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Original Issue

The Pain That Won't Go Away

Incessant pounding on legs and feet has caused an epidemic of stress fractures in the NBA

Sam Bowie is fortunate that his right leg broke all the way through. It will surely heal faster than the stress fracture he suffered in his left leg. On Nov. 7, 1986, 12,666 people in Portland's Memorial Coliseum saw Bowie catch the ball at the low post on the right side of the key, pivot and go up for a jump shot. As Bowie left the floor, those sitting near the court heard a sickening crack. By the time he landed, his right shinbone was all but sticking through the skin.

The stress fracture in Bowie's left leg was different. No one knows how or when that injury occurred, only that it was discovered in 1981 while he was a junior at Kentucky and caused him to miss two college seasons. Bowie didn't snap it going up for a shot, he didn't land the wrong way and nobody fell on him. In fact, nothing happened that Bowie or anyone else could point to and say: It occurred on this or that play. Stress fractures aren't clear-cut.

When an athlete injures himself in the absence of witnesses, doubts can arise—in the minds of coaches, fans and doctors and even the athlete himself. He knows he's hurt but doesn't know how badly. An athlete is trained to play with pain. So how does he distinguish a nagging soreness he feels after last night's bump under the boards from the pain of a broken bone that could end a season or a career? Stress fractures are insidious because they occur over time. They sneak up on an athlete and may, if he keeps playing, develop into full-fledged, clear-through-the-bone fractures. And they probably afflict basketball players, whose legs and feet take incessant and tremendous pounding, with greater frequency than any other group of athletes.

The Boston Celtics' Bill Walton has become a sort of guru to stress fracture sufferers. The injury has interrupted his career three times, once almost ending it. "One of the hardest things about stress fractures for athletes is the mental uncertainty," says Walton, who suffered his first such injury in his left foot as a member of the Trail Blazers in 1978. "There has been no impact that tells a player, 'I know I'm hurt.' Nothing has changed, but he can't play anymore. Players have come to me angry and confused. I have to let them know that they're not faking."

One of those who went to Walton was Philadelphia's Andrew Toney, who missed some of this season and most of last because of stress fractures in both feet. Chicago's Michael Jordan and Portland's Clyde Drexler have also had stress fractures. Washington's Frank Johnson is recovering from his fourth in two years. Utah's Darrell Griffith and New York's Bill Cartwright missed most of last season because of them. "We see many more than when I started," says Ron Culp, the Trail Blazers' trainer who has worked in the NBA for 17 years. "And it's not that there are more of all kinds of injuries—just more stress fractures."

Dr. Norman Scott, the Knicks' team physician, agrees, saying, "At least one third of the players in the NBA have had foot fractures of some kind." That adds up to about 100 players. However, no one knows exactly how many stress fractures have occurred in the NBA, or whether there were more this season than in seasons past. To get some answers, the NBA has begun studying what it considers to be a stress fracture epidemic. In addition to determining their frequency, physicians are seeking to learn how they differ from more acute breaks and how best to detect, treat and, most important, prevent them.

Stress fractures impair not only the health of the athlete but also the health of his team and league. "They're affecting performance and economics," says Bullets team physician Dr. Steve Haas. "People won't come to a game if a player like Michael Jordan is out. And it's obviously an economic factor to the player, too. The study is in everybody's best interest. [NBA commissioner] David Stern doesn't want all his guys breaking their feet. Agents, owners and players don't, either."

After Jordan's fracture was diagnosed in late October 1985, the Bulls appeared to ignore economics when they asked him to sit out the rest of the '85-86 season. With Jordan out of the lineup, Chicago's average home attendance dropped 17%. But the Bulls were thinking of Jordan's long-term revenue potential as well as his health. There may also have been another factor in the Bulls' thinking. Had Chicago played all season without Jordan, it might have been a contender for the NBA's top draft choice. As it was, Jordan returned in March at his own insistence, after suggesting that the club may not have been doing its best to win.

Dr. Lyle Micheli, director of sports medicine at Children's Hospital in Boston, says that because basketball requires players to work so hard, it is "set up for stress fractures." Running, jumping, starting and stopping on hard floors night after night puts tremendous torsion on players' legs. "In running, 2.8 times body weight hits the ground with every stride," says Dr. Tony Daly, team physician for the Clippers who has also worked with Olympic runners and athletes in almost every sport. "In jumping, it's 4.5 times body weight, and that figure is for the average athlete, not the NBA player."

A stress fracture begins when the shocks and strains of playing game after game create microscopic cracks in the outer layers of bone—usually in the legs and feet. If the pounding continues and those tiny crevices, which often go undetected, aren't allowed to heal, they can enlarge. When the cracks become large enough to cause pain, they are stress fractures.

Bone is alive. Like muscle and skin and blood, it is composed of cells. When cells become old or damaged, new, larger and healthier cells take their place. As with muscle, that turnover makes bone tissue healthier. This is partly why lifting weights, which initially damages the muscle tissue, ultimately makes biceps bigger and stronger. "Bone cells have a certain amount of turnover," says Dr. Micheli. "If bone is stressed slowly and gradually, it will get stronger and stronger." Says Dr. Peter Jokl, associate professor of orthopedic surgery at Yale, "It's like wind on trees. If it's constant over time, the trees will adapt. If there's too much at one time, they'll crack."

Most of what is known about stress fractures comes from studies of male ballet dancers and soldiers. Dancers develop their injuries by jumping and landing and moving with the added weight of another person in their arms. Soldiers get them from pounding their feet for hours while carrying heavy backpacks. For that reason stress fractures, first described in 1855, have often been referred to as "march" fractures. "If you take new recruits and march them enough, each of them will probably get one," says Jokl.

If a basketball player follows a night game with an afternoon game, he may feel as though he has just finished a 25-mile hike with a full pack. This is also when he might feel the first signs of a stress fracture. "It's a dull ache that won't go away," says Walton. "The more you play, the worse it gets, until you can't play anymore. Mostly you just feel pain. With continued activity the dull ache gets more intense and sharper until it hurts all the time." That dull ache is caused by the microscopic cracks and the body's reaction to them. The more intense, sharp pain usually indicates that the crack is growing.

Pain is the primary symptom of a stress fracture. And thanks, in part, to Walton, athletes these days tend to be taken more seriously when they complain of severe pain in their legs and feet. On April 21, 1978, an hour before a playoff game against Seattle, Dr. Bob Cook, Portland's team physician, twice injected a painkiller into Walton's left foot. It wasn't the first time Walton had taken such injections, but it would be the last. The day after the game, X-rays revealed that Walton had broken a bone. He sued the Trail Blazers and Cook, claiming that the injections had masked the pain—the symptom that might have prevented him from playing and from breaking the foot. The suit was settled out of court four days before the trial was to begin.

If painkillers were used indiscriminately in the NBA before the Walton suit, they aren't now. Says Cook, "Anything that masks pain, that is not therapeutic, is a definite no. The patient has to have a physical complaint. You have to know where to look." Conventional X-rays don't always help. In fact, X-rays of Walton's foot taken immediately after that Seattle game were negative. A more exacting measure today can be made by a special X-ray procedure called a bone scan. When Cook was searching for the source of Walton's pain nine years ago, bone scans were not routine diagnostic tools. "If I could have done one thing differently [in Walton's case], I would have gotten a bone scan," says Cook.

In this procedure, a patient is injected with a radioactive element that is incorporated into new bone formation. Because new bone forms at the injury site, the radioactive element collects there. That spot will show up on an X-ray. "If the scan shows no increased uptake, there is no stress fracture," Daly says. "If there is increased uptake, you have to decide if it's from an old injury. It can be positive for two years."

An area of increased uptake is called a hot spot. "I would bet that every player in the NBA has had a hot spot at one time," says Dr. Cook. Envision a wire hanger as a bone. If you bend the hanger back and forth, the weak point that develops would correspond to the bone's hot spot. If the bending continued until the wire broke, you would have the equivalent of a stress fracture.

The problem with Bowie's left leg is more complicated than that with most other stress fractures, but it indicates how difficult diagnosis and treatment can be. August 1981: picture day for the Kentucky basketball team. A photographer asks Bowie to jump a little higher. Bowie can't because his left leg hurts. Two weeks later X-rays reveal a fracture. Sept. 15, 1981: His left leg is put in the first of two casts he'll wear for a total of 11½ weeks. He sits out the 1981-82 season. July 29, 1982: X-rays show weakening in the area where the fracture had been detected a year earlier. Aug. 3, 1982: Another cast is applied, this one for six weeks. Oct. 20, 1982: After 10 days of tests at the Campbell Clinic in Memphis, bone graft surgery is performed. Parts of Bowie's hipbone are grafted to his left shin—on the side opposite the crack—to strengthen the leg. He sits out the 1982-83 season.

"I never thought for one minute that I would miss two years of basketball in college," says Bowie. "For a little hairline crack to heal? I missed one year to try the natural healing process. I missed another year after the surgery." If he had to do it over again, Bowie says, he would have opted for immediate surgery. "Hindsight's 20/20, but I got nothing out of that year in the cast."

After reviewing Bowie's medical history, Cook agrees. "I would try to avoid the prolonged cast time," he says. "It's hard to overcome the atrophy." But, says Dr. George Gumbert, who was Bowie's doctor at Kentucky, "I would still try the conservative technique. In a pro athlete, where his bread-and-butter depends on his ability to play, I would operate sooner. In a college athlete, I'd be less inclined to operate since the complications of surgery aren't insignificant. In a way I'm sorry I didn't operate sooner in Bowie's case." Gumbert's uncertainty is shared by many of the doctors who treat stress fractures. "If we operate sooner and we're successful, then everything's great," he says of Bowie's case. "If we operate and there are complications, then we may have ruined this lad."

After a game with the Blazers on Jan. 10, 1986, Bowie feared he had broken his left leg again. No new break appeared on conventional X-rays or bone scans, but the pain had returned. Cook advised another bone graft operation on March 5, 1986, hoping that surgery would eliminate the pain for good. Unlike the graft done 3½ years earlier in Memphis, this second graft placed the bone transplant inside the crack.

Last fall, during preseason workouts, Bowie complained of soreness in his right leg. Cook says a standard X-ray showed "a very subtle defect" there. Cook's considerable experience with stress fractures convinced him that the defect in the right leg would show on a bone scan as a hot spot, so he didn't order one. "We put him on an anti-inflammatory drug, had him ice the leg, and applied an electrical bone stimulator and limited his practice time," he says. The doctor left it up to Bowie to stop practicing when he felt pain. "The worst-case scenario was a progression to a traumatic fracture," says Cook.

"This was my worst nightmare," says Bowie. "I had discomfort in my right leg, but nothing that I was concerned about. When you play on this level you have aches and pains all the time. No one in the NBA is ever one hundred percent. You don't go to the trainers every time you have pain." But only when a player complains of pain can a trainer or doctor determine what may be wrong. Says Cook, "It's an art [for a doctor] to determine how active a person can be. If there's a lot of pain when a player plays 35 minutes per game and none at 20 minutes per game, you know what to do. You have to keep activity within his pain threshold."

But in an era of guaranteed contracts, a player's word about how he feels is not always enough to satisfy a team's owner. Says the Bullets' Dr. Haas, "I have to make a decision as to whether or not [a player's] pain is reasonable."

Bowie is leery of being categorized as injury-prone. But the length of his medical chart invites comparisons with such players as Kareem Abdul-Jabbar and Julius Erving, who have played pro ball for a combined 34 seasons without a stress fracture. What makes one player more susceptible to stress fractures than another?

One factor is training. Team physicians can't monitor off-season conditioning programs because the NBA Players Association won't let them examine a player without his permission until training camps open. And many doctors believe that players develop stress fractures because they begin intense training too soon after a lazy off-season. Because the body replaces bone tissue more slowly than muscle tissue, a player can appear to be strong, but his bones may not be. Says Yale's Dr. Jokl, "A person can train too quickly. While the muscles can accommodate, the bone can't."

The NBA's stress fracture study will examine the forces that playing basketball inflicts on the bones of the legs and feet. It will also examine such other variables as the effect of court surfaces and anatomical conditions like flat feet and high arches. Walton, for one, has such high arches that doctors have told him he's lucky to have had as few injuries as he has. Six players from each of seven teams will undergo tests in Washington, Boston, Phoenix, Sacramento. Philadelphia, Portland and Chicago. High-speed cameras will record the subjects performing a series of basketball movements, such as cutting or pulling up for jump shots, while sensors register the forces on their feet. But despite the intricacies of their high-tech equipment, nothing will give researchers more headaches than the lowest-tech part of the study—shoes. "Shoes play a part in stress fractures,' says Daly. "Basketball shoes don't seem to be as good as running shoes."

"Basketball is more complex than running," says Peter Cavanagh, the Penn State biomechanic who will coordinate the NBA study. "In running, you strike the ground in the same way over and over. Basketball has dozens of different [foot and leg] movements. You could design shoes that would protect against stress fractures on rebounds, but then the player couldn't run in them."

Economics hastened the improvement of runners' shoes in the late '70s. Better shoes meant increased sales, and the manufacturers invested some of their profits in further research. The economics of the basketball shoe business is entirely different.

Of the six million or more pairs of basketball shoes sold in 1986, many were bought because they were endorsed by Jordan or Larry Bird or Magic Johnson and for no other reason. Even at the game's higher levels, players don't choose shoes very carefully. Most college players simply wear the brand they get from their coaches, many of whom depend on shoe company contracts for a substantial portion of their income.

Pro basketball players, for the most part, wear the shoes they are paid to wear. Jordan's five-year endorsement contract with Nike is estimated to be worth $5 million. It is rare for an NBA player to have custom-made shoes. "I need to do whatever it takes to keep me healthy. If that's shoes, fine," says Bowie. "But it's going to be hard to come to some guy making a million dollars for wearing one shoe and ask him to change. You have to experience [a stress fracture]."

Most players' agents aren't farsighted enough to consider the potential damage shoes might do to their clients' long-term productivity. It's unlikely that an agent would advise a player to wear a better shoe from a company offering $500,000 less than some other manufacturer. Besides, specially designing shoes isn't cost-effective for manufacturers. Says John Robinson, of Nike, "I come to our marketing people with new, radical designs and they say, 'People won't buy that.' The basketball market is very traditional." Some of those traditionalists maintain that stress fractures are nothing new, that they're just charley horses or twisted ankles with a fancy name. Says Dr. Haas of the Bullets, "You always hear arguments like, 'Players aren't like they used to be.... When I was their age, we played with pain.' "

Andrew Toney doesn't want to play despite pain. For the last year and a half, the 76er guard has complained of pain in both feet from stress fractures. Doctors recommended exploratory surgery. In early January the Sixers gave Toney a choice: Participate in practice and games or have an operation. Toney began playing again on Jan. 25. Since then, he has had to sit out three games because of pain.

Toney doesn't want to have surgery. Bowie is sorry he didn't have surgery sooner. Walton has had surgery more times than he cares to count. Others will have to weigh similar decisions. "Most NBA players are in the red zone on the speedometer," says Cook. "The level of human performance has increased. They're on the brink of catastrophic injury most of the time."





Cavanagh studies stress points (dots) on high-speed film.



Four years after a bone graft in his left leg, Bowie fractured the right one clear through.



Daly (above) and others are studying ways athletes can avoid the pain and frustration that nearly ended Walton's career in 1978.



[See caption above.]



Jordan caused the Bulls stress by defying their order to sit through the '85-86 season.


A stress fracture begins when the shocks and strains of playing game after game create a tiny, often undetected crack in the outer layer of bone (left). If the pounding continues and the crevice is not allowed to heal, it can enlarge until it becomes a full-fledged break (below).