Treat injuries before they occur
An excerpt from BALLISTIC
Legendary NBA coach Phil Jackson won his tenth NBA title at about 10:30 p.m. on June 14, 2009. A couple of hours later, his blue suit jacket still a little champagne-sticky, the Lakers’ sixty-three-year-old leader exited Orlando’s Amway Arena in a phalanx of his adult children.
I happened to be a few steps behind. What I remember most aren’t the hats with the Roman numeral ten—X—his kids wore, nor their joyous expressions. Instead, it’s the pained look on Phil’s face. The greatest coach in the history of the game waddled the endless arena hallway with surgically fused vertebrae, balloon stents in his arteries, and none of his original hips or knees. The family shuffled at Phil’s pace. After playing for twelve NBA seasons and coaching for twenty-three, Phil could barely walk.
He’s hardly alone. According to the Centers for Disease Control and Prevention, even before the pandemic 71 percent of young Americans “would not be able to join the military if they wanted to,” because they’re not fit enough. Twelve percent of Americans have serious difficulty walking or climbing stairs. About 31 million Americans age fifty or older “get no physical activity beyond that of daily living.” In 1969, half of American kids walked or biked to grade school; in 2009, it was less than 13 percent.
In short, we can’t move—and it’s killing us. The American College of Sports Medicine submitted a report to the US Secretary of Health and Human Services called Exercise Is Medicine, which notes that physical activity improves bone health, cognitive function, heart disease, stroke, many cancers, dementia, sleep, anxiety, depression, multiple sclerosis, hypertension, quality of life, and mortality. The World Health
Organization says inactivity causes five million deaths a year.
Talk to your doctor, they say, before starting an exercise program. With immobility the fourth-leading cause of global death, who do you talk to before not exercising? Joining a gym or going for a run seems, by comparison, safe and healthy. But, we all understand, along the way, something might hurt. From 2008 to 2018, the rate of Americans seeking medical help for injuries (at least, those not caused by car accidents) climbed in almost every age group, gender, and subcategory.
We can be bloody-minded about how we move, pushing our bodies like drill sergeants. Trainers describe a trend: People tend to do what they did in high school. Put on thirty extra pounds in the pandemic?
You might dig out those decades-old soccer cleats, join a league, and expect to race through the midfield like the old days. NBA players do the same thing: Hip starts hurting three years into your professional career? The first thought for many is to bring back the weight-lifting routine they had when they were seventeen, when they hammer dunked on everybody and felt amazing.
But that high-schooler had a certain lung capacity, hip range of motion, and glute strength, not to mention the spine of someone who hadn’t yet spent decades working on a laptop. Dead-sprinting the left wing of a soccer field, or cutting through the lane to catch a lob on the basketball court, wasn’t much to ask of a teenaged body with bounce, wind, and muscle to spare.
It’s common sense that if you park a car for twenty years, you might need to take it to a mechanic before hitting the open road. The same is true of our bodies. But we’re more complicated, needing more than an oil change and four new tires. How do you maintain an athletic body?
Reliable answers to that question can be so maddeningly elusive that they seem not to exist at all. Injuries feel inevitable to weekend joggers and professional athletes alike. Bad backs, trick knees, degraded hips—who doesn’t have at least one body concern and a grab bag of theories about stretching, yoga, massage, physical therapy, cupping, weight lifting, or whatever else feels right? But when it comes to evidence-based sports injury prevention, there’s just not a lot to go on. If you want a solution to move and feel better, you probably feel like I did for most of my life: a little lost.
In my decades as an athlete, I have suffered plenty of injuries, and I hated every one of them—because I love to move. In high school I ran track and cross-country, raced on skis, and played a little soccer. In the decades since, I’ve biked across states, run all kinds of marathons, and taken a thousand or so hard workout classes. And along the way, I’ve had wildly frustrating experiences, doctor-hopping, looking for relief from hip muscles in revolt, Achilles tendinitis, and a whopper of a lumbar crisis.
That pain felt like a personal failing, until I noticed identical things happening to the best athletes in the world. For the last quarter century, I’ve worked as a journalist covering the free-moving sport of basketball.
The NBA boasts some of the world’s most extraordinary, highest-paid athletes. But even as data made the game more exciting and sent viewership soaring, the athletes worth hundreds of millions spent more and more time on the bench.
I’ll never forget the day that a physical therapist recommended that, before sitting down on a chair, in deference to my hips, I first put down a pad shaped like a wedge of cheese. I hesitated. Was this really how I’d roll into restaurants for the rest of my life? The next day I spotted something hilarious during a Laker game: As LeBron James checked out of the game, a trainer slipped an identical cheese wedge onto his seat.
The NBA devours athletic bodies. I grew up in Oregon, where Bill Walton won the 1977 NBA championship—then sued the Portland Trail Blazers for mismanaging his injuries. He missed three of the next four seasons. Larry Bird missed almost two hundred games, then retired prematurely. Citing the toll on his body, Michael Jordan sat out almost four seasons because he was hurt, playing baseball, or retired. Kobe Bryant, Dwyane Wade, Shaquille O’Neal, and Stephen Curry each sat out hundreds of games
In the mid-1990s, Grant Hill got more All-Star fan votes than Jordan, then suffered a brutal string of injuries that he attributes to “archaic” training methods. Ankle surgery blossomed into a staph infection that nearly killed him; Hill was never more than a role player after that. Over the course of his career, Hill missed more than six seasons’ worth of regular-season games. (In a league where a typical career lasts three years, Hill sat in street clothes for two NBA careers.)
Once upon a time, baseball’s Cal Ripken Jr. played 2,632 consecutive games and lulled sports fans into believing that a human can be athletically elite and stable over the long term. Since then, players have become measurably bigger, stronger, and faster. But these increases seemed to reduce their longevity, mental health, and robustness. For all we have learned about cutting-edge performance, we seem to have learned very little about preventing injury. Sports are still lousy with meatheaded “rub some dirt on it” thinking that seamlessly transitions into “next man up” when it all goes awry.
Like race cars, NBA players are in the garage often and sometimes badly wrecked. One expert casually told me that the NBA has a 100 percent injury rate. “Every game you don’t get hurt,” he said, “is a game closer to your next injury.” Many of the league’s would-be superstars never reach their would-be primes: Anfernee Hardaway drew comparisons to Magic Johnson, but knee injuries meant he played in his last All-Star Game at age twenty-six. Other than a five-game comeback in 2010, Yao Ming stopped playing at age twenty-eight. We may never know what Zion Williamson could have been. A dozen big-name players, including Giannis Antetokounmpo, Jimmy Butler, and Kawhi Leonard missed games in the 2024 playoffs.
Magnetic resonance imaging and surgical techniques march forward; surgeries to repair a torn Achilles or anterior cruciate ligament have improved. Doctors have incredible new insights into what happens after an injury has occurred, but that doesn’t lead to fewer injuries in the first place. The crisis continues.
At the 2014 MIT Sloan Sports Analytics Conference, I was a last-minute invitee to a private-room dinner hosted by former Goldman Sachs executive Dave Heller, then one of the investors who ran the Philadelphia 76ers. A few dozen people ate around a ring of tables as Heller steered the conversation like Oprah. The conference is about how big data can improve sports decision-making.
By 2014, wearable devices, sleep studies, and player tracking data had started a conversation that we continued, around Heller’s table, about player health. I said something about making sure the league doesn’t “break Derrick Rose.” Rose was the Chicago Bulls’ next great guard after Jordan. Rose wasn’t a great shooter, nor was he especially tall, but he had won an MVP award doing things that made fans (and even sportswriters) love basketball, heroically taking on bigger defenders in the paint and launching himself to score in spectacular ways.
The Bulls star was, at the time, rehabbing a torn left ACL. Somewhere off to my right, a white man in a suit piped up. He had the slick smugness of Kieran Culkin in Succession. I never learned his name, but I’ll never forget that he said, “What do I care if I break Derrick Rose? I’ll get another one.”
It was outrageous, racist, and, upon reflection, not far from everyday NBA thinking. The Bulls did break Derrick Rose, and they did get another one. High-scoring guard Zach LaVine, measured as one of the finest athletes in league history, tore his ACL, too.
To better understand why all these players were getting hurt, I began a side project researching the science of injuries, reading studies, interviewing doctors, and attending conferences. Meanwhile, the problem had grown personal. At Heller’s dinner, I had been sitting awkwardly to avoid shooting pain. A few months earlier, I had tweaked something while running a half-marathon.
Now, stepping off curbs, kicking balls, sleeping, sprinting, coughing, and sneezing—almost every ordinary, everyday action infused my body with thunderous jolts of pain. A few weeks after that dinner at Sloan, I was introduced as the head of a sixty-person division of ESPN covering the NBA in digital and print media. Just as sitting was becoming an emotional trial, I would spend long hours in conference rooms, behind the steering wheel, crammed into airplane seats, and hunched over in front of a computer. My kids mocked me ruthlessly for it, but out of desperation, I became the guy stretching his hamstrings in the boarding area.
I might have felt bad for Phil Jackson at the 2009 Finals in Orlando; but by the 2014 Finals in Miami, I felt like Phil Jackson. As the Miami Heat battled the Spurs, I battled a tricky hip and a trickier back. I slept poorly and stopped running. When I finally got an MRI in the middle of the Finals, I hated the feeling of slipping on surgical booties before climbing into the MRI tube; I just wasn’t ready to be frail and medicalized.
What I hated even more was the radiologist’s grave tone as he called to tell me about a torn muscle in my pelvic floor, a torn labrum in my hip, a worrisome lower-back problem with a complex name, and (after I asked, joking, “Is there anything else?”) pelvic bones that rubbed together in front, known as osteitis pubis. None was fatal to me as a person; each might be fatal to me as an athlete. I was recommended for back surgery, pelvic floor surgery, physical therapy, and whatever other medicalized hell might follow.
When you’re hurt, a lot of the professional advice comes from the three horsemen of the free-movement apocalypse: radiology, surgery, and pharma. They circle injured athletes like vultures, eager to feast, it feels, on the carcass of your athletic life. They put you on a table or in a tube and tell you to lie still. Sometimes they cut you open and repair something, and then recommend milquetoast baby steps that fall well short of a full return to movement. The current regime might get you back to driving a car and sitting at a desk, but no one seems to care whether or not you get back to the bouncy movements that make life so fun. Had a flubbed half step in a half-marathon really ruined the second half of my life?
Knowing that research shows that back surgery comes with massive risks (and, probably, more surgical booties), I never considered it. But I could feel the vibrancy slip from my life. The Bulls might be able to get another Derrick Rose, but Derrick and I would keep our injured selves forever. I thought of all the friends and family mired in the aftermath of big injuries, and swore I would do whatever work was necessary to keep moving. But what was that work?
I got interested in the injury epidemic because I cared about the NBA and its players. As I tasted my own athletic fragility, it became clear how quietly and constantly athletic dreams shatter. The degree to which the world shrugs at that carnage feels dangerous. Was there a way to avoid the three horsemen? Could someone show me how to prevent injury in the first place?
After years of researching this question, I found myself in Santa Barbara, where I visited the Peak Performance Project and met Marcus Elliott, MD. At P3 (as everyone calls it), Marcus and his team had developed a method that not only could have predicted Derrick Rose’s injury, but might have prevented it from happening in the first place. You meet a lot of people in the world of sports who “have a method,” but Marcus had something better: he had data.
Marcus tore his ACL at high school football practice in 1982. For months, Marcus mourned his college football dreams, but he emerged with a life plan that drives him still. To paraphrase the main character in Andy Weir’s The Martian, Marcus made it his mission to science the shit out of sports injuries. He studied under globally known physiologists, surgeons, and exercise scientists on his way to a medical degree at Harvard. Marcus devised a program to prevent hamstring injuries among the New England Patriots; then the Seattle Mariners made him Major League Baseball’s first director of sports science.
With each passing year, Marcus’s mission clarified. “The big wins, the big impacts of medical history to this point, they’re all related to prevention,” says Marcus. “Like, all of them.”
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