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Why would a bone bruise shut Rui Hachimura down for a month?

Here is the second part of our interview with Dr. Matthew Levine of The Centers for Advanced Orthopaedics in Maryland. This time we focus on the Washington Wizards forward.

Washington Wizards v Los Angeles Lakers Photo by Adam Pantozzi/NBAE via Getty Images

Yesterday, we had the first part of our interview with Dr. Matthew J. Levine of The Centers for Advanced Orthopaedics where we discussed hamstring injuries, like the one Washington Wizards guard Delon Wright is suffering. Dr. Levine is an orthopaedic surgeon who specializes in sports medicine. He also serves as a team physician at Tuscarora High School* in Frederick, Md.

In this part, we discussed forward Rui Hachimura’s ankle injury.

As a disclaimer, the answers Dr. Levine gave should be considered as general trends among people in a similar situation as Hachimura. They are not to be taken as medical advice. The information below is also not an indication of what Williams has experienced or is experiencing. Please consult your doctor for your specific situation.

Our questions are below.

Bullets Forever: Rui Hachimura has missed all of the Wizards’ games since Nov. 18 when he suffered an ankle injury which was later determined to be a bone bruise. This sounds a bit rudimentary, but what is the function of the ankle’s function for the leg and foot?

Dr. Levine: The ankle is what I would describe as a joint. It allows your foot to flex and extend or point your foot and bring your toes up and rotate a little bit side to side. And then it connects into some portions of the foot that then allow some of the other rotational components that allow a multi range of, of motion throughout the ankle foot complex.

But essentially it’s the joint that the ankle is the joint that connects the leg to the foot, and those bones are held together by ligaments and then muscles act on the bones as well. And then the muscles control the direction of movement while the ligaments are providing these stabilizing forces. When you sprain, roll, your or break your ankle, the stabilization is gone so the muscles can’t work in their normal manner.

BF: How do bone bruises happen?

Dr. Levine: when the ankle is injured or destabilized, the bones in the ankle can impact each other as well. That can be painful. Sometimes you’ll get little fractures or little breaks. These little breaks are what we call bone bruises or bone contusions.

BF: What is the difference between a bruise like someone falling on his or her buttocks and getting a bruise in that area, and a bone bruise? To the average person, one would probably think of bruises as something that’s visible as opposed to something on the bone.

Dr. Levine: The bruise you are talking about is a tissue bruise. In that case, you have visible bleeding that is generally contained within the skin. Its’ what we call ecchymosis or the bruising that you would see on the skin and say, ”You have a bruise.”

In the case of bones, there a very rigid structure that doesn’t allow that blood to sort of diffuse out and see it on the skin level. But bone is a living organism. If you think about the interior portions of a bone is like the lattice structure of a sugar cube. You can get little with little cells in there that make bone and wear bone out. There’s osteoblasts and osteoclast that constantly remodel the bone. But those tiny little structures inside the bone can get little fractures or cracks in them. And the bone then gets fluid or bleeding and things deep inside the bone that bring the healing responses of the body. These are also bruises, but they are generally not as visible because the bleeding stays within the bone.

BF: How long do bone bruises take to heal?

Dr. Levine: Since bone bruises are injuries that are generally contained, they also take longer to recover than a tissue bruise. When I have patients with bone bruises, I often tell them it can be, it can be a short recovery or within six weeks. But it can be up to three months. And I’ve had patients who had bone bruises for up to six months. The six month figure is on the on the long end of things.

Most people are able to get back to doing some lighter levels of physical activity prior to the end of these timetables. But that initial level of pain really has to resolve before they’re able to function well. The athlete’s body will constantly respond to that pain and prevent them from performing at their normal level. The muscles won’t work when the body is sensing pain. It’s called reflex inhibition, prevents the muscles from doing things that are gonna cause pain to oneself.

BF: You mentioned that the time table to recover from this injury can take anywhere from three to six months. Does that apply to the general population or to professional or other serious athletes?

Dr. Levine: This applies to anyone. Professional athletes are a little bit different in terms of treatment, but we don’t typically get repeat MRIs to see if the bone bruise went away. We know that over time they do tend to resolve after clinical treatment and when their pain levels have diminished enough. When someone’s pain has gone enough, they’re functionally able to do the things that they need to do. That’s when they’re cleared to play.

BF: How could bone bruises be frustrating for athletes, moreso than an “average joe?”

Dr. Levine: I would say bone bruises are a particularly frustrating injury for high level athletes because when they try to push themselves to perform at the level they need to push, that’s when they’ll have recurrent pain, which keeps them from performing well.

A “weekend warrior” in the recreational league or someone who just wants to work out for personal fitness alone is more likely to just modify their routines to get around the pain. But for serious high level athletes, they have to push their bodies more to perform.

Bone bruises are also frustrating for athletes (and anyone else) because there aren’t too many treatments available for them besides time and rest. A hamstring injury on the other hand can be treated with anti-inflammatories, massages etc.

BF: In short, is Hachimura’s recovery of roughly one month so far normal?

Dr. Levine: Yes. He may be doing some other activities like shoot around to keep his skills fresh. But with a bone bruise, Hachimura is not playing until the pain goes away and when the bruise resolves itself.

BF: You mentioned that you are a team physician for Tuscarora High School in Frederick County, Md.** Do you or have you worked with athletes at the college or professional level in the past?

Dr. Levine: My practice also works with the other Frederick County high schools as well as Hood College, an NCAA Division III school and Frederick Community College. And we see some people from Mount St. Mary’s University, an NCAA Division I school, even though we’re not official team physicians.

I also served my sports medicine fellowship at Duke University in Durham, NC. While there, I traveled with their soccer and lacrosse teams. And yes, I also worked with players on the men’s and women’s basketball teams.

BF: Last question — at the high school level, players often play multiple sports during the academic year. But there are students who focus on one sport and college athletes also generally focus on one sport. Are players who do multiple sports year round more susceptible to injury?

Dr. Levine: To the contrary. high school athletes who perform in multiple sports often suffer fewer injuries during a season that “single sport” athletes. One possible reason why is because different sports require different athletes to use different muscle groups.

There is some research that has shown that high school athletes who were multi-sport athletes when they became single sport athletes in college were less likely to get injured in their sport in college.

It is also true that the highest performing single sport athletes in college sometimes tended to be single sport athletes all through high school. While they may have performed at a higher level, but they have a higher risk of injury due to overtraining.

At the college level and high school as well, teams do offseason training and weightifting to mitigate the risk of overtraining and injury.

Thanks to Dr. Levine and the Centers for Advanced Orthopaedics for helping us learn more about sports injuries. We will continue to check in with them if and when Wizards and Mystics players get them.

*There is also a Tuscarora HS in Leesburg, Va. which is about a 30-35 minute drive south of Tuscarora HS in Maryland. Dr. Levine confirmed with us that he works with the Maryland school.

**For those of you not familiar with the geography of the D.C. area, there is a Frederick County, Va. which is located southwest of Frederick County, Md. It is the county that surrounds Winchester City. And Frederick County also happens to be where former site manager Jake Whitacre grew up!