Lonzo Ball’s Knee Troubles: Should We Be Worried Long-Term?

What the heck is going on with Lonzo Ball’s knee?  He gets hurt, comes back, gets hurt again, he gets some sort of injection, that doesn’t seem to work, gets minor surgery….what’s the deal.

Is he doomed to a career of knee problems and what-ifs?  Or does it all make sense and add up when you understand the details?  (You can probably guess which one I’m leaning towards…)

Lonzo Ball’s knee saga began on January 13th when he suffered an MCL grade I tear (all sprains = tears, don’t trip) against the Mavericks, tweaking his knee after a collision with fellow rookie Dennis Smith. That injury kept him out nearly 6 weeks, and a month later, he suffered a a bone bruise in the same knee which caused him to miss the final 8 games of the Lakers’ regular season.  In mid May, a PRP injection was used on Lonzo Ball’s knee and then 8 weeks later underwent arthroscopic surgery on the left knee to clear up a meniscus injury.

I understand why Lakers fans (I’m one myself, born into it) may be leaning towards option 1 and wringing their hands over Lonzo Ball’s knee saga. He’s had a string of incidents over the course of months with that left knee.  That being said, I’m here to tell you:

It’s truly not that big of a deal.

Each of his injuries, procedures, and timelines are connected and make sense when you understand the details.

Before I get into the specifics of Lonzo Ball’s knee, there are two key things to keep in mind:

  1. Medicine, rehabilitation, and treatment aren’t black and white. It’s not as simple as – here’s the problem, do an intervention, and everything is fixed.  That’s just not how it works. You have indicators that inform your diagnosis and then you have a plan of care that can consist of plan A, B, C, D and so on.  Also, symptoms may not manifest right away so something may become painful that actually occurred months previous.
  2. Each of Lonzo Ball’s knee issues are very likely connected and stem from his original MCL grade I tear.  If these were all separate isolated incidents then I’d be thinking “yo, this might be hinting at something long-term”, especially if they were non-contact injuries (they weren’t).  Therefore, the multiple injuries and treatments, although not ideal, make sense medically and are still within normal variance for his medical plan of care.

With that in mind, I’ll take you through each injury to Lonzo Ball’s knee and illuminate how each are connected and why the timelines and procedures all make sense.

So lets go.

I. Lonzo Ball’s Knee: Grade 1 MCL Tear

Lonzo Ball’s knee issues all began when he suffered a grade 1 MCL tear against the Mavericks on January 13th.  The MCL or medial collateral ligament is a ligament on the inside (medial) part of your knee.  I think of ligaments like rubber bands that stretch and tighten to keep joints stable.

Enjoy some anatomy:

lonzo ball's knee
Credit – 3D4Medical and 3CBPerformance

The MCL’s main functions are to stabilize your knee joint when it goes inwards aka “knee valgus”:

lonzo ball's knee
Credit – DSM Spine + Sport

and/or when the knee rotates inwards or outwards aka “internal or external rotation”:

lonzo ball's knee
Credit – PhysioTutors

When there’s too much force and the joint moves past it’s normal range of motion, the MCL gets overstretched and fibers tear. Like this:

lonzo ball's knee
Credit – Omaha Physical Therapy Institute

The extent of tearing determines the severity of the injury. In Lonzo’s case, just a few fibers tore which equates to a grade I MCL tear – no big deal.

lonzo ball's knee

It’s the most common knee ligament injury and highly prevalent in basketball players (click here and here for more info), with NBA players returning to play in roughly 15 days.

So why was Lonzo out 6 weeks?  There’s a valid reason at the intersection of 2 factors:

  1. There’s evidence that a grade 1 ligament tear, compared to the more severe grade 2 or grade 3 (complete) tear, induces a less proportional healing response. For that reason, the pain from a grade 1 tear may actually linger longer than its more serious counterparts. In other words, the body doesn’t take the grade 1 tear as seriously and therefore doesn’t take an “all hands on deck” approach to mobilize the body’s resources, like it would with a more severe tear.
  2. Lakers head athletic trainer Marco Nunez used an extremely conservative “zero pain” return to play protocol during Lonzo’s MCL rehab. If Lonzo Ball’s knee had any pain during or after activity, he wasn’t allowed to progress to the next step.  Nunez did the same thing with Ingram during his groin strain.

So when you combine the longer pain duration of a grade 1 MCL tear with Nunez’s criteria of “zero pain”, Lonzo’s extended timeline makes sense.

Unfortunately, Lonzo Ball’s knee injuries continued shortly after returning…

II. Lonzo Ball’s Knee Bone Bruise

Before we delve into Lonzo Ball’s knee bone bruise, you might be wondering why I’m calling it a bone bruise when the Lakers reported it as a “lateral knee contusion”.

A “contusion” is a nebulous term that doesn’t give us much information – it can be a simple bruise, it can be something more menacing .  However, when a player has that diagnosis and misses significant time (Lonzo missed the final 8 games of the season), it’s almost certainly a bone bruise.

Lonzo’s bone bruise occurred against the Mavericks (maybe we should just sit him out against the Mavs from here on out) when the outside of his knee made contact with Dirk’s after a defensive switch during pick and roll action.

Here’s the video:

lonzo ball's knee
Credit – Spectrum Sportsnet

We can’t see the exact moment of contact because Julius is in the way but it’s still evident that Dirk’s knee made contact with the outside (lateral) part of Lonzo’s knee at a slow pace. You can see Lonzo immediately start limping and favoring his left.

Normally, this sort of knee to knee contact at a low speed would’t do much – it would smart for a bit and then you’d back to playing.

For a bone bruise to occur from direct contact, it takes a hard hit. Like the hit Andre Iguodala took from James Harden during the Western Conference Finals:

lonzo ball's knee
Credit – NBCSN Bay Area

Like Lonzo, Igoudala’s injury was officially called a lateral knee contusion but known to be a bone bruise.  It’s intentionally hazy medical speak.

Anyways, the pressing question is this:  The bone bruise makes sense in Iguodala’s case because the force of the impact with Harden’s knee, but how did Lonzo suffer a similar injury by merely tapping knees with Dirk at a liesurely pace?

There’s something else going on here.

That something is known as ligament laxity (looseness), which is commonly seen after an MCL injury. I’ll let Dr. Shounuck Patel, DO explain:

“Even after the MCL completely heals and is pain-free during movement, that doesn’t mean it’s exactly the same as before.  Ligaments, when stretched, will re-tighten but may not be as tight as they once were. I think of it like those rubber bands that are placed around vegetables in the grocery store. If you over-stretch the rubber band, it will re-tighten and still  be able to get the job done but it’s not as as tight as before.”

This laxity in the MCL can turn previously innocuous movements and contact into potentially harmful movements and contact. In Lonzo’s case, Dirk hit him on the outside of the knee which placed Lonzo Ball’s knee into a valgus (inward) position.  Back to Dr. Shounuck Patel, DO for the explanation:

“The primary function of the MCL is to resist valgus (inward) force and movements.  When the knee goes inwards, the inner (medial) aspects of the tibia (shin bone) and femur (thigh bone) gap/pull apart and the MCL is tensioned.  Simultaneously, the outer (lateral) aspects of the tibia and femur come closer together.”

lonzo knee
Credit – Omaha Physical Therapy Institute

“So if the MCL is looser than usual, the valgus (inward) force from Dirk hitting the outside of Lonzo’s knee could result in the outer edges of those bones actually hitting together and creating a bone bruise.”

Here’s what a bone bruise looks like anatomically:

lonzo ball's knee
Credit – MD Health

A bone bruise is a really painful injury but, if taken care of appropriately, doesn’t have any long-term consequences.

So we’ve covered both the MCL and bone bruise injuries – injuries we knew about during the season – but what about this recent news of a meniscus problem?

III. The Meniscus

In the off-season, we learned that Lonzo Ball’s knee had some left knee meniscal issues (how we found that out is a different story altogether). Generally, the meniscus is a dual crescent shaped pad that sits between your knee bones – the femur (thigh bone) and tibia (shin bone).

Take a look:

Lonzo ball knee
Credit – Huang Orthopedics

The meniscus functions as a cushion to dampen forces placed on the knee, lubricate the knee joint, and stabilize the knee joint during rotation.

After the news of this meniscus trouble broke, I definitely heard panic about how it could be a sign of chronic problems in Lonzo Ball’s knee (those concerns were what drove me to write this piece).

It’s very likely NOT an indicator of chronic issues.  In fact, I’d expect Lonzo to have some meniscus issues due to his previous MCL injury.

Here’s why:

A. The MCL and medial (inner) meniscus are physically connected

lonzo ball's knee
Credit – 3D4Medical & 3CBPerformance

Due to this physical connection, when the MCL gets damaged, the meniscus can also get damaged. During a physical exam, a meniscus injury is easily mistakable for an MCL injury and vice-versa.

Research has shown that in 5% of cases there’s a diagnosable meniscus tear visible on MRI following an MCL injury.

NOTE: This doesn’t mean that in the other 95% of cases there isn’t simultaneous meniscus injury. It just means there isn’t enough MRI evidence to diagnose it as a tear.

It’s well within the realm of possibility that Lonzo Ball’s knee had some meniscal damage along with his original MCL injury. This may or may not have manifested as symptomatic at that time.

With small meniscus tears (like Lonzo had), it’s difficult to infer a timeline because the symptoms and timing of symptoms are both variable.

Symptoms can range from pain and swelling in the knee to clicking in the knee during movement to the knee intermittently catching during movement to the knee “giving out” to a feeling that the knee isn’t moving properly (this called “proprioceptive misinformation”)…all the way to zero pain or movement issues.

For example, most patients can ambulate after a small tear and continue to participate in activity. Further, there’s emerging evidence that shows meniscus damage on an MRI doesn’t correlate with pain in the knee.  This lines up with the fact that force absorbing tissue in the body (other examples include cartilage and the discs in our back) naturally change over time.

Additionally, the timing of symptoms is variable. Some may have immediate symptoms, some may have insidious symptoms and deficits that pop up in the next days or weeks or months, and in some cases symptoms may never appear.

Further, there’s again that issue of MCL looseness following a tear…

B. MCL Laxity

It’s also within the realm of possibility that the meniscus may not have been damaged during Lonzo’s MCL injury.  Instead, the increased laxity (looseness) of his MCL could have changed the mechanics of his left knee, resulting in altered loading patterns at his knee joint and increased wear/irritation of his meniscus.

There’s also the possibility of….

C. A Combination of Both

Finally (!), it’s also possible that the original MCL injury did cause some damage to the meniscus and then the increased laxity from the MCL and resultant change in knee mechanics exacerbated that meniscus damage, leading to symptoms.

___

Here’s my educated guess about Lonzo Ball’s knee meniscus timeline and symptoms:

  1. His meniscus took some damage during the MCL injury (but not enough to be officially diagnosed on MRI as a tear). This may have contributed to his extended pain response.  However, that pain was definitely gone by the time he returned because Marco Nunez was stringent about having no pain and wouldn’t have let him play otherwise.
  2. I’m very confident Lonzo wasn’t having any clicking or intermittent catching of the knee at that time because those are overt signs of meniscus injury.  Nunez and the medical staff would recognize that immediately.
  3. At some point during the final 8 games and into the off-season, Lonzo’s meniscus became symptomatic – possibly due to a looser MCL altering his knee mechanics which changed how the meniscus is loaded during movement and led to irritation.

Regardless of the exact details, the theme is the same:  the meniscus issue is very likely related to the original MCL injury. 

With this in mind, the medical team now has some choices to make…

IV. Medical Decision-Making

At this point, the calculation for his medical team went something like this:

“Ok, we believe Lonzo Ball’s knee (they’re very formal evidently) has some MCL laxity (perhaps the root cause of the bone bruise and possibly of the meniscus injury), there’s some meniscal involvement that has become symptomatic, and there’s residual inflammation in the knee joint (due to the bone bruise and meniscus).  So what’s the best route we can take here?”

In this set of circumstances, most medical staffs won’t start with an invasive surgical procedure.  Rather, the first step is taking a conservative option that can potentially address some or all of the issues.  They chose…

A. PRP

PRP stands for platelet-rich plasma therapy. It’s an injection that re-introduces certain components of your own blood in order to stimulate healing.

lonzo ball's knee
Credit – Advancells.com

For an in-depth explanation of PRP and how it would help Lonzo’s left knee, read my full interview with Dr. Shounuck Patel (his quotes above were from that piece).

Although PRP continues to be an emerging field of medicine with research of its efficacy and effectiveness ongoing (as is the case with any new treatment), there is evidence that a targeted PRP injection with guided imaging (this skilled technique is known as interventional orthopedics and only practiced by a handful of PRP providers) can:

  • Re-tighten the MCL (this would directly restore optimal knee mechanics and indirectly address the bone bruise by taking pressure off the knee’s lateral compartment)
  • Stimulate meniscus repair (addressing the meniscus)
  • Normalize inflammation in the knee joint (taking it from a negative inflammatory environment to neutral)

It makes sense to take this route first since you can potentially kill 3 birds with 1 stone.  Additionally, it’s a quick non-invasive procedure that takes about 30 minutes and Lonzo is walking out the same day.

Further, PRP’s only drawback is mild to moderate pain in the first 2-3 weeks as the body’s healing factors kick on and do their work.  That timeframe is why Lonzo took a month off from on-court basketball activities after the injection. He was allowing those self-healing processes to play out.

However, Lonzo continued to experience some meniscal irritation in his left knee even after the PRP injection and 4+ weeks of rehab. This doesn’t mean the PRP was an abject failure because it could have helped re-tighten the MCL and neutralize inflammation. However, for the meniscus, a more invasive approach was now indicated…

B. Knee Arthroscopic Surgery

A key indicator for arthroscopic knee surgery on the meniscus is having little improvement in symptoms after 3 to 6 weeks of conservative treatment.  After PRP & rehab didn’t fully resolve the meniscus problem, Lonzo found himself in this boat.

Lonzo Ball's knee

Therefore, the medical decision calculation shifted towards arthroscopic surgery which Lonzo had on July 18th.

In an arthroscopic surgery , the surgeon makes tiny cuts and inserts a tiny camera to see the joint.  Based on that visual information, the surgeon decides on a plan of care and then uses tiny instruments to execute that choice.

lonzo ball's knee
Credit – Dr. Kunal

For a little more detail, check out this video:

For a meniscus, that plan of care is usually one of two things:

  1. Remove the damaged part of the meniscus (called a “partial meniscectomy”)
  2. Repair the meniscus (a “meniscus repair”).

That decision often depends on the location of the tear.  The outer 1/4 of the meniscus is fully vascularized (meaning it gets a full blood supply) so it’s likely to heal  (blood brings healing and growth factors to the area) after it’s repaired (stitched back together). However, the rest of the meniscus doesn’t have a full blood supply so if the tear is in that region, it’s unlikely to heal. Therefore, in those cases, it’s removed.

lonzo ball's knee
Red-red = full blood supply
Red-white = some blood supply
White-white = no blood supply

In either case, the surgeon’s goal is to retain as much of the meniscus as possible because, as my NAU professor Dr. Carl DeRosa used to say, if you change the biology too much, “it’s not the same model”.

Additionally, the surgeon may also repair the roots of the meniscus.  This technique is relatively new and there’s emerging evidence that preserving or repairing injured roots of the meniscus (think of the roots as anchoring the meniscus down to the bone) can benefit overall recovery and function.

Although no details have been released and likely will never be released about Lonzo’s specific procedure, I believe his surgery was the partial meniscectomy (removal of the torn/irritated piece of meniscus) for three reasons:

1 – In most cases where the meniscus was aggravated over time, as I believe was the case for Lonzo Ball’s knee, a partial meniscectomy is indicated.

2 – The team has said Lonzo will be back & healthy for training camp, which is about 8 weeks from now.  The typical timetable for return to sports after a partial meniscectomy is 6 weeks whereas it’s 12 weeks for a meniscus repair.  That again leads me to believe Lonzo had the partial removal.

3 – After a meniscus repair, the rehab protocol is to have the knee straight and locked in a brace for 4-6 weeks.  However, Lonzo was sighted days after surgery with just a wrap on his knee, while dual wielding canes as he gradually returns to full weight-bearing (if you can guess where he is, you a real one):

Lonzo Ball's knee
Credit – Twitter Carlrosh

That really leads me to believe he had the partial meniscectomy.

Ok cool, so he probably had the partial meniscectomy but what does that mean for his long-term future?

V. Long-Term Implications

Research shows that people under 35 years old (Lonzo is a wee young lad at 20) with isolated meniscus tears who undergo arthroscopic meniscus surgery do very well. One study followed people for 10 years after the surgery and nearly 95% were satisfied with the surgery and over 85% were completely symptom free at 10 years out.

However, a partial meniscus removal (as compared to a meniscus repair) does come with one risk factor:  An increased risk of developing osteoarthritis in the knee joint.

That being said, there are numerous ways for Lonzo to buffer against that risk, including:

  • Consistent and disciplined strength and conditioning work
  • Proprioceptive training (your body’s awareness of itself in space)
  • Neuromuscular training (the unconscious process through which muscles are timed and activated to control dynamic joint stability)

Each plays a role in optimizing Lonzo’s muscles to absorb shock effectively and take pressure off his joints while creating fluid and stable movement patterns. He and the training staff will have to be extra vigilant about his mind and body.

Maybe Lebron can teach him a few things (to learn about how Lebron takes care of himself, I wrote this piece for GrandStand Central).

VI. All in All

The grade 1 MCL injury in January was the central player in Lonzo Ball’s knee saga. It’s the trunk of the tree and each of the subsequent knee injuries stem off that, whether it’s due to anatomical, functional, or risk relationships. All the injuries are connected and none came out of the blue.  It’s not ideal obviously but much much less alarming than multiple unrelated injuries.

I created this flow chart as a visual summary of the timelines and relationships:

lonzo ball's knee
Credit – draw.io

The key for Lonzo’s medical plan was addressing both the underlying (residual MCL laxity) and immediate issues (meniscus). The team did that by using the PRP procedure to restore MCL tightness and stimulate healing of the meniscus.  When the latter wasn’t completely successful,  arthroscopic knee surgery stepped up to plate and removed the irritated bit of meniscus.

I’m confident that Lonzo will recover very well in the short-term and his risk will be mitigated in the long-term. People under 35 have excellent long-term outcome with arthroscopic meniscus surgery and the Lakers’ have a world-class support system that mandates consistent high quality rehab, strength, conditioning, fitness, and mental well-being,

Additionally, the plan of care that we’ve seen throughout Lonzo Ball’s knee issues have provided substantial insight into the medical staff’s thought process.

I love what I’ve seen.

The medical staff has calculated risk/reward every step of the way while creating a methodical and logical intervention plan, complemented by an incremental and measured approach to rehab, strength, and conditioning.

The reality of medicine is that it’s an inexact science. You can do everything right,  anticipate all possible avenues, and still not get the outcome you wanted. That’s the beauty and beast of the human body.

With that in mind, you have to make sure your clinical decision-making and processes are excellent and provide the best chance to achieve the best outcome for your patient.   That sound process & decision making has been evident with Lonzo Ball’s knee every step of the way.

I can confidently say he’s in good hands – they even forced him, I mean educated and persuaded him, to trade in his lettuce and cheese “salads” for real meals.

lonzo ball's knee
Credit – Backstage Lakers

Thanks for reading and until next time.

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