'Pain's hangover'

An exclusive excerpt from Henry Abbott's new sports science book, Ballistic.

I’ve spent the last few years writing Ballistic, coming out May 6, from W.W. Norton & Co. It’s about Harvard M.D. Marcus Elliott who built a lab, called P3, that aims to prevent sports injuries in the way that echocardiograms prevent heart attacks or vaccines present measles.

35 years into his journey, he has a team of biomechanists and data science engineers who have 134.4 terabytes of data from in-person assessments of thousands of elite athletes including more than 70% of the current NBA. That data has interesting lessons for all of us.

A high NBA draft pick showed up at P3 with his team in the days before his first NBA game. His assessment mostly went well. He jumped beautifully. His movement was NBA-grade. He had the tools.

But the force plates saw something. “When he would land from a jump, for a second jump, he would always keep the left heel off the ground. It would never touch the ground,” Marcus says. “It’s very, very rare that we have an athlete that lands from a jump and goes up for a second jump, and their heels don’t touch the ground. It never happens—unless there’s compensation for a big, big injury—or a big mechanical issue.”

The left heel’s reluctance shifted the force of landing to the right. “Significantly more force through his right side on every landing,” says Marcus. “Over 60 percent of his net force is being absorbed by his right side.”

P3’s motion-capture system—shiny and new at the time—saw a thicket of risks to the right knee. Not only had his weird movement added force, but it had also complicated the player’s biomechanics. ACL tears are rare, but they’re much more common in knees that move like that one.

P3 doesn’t have a private exam room or a white noise machine to deliver news in privacy, but when necessary they huddle close and share secrets. The team honchos, across the room on the couches, wouldn’t hear a word over the music.

Marcus and lead biomechanist Eric Leidersdorf told the player they saw worrisome forces through his right knee. “That resonated,” Marcus says. “He told us that his right knee had been hurting. And then he told us that he had been shut down for the last month of the summer, meaning he wasn’t playing basketball because he was hurting that much.”

Baseball and football players go weeks without playing their sports. But ballers ball. Almost no matter what P3 tells NBA players to do, they play. Basketball has pull. Sitting out a month of this game at that age set off alarm bells.

“And then,” Marcus says, “he told us he got an MRI, off the record, two weeks ago.” Only his agent knew. Thankfully, the MRI showed no major damage—but he was still in pain. “To have great pain, is to have certainty,” writes Elaine Scarry in The Body in Pain. “To hear that another person has pain is to have doubt.” In other words, pain is invisible.

But P3’s technology makes pain somewhat visible. Nobody had noticed the player’s elevated heel, or sore knee, during a well-televised season. But the SIMI motion capture system saw them. “He starts revealing more and more and more because he has confidence that we have information that he needs,” says Marcus. “We’re predicting the future. And he’s saying, ‘Well, the future is here right now.’”

Training camp began in a few days. It would mean in-your-face physical tests against the best in the world. Playing time, scoring opportunities, and ultimately millions of dollars were at stake.

The player said he planned to play.

That may sound silly or brutish. But it’s common. Pain is the invisible lifeblood of elite sports. (What’s the reason most of us don’t know how fast we could really run? Because it would hurt, right?) At the bleeding edge of performance, the limits are regularly expressed in suffering. Tour de France racers describe their own chosen sport as a “suffer fest.” One has a story of grinding his teeth flat as a more-pleasant distraction from the race’s other pain. The NBA lauds Isiah Thomas or Willis Reed for playing badly hurt. Professional athletes touch those limits for a living. This player had a clean MRI, whippersnapper youth, and elite athleticism; to sit would ruin his reputation.

The fact that the player had tested as one of the best movers on the planet on one and a half feet is mind-blowing. His body invented a new movement pattern on the fly, and it worked. He could move.

“But now the problem is it’s threatening his career,” Marcus says.

“After he told us all this about his knee, he told us that he had had plantar fasciitis on his left foot,” says Marcus. “So, this entire time when he’s going out trying to be the best player in college basketball, his left foot hurts. He developed these movement patterns that saved his left foot.”

And it worked. “His left foot,” says Marcus, “is perfect. He doesn’t have any scar tissue, the tissue quality is perfect, and mobility is perfect.”

The fasciitis was cured. But he still won’t put his left heel down. Because “pain is an amazing teacher,” says Rachel Zoffness, Ph.D., a pain psychologist, Stanford lecturer, and assistant clinical professor at the University of California, San Francisco School of Medicine. The human brain might be the most beautiful and intricate of all creations. But it makes mistakes. Pain, according to Zoffness, is “the brain’s opinion” about the danger you’re in.

Zoffness tells a story first published in the British Medical Journal about a construction worker who jumped off a ledge and—oops!—onto a seven-inch nail. The nail poked out the top of his left boot and popped the balloon of normalcy. At the ER, they administered intravenous fentanyl and midazolam before very carefully sawing away his boot.

Inside, though, they found a perfect left foot. No blood, no wound, no nothing. Surprise! The nail had threaded between toes. The worker’s brain had formed the opinion that the body was damaged, and sent pain signals—not because it felt the nail tearing flesh, but because it saw a nail poking through a boot top.

The brain can project real pain into pristine flesh. It can even project real pain into no flesh at all. Amputees can experience pain, called phantom limb pain, in an absent arm or leg. The homunculus is the brain’s map of the body. One way to treat phantom limb pain is mirror therapy, in which the patient looks in a mirror while completing prescribed movements. Eventually, the homunculus updates with better information about where the body ends.

“The word for what’s happening is kinesiophobia,” says Zoffness when she hears about the rookie who wouldn’t put his foot down. In the literature, kinesiophobia is defined as “an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability due to painful injury or reinjury.” It’s common, even in healthy tissue. Sometimes the brain’s opinion of danger is wrong.

“You’re terrified it’ll hurt again,” says Zoffness. That construction worker’s ability to use his left foot improved dramatically once he would see it wasn’t damaged.

“The solution is that his brain needs to learn that it’s safe to put his whole heel down, but the brain won’t know that it’s safe without concrete evidence,” says Zoffness.

In the back of P3, they devised a program. But mostly, they cheered him on when he got his weight distributed evenly. The team helped coach it, and after a few weeks he had freed his movement habits from pain’s hangover. “And that was all it took,” says Marcus. “It wasn’t building new systems. It wasn’t rehabbing anything—nothing was broken. It was just giving him feedback on when he was more symmetric, and when he was getting his heel down to the ground.”