Iguodala’s lateral leg bone bruise: Will the Finals get Iggy with it?

Andre Iguodala hasn’t played since game 3 of the Western conference finals when he suffered a lateral leg bone bruise while defending a drive by James Harden.

Here’s the video of when it happened (go to the :11 second mark)

As Harden is driving into the paint, his right knee smacks into the outer part of Iggy’s left knee.  Iguodala’s return for the Finals remains uncertain, and he’s a game-time decision for game 3 of the Finals.

If you’ve been wondering: “It’s just a dang bruise– why can’t he just suck it up and play?”. You’re in the right place.  Iggys probably had a similar thought at some point too.

A bone bruise isn’t to be confused with your normal superficial bruise that results in some discoloration and mild pain for a couple days.  A bone bruise is actually affecting the bone itself (more on that in a sec).

I’ve personally been through one (bicycles and car bumpers don’t’ mix well) and it’s extremely painful and frustrating. Using my lens as a DPT, Doctor of Physical Therapy, I’ll explain Iguodala’s lateral leg bone bruise and timeline for return by answering the following questions:

  • What exactly is a bone bruise?
  • Why is it so painful?
  • What specifically about a lateral leg bone can muddy the return to play timeline?
  • When will Iggy actually be back?

To note, this is a quick injury update and not a more comprehensive review like many of my other posts. With that in mind, here we go:

I. What is a bone bruise?

A bone bruise involves a microfracture of your bone – technically, it’s called a microtrabecular fracture. It’s one step below a fracture and one of the four types of fractures that occur in the human body.

Here’s a visual:

lateral leg bone bruise
Credit – MD Health

There are three distinct types of bone bruise. Based on mechanism – a direct high force trauma to the bone- and prevalence – most common in the lower body – I believe Iggy’s lateral leg bone bruise is a sub-periosteal hematoma (no, I didn’t just make those words up).

To understand what that is, let’s start with some bone anatomy (take note of the periosteum):

lateral leg bone bruise
Credit – 123RF

The periosteum is a dense membrane of connective tissue (bone is a living biological material) that covers the outer surfaces of all your bones, except at the joints of long bones. It also contains blood vessels and nerve fibers.

When the bone takes a direct hit, like this…

lateral leg bone bruise
Credit – NBCSN Bay Area

…and that force is transferred to the periosteum, blood vessels get damaged and blood collects underneath it. When the blood clots, it forms a hematoma. Thus, it’s called a sub-periosteal (below the periosteum) hematoma (solidified collection of blood within a tissue).

In Iggy’s case, that sub-periosteal hematoma is on the outside of his left leg, therefore it’s termed a “lateral leg bone bruise”. These don’t show up on x-rays because there’s no fracture but can be seen on an MRI due to corresponding swelling.

Check out this side by side representation (this is of the wrist but same concept applies):

Now that we know what a bone bruise is, what makes it so darn painful…

II. The anguish of a bone bruise

There’s 2 reasons why a bone bruise is so painful:

A. Inflammatory response and swelling

Like any other damaged tissue, the body starts an inflammatory response to help heal the periosteum. This causes pain and swelling in the area and possibly in the soft tissues around it. For example, Iggy may have residual swelling in his left quads, hamstrings, and possibly calf – creating more pain and limiting function.

Additionally, after the hematoma is formed, the body starts an inflammatory response to break down and reabsorb it. This inflammation response creates pain and the inflammation continues as long as the hematoma remains.

2 – High nerve density of the bones

The periosteum (outer layer of the bone) contains a lot of nerves and nerve endings. At the time of injury, a lot of these nerve fibers are stimulated which creates an extreme pain response.

Iggy wasn’t happy:

lateral leg bone bruise
Credit – NBCSN Bay Area

He immediately started grabbing at it and hopping on the other foot.

If bleeding continues under the periosteum (outer layer of the bone), these nerve fibers continue to be stimulated. That’s why in the first few days after a bone bruise, you want to avoid activities that increase blood flow to the area. Things like hot showers, massage, excessive activity, heat rubs. This can lead to prolonged bleeding which causes prolonged pain and recovery times.

Additionally, a physical mass (the clotted blood) underneath the periosteum can stimulate nerve fibers during movement. That’s one reason Iggy is still having a high level of pain with movement – every time that leg moves, those nerve fibers are firing.

When I had my injury, getting out of my seat and walking to to the doorway of my classroom felt like hell and back again – it’s so painful. You don’t realize just how innervated bones are until they’re constantly reminding you of it.

The pain from a bone bruise can last for weeks to months. Generally, it takes at least 3 weeks for a bone bruise to clear (some can last for up to 2 years – that doesn’t mean there are physical symptoms for 2 years, rather they will show up on an MRI for that long).

Additionally, there’s one issue specific to a lateral leg bone bruise that makes Iggy’s recovery more difficult and variable in nature…

III. Lateral leg bone bruise – nerve issues

In addition to the pain of the lateral leg bone bruise, Iggy continues to have “inflammation of the nerve surrounding the left knee”.

When Iggy got hit on the outside of his knee, it seems that a nerve took some damage as well. The lateral part of the knee houses multiple nerves, take a look:

lateral leg bone bruise
Credit – OklahomaPainManagement

Two of these are very near the surface and prone to irritation – the common peroneal nerve and the lateral sural nerve:

lateral leg bone bruise
Credit – NatomImages

Nerves, like tissue, have an inflammatory healing response when damaged.This nerve swelling (termed “neuritis”) can create additonal symptoms, including:

  • Tingling
  • Sharp, stabbing pains
  • Numbness
  • Feeling of “tightness” in that area
  • A buzzing or shocking sensation
  • In the case of a nerve that controls movement, weakness and possible atrophy of those muscles

Not fun…but what are Iggy and the Warriors medical staff doing to treat it?

III. Treatment

If this injury was during the regular season, my guess is Iggy and the Warriors staff would treat it far more conservatively – allowing the body’s inflammation response to take its course while taking measures to reduce symptoms (medication, modifying activity, etc).

However, Iggy doesn’t have the luxury of time right now.

Therefore, the target of treatment is reducing the inflammation and pain as quickly as possible, down to the point where Iggy can tolerate moving on it. Thus far, that hasn’t happened and he hasn’t played.

So….

IV. When will Iggy be back?

There’s a chance that he plays in game 3 of the Finals and if he does play, there will be a minutes restriction . The timeline for his return has been so variable because of how painful a bone bruise is during movement and the added layer of pain and variability that comes with the nerve inflammation.

As Iggy said leading up to game 1:

“Just keep grinding away at the process….we’ve had some really good days and some really bad days…so just keep pushing, trying to get through it.”

He will continue to get evaluated on a day by day and game by game basis – regardless of whether he plays tonight or not.

I have no doubt that if he was able to tolerate the pain, he would already be playing…and by all accounts, he’s doing everything he can to speed up the process – getting a 2nd opinion and actively seeking any remedy to alleviate the discomfort.

There’s a lot of frustration – which doesn’t help at all with the healing environment and process –but that’s natural: it’s a very frustrating injury that occurred at the worst time of the season.

If he does play tonight, the major question will be how the bone bruise and knee respond to the increased intensity of in-game action. If his pain level blows up again, he’ll likely have to sit out again.  Regardless, if JR continues to not know the score and run out the clock on game-winning chances, the Warriors may not even need him.

Thanks for reading and until next time.

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