CP3’s hamstring injury: The risk, recovery, and road to game 7

In the waning seconds of the Rockets’ Game 5 victory over the Warriors, CP3 pulled up lame with a hamstring injury – the team termed it a “hamstring strain”.  Not surprising that he injured it.

Here’s the video:

Based on three factors – the way he injured it, his noticeable limp afterwards, and his very subdued demeanor*- my educated guess is that it’s a grade II (moderate) tear of the hamstring.

*Completely anecdotal but with painful or higher severity injuries, I’ve commonly seen a reaction that is on either end of the spectrum – really subdued, like Kobe’s reaction after his achilles tear, or really demonstrative, like Paul Pierce after a paper-cut.

CP3’s already been ruled out for game 6 with the hamstring injury so the question becomes – if Houston loses tonight, can he play in game 7 on Monday night and how effective will he be?

I’ll answer those questions and these as well:

  • Why am I not surprised that CP3 pulled the hamstring?
  • Did Harden’s (annual) choking routine contribute?
  • What treatment is CP3 receiving for the hamstring injury?
  • If he does play, what can we expect?

To note- this piece is intended to be an update, not a comprehensive review of injury. If you want a more detailed look at the hamstring, check out this post.

So here we go:

I.Why I’m not surprised about the hamstring injury

CP3, unfortunately, has multiple risk factors that increase his risk of hamstring injury.  These include previous hamstring injuries, other lower body injuries, age, and his style of play.

A. Previous hamstring injury

CP3 has a long history with hamstring injury – he’s dealt with them on 4 different occasions in the past – and is reported to have dealt with a nagging left hamstring throughout the course of this season, including missing 3 games in late March.

A previous hamstring injury is the biggest indicator for future hamstring injury.  Research shows you’re up to 6x more likely to re-injure the hamstring, most likely within the first 2 months. CP3 falls right within that 2 month timeframe.

Additionally, studies have shown increased risk thereafter as well – up to a  year or longer in some studies.

B. Other lower body injuries

The lower body is a like a series of chain links – injury to one puts increased compensatory stress on the others. Over time, this leads to them wearing down and being more susceptible to injury.  This concept of interdependence is known as the kinetic chain.

hamstring injury
Credit – Kinetica

CP3’s lower body injury history is extensive.  In the last 4 seasons alone, he’s had 11 reported lower body injuries (and who knows how long they have been lingering or not).  That puts constant stress and over-compensation into other parts of the lower body – not a good recipe for health.

C. Age

As athletes get older, the risk for hamstring injury increases.  We’re not exactly sure why but the numbers bear it out.

Research shows that athletes older than 25 are 4.5x more likely to strain a hamstring compared to their younger counterparts.  Generally, hamstring injury risk increases annually by 30% after the start of a pro career (!).

CP3 is 33 years old, in his 13th NBA season. That’s a whole lot of percents.

D. Basketball specific

Playing basketball involves running at a high speed, a high volume of running, and constant acceleration and deceleration.  Each of these has been shown to increase the prevalence of hamstring injury, in some cases by upwards of 15%.

CP3 is doing each of these throughout the course of the game:

  • Houston plays at a fast pace so he’s constantly running a high volume at high speeds
  • Defensively, he’s constantly navigating screen and roll and switching defensively which involves constant acceleration and deceleration
  • Offensively in the half court, Houston is the heaviest ISO team in history and count on CP3 to create. He relies heavily on his change of pace especially off the threat of his jumper, hesitation dribble, and lane navigation – again, constant acceleration and deceleration. Like this:

Additionally, research shows that the risk of hamstring injury goes up as the the level of competition goes up.  CP3’s at the highest level of basketball competition, the NBA, and this is the deepest he’s ever been in the playoffs.  These games are the highest level of competition and intensity CP3 has ever been a part of (unless you count him, Doc, and Blake barricading DeAndre).

Lastly, certain combined movements that are common to basketball place significant stress on the hamstrings.  One of these movements is flexing the hip (bringing the hip) while extending (straightening) the knee.

That’s exactly what happened to CP3 during his hamstring injury, take a look:

hamstring injury
Credit – TNT

The hamstring crosses both of these joint (aka it’s a “two joint muscle”) so this stretches and tensions the hamstring from both sides, like pulling apart a band on both ends.

E. Fatigue

Fatigue can increase the injury risk for a hamstring injury.  Research has shown, in multiple sports, that hamstring injuries increase during the latter stages of a match. This may be due to decreased hamstring torque and strength as fatigue sets in.

This lines up with CP3’s hamstring injury as it occurred in the closing seconds of the game when fatigue is highest. Additionally, this is the longest season he’s ever played (finally putting the “never been to the conference finals” talk to bed) so the accumulated fatigue on his body is at an all-time high as well.

Adding to that, Harden had another terrible offensive game (if you’re interested in why pressure leads to “choking”, read this) which put forced CP3 to take on a greater role.  Let’s speak on that in more detail…

II. Harden’s role in the hamstring injury

Harden’s ability to bear the brunt of the offensive load this season and allow CP3 to pick his spots has been critical in keeping CP3 relatively healthy. I’d imagine that was one of the key selling points for CP3 in coming to Houston – being able to extend his career by decreasing wear and tear.

However, Harden’s last 6.5 quarters of the series, from the midpoint of the 2nd quarter of game 4 to the end of game 5, have offensively been offensive. He’s missed his last 20 3-point and shot under 30% overall.

Due to Harden’s ineffectiveness in game 5, CP3 was forced to increase his role in the 2nd half. This increased usage meant increased strain and accumulative fatigue on CP3’s body, increasing the aforementioned fatigue factor risk.

It was pretty obvious just how tired CP3 was late in the game – his jersey untucked, looking completely worn out, with a semi-dazed look.  Reggie Miller explicitly mentioned it as well. It’s no coincidence CP3 re-injured his hamstring in the game where he had to expend the most energy and increase his fatigue level.

III. Treatment

The average time athletes lose to a hamstring injury is about 20 days. Obviously, CP3 doesn’t have anything close to that and the treatment will reflect that.

His treatment through the weekend has one goal: reduce and manage pain.  There isn’t enough time for the torn hamstring fibers to effectively heal so you make the most with what you got.  Lets start with the tissue itself:

A. Micro (the tissue)

The rehab staff will be working around the clock on managing and mitigating inflammation.  Inflammation is generally a natural healing response of the body but in the acute (short-term) phase, it’s going to cause pain and interfere with function.

Here are some ways the medical staff can reduce the inflammation in CP3’s hamstring (if you want a more detailed look at recovery, read my piece on Lebron’s recovery regiment):

  • Hands-on soft tissue massage
    • This aides in flushing out swelling and provides a manual input that reduces pain (human touch can be very therapeutic)
  • Gentle, active movement
    • This can help flush out inflammation and increase repair. Active muscle contraction leads to increased blood flow to the muscles (blood carries nutrients and discards of waste by-products) and is the body’s way of “pumping” fluid and inflammation back into the venous and lymphatic systems.
  • Ice baths/wraps
    • There’s conflicting evidence on ice reducing inflammation but the idea is that by reducing body temperature, metabolism is slowed and blood vessels constrict (tighten) to reduce inflammation and flush toxic by-products out of muscles.
    • There’s also a positive psychological component as many athletes report feeling better after an ice bath.
hamstring injury
Credit – Uncrate
  • Hot/cold contrast baths
    • These are exactly as they sound – a bath where the water temperature changes back and forth between hold and cold
    • The science behind them is that the cold temperature constricts (tightens) blood vessels and the hot temperature dilates (widens) blood vessels. This alternating motion of the blood vessels mimics the “muscle pumping” action of the body — reducing inflammation and removing metabolic wastes from the muscles.
    • There is some evidence to support this and generally, it’s been shown to have about the same therapeutic benefit as an ice bath. For a professional athlete trying to recover as quickly as possible, why not do both?
  • Compression wraps
    • There’s decent evidence that wearing compression tights can help reduce inflammation and eliminate toxic by-products via stimulating blood flow to the muscles. For these benefits to occur, the compression gear must be very tight and it must be worn for multiple hours.  Here’s Lebron rocking them:
hamstring injury
Credit – Nike
  • Normatec gear
    • This gear features a programmed compression system that pulsates in a pattern to mimic muscular contraction of the legs and clear out inflammation. Here’s a picture of what they look like and how they work:
Hamstring injury
Credit – Champion Crytherapy
hamstring injury
Credit – Triathlete.com
  • Cryotherapy
    • A cryotherapy chamber mimics the therapeutic effects of an ice bath (decreased inflammation and pain) in significantly less time. You stand in a chamber that uses gasified liquid nitrogen to cool the air around you to as low as -200 degrees F.
    • The overall evidence behind it is still lacking but there is increasing evidence that cryotherapy can help mitigate inflammatory markers, has anti-oxidant properties, and in some cases, better sleep.  Check out this video:

  • Hyperbaric chamber
    • These chambers can increase the amount of oxygen getting to CP3’s muscles and tissues. Here’s what this chamber looks like:
    • The science behind it is that pumping in 100% oxygen at a pressure higher than the atmosphere (defined as 1 absolute atmosphere or 1 ATA) leads to increased oxygen in the system. For example, at 2ATA, LeBron’s blood oxygen content is 2.5% higher than normal.
    • This increased oxygen level aides in recovery because increased oxygen equals more energy for the body’s cells and repair processes.  A visual:
hamstring injury
Credit – Slam
  • Medications
    • NSAIDS (non-steroidal anti-inflammatory drugs)
      • These are used to decrease inflammation but if used for longer than 5-7 days can delay healing, weaken tissue, and lead to impaired function
      • A gold-standard double-blind, randomized research trial on the use of NSAIDS in hamstring injuries actually showed no difference in outcomes between those who took NSAIDS and those who didn’t
    • Glucocorticoid injections
      • Generally, these aren’t a good idea for acute hamstring injuries because they can break down tissue and increase the risk of tendon rupture
      • The exception may be in professional/elite athletes where treatment is being handled by experienced sports med physicians.  In these cases, research shows a higher return to play rate without negative side-effects
    • OTC (over the counter)
      • To address pain directly, over the counter pain relievers like Tylenol and Advil are usually adequate for most hamstring injuries
  •  Stretching? (I get asked this a lot so I’m going to include it)
    • Stretching is actually harmful in the acute phase of hamstring injury – it can increase scar formation and increase re-injury rates (hamstring fibers are already stretched or torn so you don’t want to stretch them out farther)

B. Mezzo (systemic)

  • Bio-Mechanics
    • The glutes (butt muscles) help the hamstrings with certain movements – each take stress off the other.
    • With an injured hamstring, the glutes take on extra load (this goes back to the kinetic chain we talked about earlier) so it’s important they are strong and conditioned.
    • Here’s a glute activation and warm-up video:

  • Nervous system
    • CP3 and the team need to keep his mind and emotions in check over the weekend.  Feelings like anger, frustration, and negativity can up-regulate his sympathetic nervous system (SNS, “the fight or flight response”).
    • An up-regulated SNS can increase systemic inflammation and pain sensitivity. Managing the SNS is critical for creating an optimal healing environment
  • Sleep
    • Sleep is critical in recovery – it’s a key foundation for the mind and body.

IV. If there’s a game 7, will CP3 play and will he be limited?

Unless CP3 has a significant setback over the weekend, I expect him to suit up and try to play for game 7.  He has every method of treatment and recovery at his finger-tips and the rehab team will be working around the clock.  You combine that with a possible trip to the Finals and I don’t see him sitting this one out.

That being said, there are many things working against him here:

  • CP3’s existing risk factors
  • The very limited time-span between his injury and game
  • How involved hamstrings are in basketball movement
  • The intensity level of a conference finals game 7

Taking all those into account, it wouldn’t surprise me if he’s pretty limited or if he re-aggravates it – especially early in the game when the hamstring is still trying to get loose or late in the game when fatigue sets in.  That would put all on the onus on Harden…..

Credit – TheCommittedGeneration

Thanks for reading and until next time.


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