okay, everything’s ok," and it really doesn’t make anything more okay in your mind? Yeah, that was me.

So I hit the interwebs, hard. I figured I should be able to find some clarity on this injury somewhere –  I mean, he's not the first guy in human history to have this happen.  So I skimmed through a bunch of medical journals, abstracts, and studies.  Heck, I joined a research site so I could access some interesting-sounding articles.

I struggled to comprehend complexly constructed sentences laden with medical jargon. It felt like I was looking up every third word ("What the heck is an abductor pollicis brevis?").

In the end though, I felt like I got a pretty decent picture of what goes on with these types of injuries. Below is a summary of what I found. The basics are mostly covered in this paper, and I will try to reference anything not included in it through hyperlinks.

{I am legally obligated to inform you that while I am not a doctor, I may resemble one for the purposes of this article. At least you can rest assured that I am wearing a stethoscope right now. You are advised to tear your radial collateral ligament and see a licensed professional if you need further confirmation of my conclusions.}

Meet the RCL!

picture from http://rochesterhandcenter.com/education/trauma/thumbsprain.html

The radial collateral ligament is a small ligament on the outside part of base of your thumb - as much as anything that moves as multidirectionally as a thumb can be considered to have an 'outside'.  It helps to laterally stabilize the main thumb joint (metacarpophalangeal, or MCP joint).  It turns out the ligament on the other side, the ulnar collateral ligament, is far more important to gripping and pinching.

The Injury

When LaMarcus swiped down on DeMarcus Cousins, the blunt force to the thumb tore the ligament by bending his thumb at the joint in a direction it wasn’t supposed to go.

We can assume that LaMarcus has a complete tear, since a partial tear (commonly referred to as a 'sprain') can heal by itself without surgery.  If it was partial, LA could have sat out a period of time and returned.  Since surgery seems like the only option that was ever on the table, it would have to be a complete tear.  Although it is worth noting that complete RCL tears may heal on their own, such healing is often accompanied by misaligned joints - hence the need for surgery for best outcome regardless.

When this ligament is torn, the thumb can be unstable from side-to-side, sometimes even grotesquely wobbly.  Yet the "up and down" bending motion of the thumb is unaffected, and general range of motion of the thumb can be regained even without surgery. LaMarcus’ flexible splint acts in the place of the ligament, providing lateral stability while still allowing his thumb to flex as normally as pain and swelling allow.

Surgery Options

If the injury is 3 or 4 weeks or less old, ‘primary repair’ surgery can be conducted – where each end of the original ligament is rejoined with sutures. This is what LaMarcus was originally going to do. Surgeons prefer to use original tissues when possible; it makes for a less complicated procedure. And obviously the benefit is we would assume him to be fully healed as the playoffs approach.

If the injury is more than four weeks old, the original ligament would atrophy to the point that it likely could not be sewn back together – this is apparently not as bad as it sounds. In this case, the surgeons would opt for ‘reconstruction’ surgery, where part of a little used wrist tendon would be split and stretched, or otherwise harvested and grafted in place of the original ligament.

Comparison of Surgery Risks: Now vs. Later

Although reconstruction is a more complicated procedure than primary repair, it doesn’t mean that it is more problematic. It’s fairly common as far as RCL injuries go, as lots of everyday folks injure themselves, try to ignore it for whatever reason until it becomes clear that pain or functionality will not improve, and therefore have waited too long for ‘primary repair’.

From a long term view, these days there is virtually no difference in outcome from ‘primary repair’ to ‘reconstruction’ surgery according to the studies I looked at. The ‘reconstruction’ group in one such study had an average of five months between injury and surgery, or roughly the amount of time that LaMarcus would have to wait if the Blazers made the Finals.

There are risks to reconstruction, as there are to any surgery, but no more than there are for primary repair – basically he could get surgery now and would still have the same risk of experiencing stiffness and weakness afterwards that he would have by waiting and having surgery later.  A wrist tendon is more susceptible to injury than the original RCL ligament, but so is a reattached RCL ligament.

Overall, the risk of postoperative complications in both cases are low (about 10%), and incidences of complication during either surgery are extremely rare.

Risks of Playing Through Pain

Since the splint is doing the job of the missing ligament (lateral stability), he literally has the same chance of injuring anything in his thumb as if he had never hurt anything in the first place.

I guess you can figure in a slight uptick of injury possibility based on LA maybe doing some unnatural or unfamiliar movement due to his new limitation, but as he learns the ropes of his ‘new reality’, this chance should theoretically decrease.

Because of the pounding his thumb will unavoidably take by playing, inflammation, pain and swelling will likely be a bit of a rollercoaster throughout the season, especially the earlier part. This all will classify him as having a ‘chronic injury’, but luckily it appears degeneration of the joint in chronic injuries of this kind generally occurs only after a long period of neglect, which is why I would guess a doctor could say that he can put off the surgery with a clear conscience.

Still, there is an increased risk of arthritis and/or osteoarthritis down the line which generally increases the longer the repair is put off.  This seems to be the biggest gamble that LA is taking with his health here.  But it is a calculated gamble - he may get off no worse by waiting five months for surgery, he may get some form of arthritis just from the original injury anyway, he may get some sort of arthritis just from the pounding of pro basketball even if the injury never happened.

In terms of long term functionality, one recent study found that RCL reconstruction candidates with chronic injuries had postoperative flexion of the thumb reduced by 6 degrees, but with no noticeable loss of functionality to the patients.  There will likely be some loss of strength in the hand, but again to a relatively small degree.

As far as current functionality goes, his grip will be reduced, but not nearly as much as you may think. The same study shows that male patients’ preoperative (while injured) grip strength was 91% of what their grip strength was after surgery, with both being within the normal range for healthy males. Unfortunately, no data was available on these people’s grip strength before injury, but we can assume that after the initial pain and swelling subside, LA’s left hand grip strength figures to be pretty good.

‘Pinching’ strength seems to be reduced significantly by RCL injuries – by about 50% until reconstruction - but I’m not really sure this function is so important in hoops. Unless you are pinching opposing player’s bums while playing the post as a method of distraction.

All the same, LA may need to make some adjustments on his left-handed layups – maybe using some more ‘finger roll’ action, or going up with the right hand balancing the ball, rather than palming it – at least for a while.  Rebounding habits may also have to change.

But it does appear to be as the soundbites say – it seems to come down to how well LA can deal with and manage the pain, and he likely will experience pain and swelling until it is repaired….er, excuse me, let me use the correct term befitting of my new self-earned medical degree…until it is "reconstructed".

He will never be 100% this year, but whatever percent he was on Saturday was pretty darn effective.  And it seems he has as good a chance at full recovery with surgery months from now that he does if he had surgery now.

After being initially extremely skeptical of letting him play, I now feel pretty confident about it all.  My personal journey through the desert has ended.

How about you? How did you find out about Saturday’s WWE-style surprising turn of events, and how have you processed it? Tell us some stories! And vote about your personal journey with this whole situation in the poll below: