The Trainer's Take

The Trainer's Take with Gray Vitti

Lakers head athletic trainer Gary Vitti endured what he called the toughest season of his 29 in Los Angeles, battling a plethora of injuries that kept him and his staff working around the clock. Vitti sat down with to reflect upon 2012-13, including explanations and updates on injuries to Kobe Bryant, Dwight Howard, Pau Gasol and Steve Nash.

Below is a transcription of the conversation:

MT: You've been in this chair as the Lakers head athletic trainer since 1984, and I know you've never had a Murphy's Law type of season like 2012-13 in which almost everything went wrong. How do you reflect upon it?
Vitti: I'm still getting over it. It wasn't a tough year, it was a tough 10 years in one. The NBA is different from pro football and other sports because we don't have as many players. You can go several seasons with the rotation really not missing many games, like we did a few years ago*. Theoretically it's possible, and a lot of it is luck. It was like it all caught up to us in one year, starting with Dwight Howard coming to us following back surgery. So before we even started anything, we already had an issue. Now, Dwight's back issues look pretty good, but the final piece of the puzzle was playing basketball. To compete at this level, you can't do it in practice. It's not the same as a real basketball game … period. The thing Dwight needed to do was to play himself back into shape, and that doesn't happen over night. We also forget that Steve Blake stepped on a spike that went through his foot in the preseason.
*In 2010-11, four starters – Kobe Bryant, Pau Gasol, Metta World Peace and Derek Fisher – and sixth man Lamar Odom played in all 82 games. Not one Laker played all 82 in 2012-13.

MT: Then in the second game of the season, newly-acquired point guard Steve Nash fractured his fibula. How do you explain that one?
Vitti: It was the most fluke lower extremity fracture that I have ever come across. We play 29 other teams, and I asked every single one of the team physicians if they'd seen such a fracture, and not one had seen a proximal medial head fibular fracture like Steve had. Then all the things that went along with it – nerve entrapment and so on – with Steve's preexisting issues forced us to shut him down. And then all of the things that we keep in order by working out, they manifest because he's not doing anything. When he eventually came back, he had a collectively damaged kinetic chain in which case a lot of compensation takes place. When there is compensation, there's dysfunction, and we could never get ahead of the curve because we had to play games. He was always behind the curve of everyone else, who had been playing in games and getting in game shape.

2012-13 Injury Chart

MT: And the injuries kept mounting … if you don't mind, let's go through a synopsis?
Vitti: Earl Clark has some issues but we were able to correct those early on. Steve Blake had the abdominal tear (Nov. 13), which required surgery and had some complications. Pau Gasol came in out of the typical shape he's in after playing great in the Olympics and not playing at all afterwards (prior to training camp), and had knee tendinitis issues (first sitting on Dec. 4), a concussion (Jan. 8) and then the plantar fascia tear (Feb. 5). Jordan Hill tore his hip labrum (Jan. 8), and part of that is how he plays, just bending and twisting in every which way to get his hands on balls; he went down at the wrong angle and tore the hip labrum. Antawn Jamison fell on an outstretched hand and sprained his wrist, (March 22) and played with it for the rest of the season before postseason surgery. Metta World Peace had the cartilage tear of his lateral meniscus on the left knee (March 27), and then you had Kobe spraining his ankle severely in Atlanta (March 13) before rupturing his Achilles tendon (April 12). Other players had issues as well, like Jodie Meeks spraining his ankle in Game 1 of the playoffs.

MT: Basically, your worst nightmare. How did all the injuries impact you, and how do you avoid assigning blame?
Vitti: I had a lot of sleepless nights. When things are going bad like that, when there is a bad bio rhythm going, you're staying up at night wondering if you're doing everything you can to get a guy well. That's something you can control. But then you worry about what's going to happen next. Some of that you can control, meaning, seeing if we are doing everything we can to prevent injuries with our training program. For what we can't control, you worry about who's going to get hurt next when a season like this happens, but you have to just put that out of your brain, because it's wasted energy. When you finally get everyone on the floor, another guy gets hurt, and it was just a revolving door until we lost our last game. This was my worst season in 29 years.

MT: Can you describe Howard's back injury and how it impacted his season? What should we understand about how tough it was to play months after a major surgery, and how did Dwight handle it?
Vitti: I think Dwight received a bad rap for how he returned from back surgery. Before the surgery, Dwight was losing innervation to his foot from pressure on the nerve root, and he had surgery to remove that pressure. Dr. Watkins did a great surgery and luckily the foot issue resolved quickly. Dwight did everything he was asked to do – he was compliant, diligent and worked very hard on his rehabilitation. When he plateaued, the last piece of the puzzle was to actually play basketball at the highest level, and this can’t be done in practice … the game is so much quicker and more powerful than anything you can create scrimmaging. So there came a point where we had to throw Dwight to the wolves, so to speak, and he went out there like a warrior and played himself into NBA shape. That, along with the reduction of sugar intake – which reduced his insulin spikes and resultant energy crashes allowed him to play at a higher level – (helped considerably). But once again, that does not happen overnight. Once it did you saw a stronger, more energetic Dwight Howard who was able to grab the ball high and keep it high. He stopped bringing the ball down to get enough energy to jump, which had allowed defenses to try and strip him and as a result load his shoulder labrum. So the better shape he got in and a better diet allowed him to perform at a higher level and keep himself out of positions that would potentially hurt his shoulder. Not having the understanding of this sequence of rehab created doubt amongst his critics and he took undeserved criticism. I don’t believe in excuses but I do believe in reasons – Dwight pushed himself through a very difficult injury/rehab process.

MT: As a lead up to a discussion about Bryant's Achilles, what's your understanding of playing time dispersal and how it can affect an athlete's body in various ways?
Vitti: There's a benefit-risk ratio to everything. Not just the minutes played, but all the training leading up to the games. For example, you can do a 600-pound squat in the weight room and a guy is going to get stronger, but at what risk to his body? So we create training programs that have an upside with as little downside as possible. High benefit, low risk. It's the same thing with minutes. Are they hard, grind-out minutes? Are you putting players on the floor where they have to do too much because the other guys can't help them? If you have guys in the post that an opponent has to double, it's going to make for easier minutes for the perimeter players. If not, the perimeter guys have to work harder to get open. So, yes, playing more minutes can increase the chance something happens to cause an injury, but to what extent? That's a question for every player in the NBA. As an athlete fatigues, he or she become more susceptible to injury. We know that. But it's also about how much recovery time an athlete has. The three most important things are sleep, ice water immersion and nutrition. You don't always have that available to you, although we try to create scenarios where they are.

MT: There's been so much written and discussed about how Kobe maniacally approaches preparation towards his body and his game. What's your up-close-and-personal point of view?
Vitti: Kobe Bryant is better at getting those things than anybody. He prepares to play the game at the highest level, on and off the basketball floor. Kobe will sometimes drive an hour somewhere on the road just to get into an ice bath late at night. Or he'll have a bunch of ice delivered to his hotel room and get into a bath tub of ice. He just does everything right. Everything. The last piece of his puzzle was the nutrition thing, which has gotten exponentially better in the last year and a half. He realized that as he was getting older, he needed to pay more attention to his diet than he used to. This past season, we hired Dr. Cate Shanahan as a consultant to essentially change our entire nutrition plan. We're feeding our players two square meals a day here at the facility thanks to Dr. Cate working with our terrific chef, Sandra Padilla. Then we have Cate talking to the chefs in hotel rooms on the road, and we have Whole Foods catering both our team flights and our pre and postgame meals.*.
*Stay tuned, as we'll go in depth regarding the Lakers' nutrition plan with strength and conditioning coach Tim DiFrancesco next week.

MT: OK then – Kobe's Achilles rupture occurred after he had played at least 40 minutes in seven straight tough games, six of them wins in which he carried a heavy load. There's been a lot of Monday Morning Quarterbacking going on, but how do you look back at at?
Vitti: We're all looking back thinking about it … but I don't know if it would have been different if we played him less. Plenty of players have torn their Achilles tendon that weren't playing 48 minutes per game. If you're going to use attrition as a reason to explain the injury, let's keep extrapolating it back. Maybe the 48 minutes was part of the total attrition, which included playing in the (2012) Olympics without recovery time ahead of the season. Let's go back to the truncated lockout season, which was more difficult physically because of packing more games into less time, which means less recovery. Then you can keep going back, and back, and back. Did it start before the lockout year (with three straight trips to the Finals from 2008-10?). With an emphasis that he didn't have enough recovery time the whole way through? Where along that continuum was there a mistake? Or was it the entire continuum? He got injured in game 80? Why wasn't it game 74? It's an inexact science. I'm not saying that the cause was all the attrition going way back, but just that if you're talking about 48 minutes, you have to keep going back. If he played 30 minutes a game, he still may have ruptured the Achilles.

Kobe Bryant

MT: In short, if we're going to use attrition as an argument, don't simplify it to the limited window of increased playing time, but consider the whole picture. And even so, we still don't know why that particular injury occurred. Alas, can take us through what's occurred from the moment he took that step to his left on Harrison Barnes.
Vitti: I knew right away that (the Achilles) was torn. I felt a hole in my gut. You know there's nothing you can do. It's over. Now, the sooner you realize that and start doing what you have to do to fix it – which is have the surgery and start rehab – the better you're going to be. The more you dwell on it, the less constructive it is, because it's not going to change anything. This is where the kid* is unbelievable – by the time I got home that night, Kobe had already decided that he was going to have the surgery. That's how special he is. He didn't dwell on it. He saw what it was, and immediately turned his focus to 'No more poor me, let's get ready for the next one.' He made it easy for everybody that way.
*Vitti met Kobe when Bryant was a 17-year-old rookie and has known him for half of Bryant's life.

So then the key was a good, solid surgery, which we had with Dr. Neal ElAttrache and our team doctor, Steve Lombardo, at Kerlan–Jobe Orthopedic Clinic. Then the key is to not lengthen the tendon too quickly, because once it's too long, it's over, and you can't make it short. If the tendon is too elongated, you lose the mechanical advantage of moving the foot and you can't run and jump with the power you need. That's where we are right now. As of (last week) he was out of crutches and out of the boot, and is in a specially designed Nike shoe with an inch-and-a-half wedge (that Kobe called his 'Medical Mamba's'), and as time progresses, we'll slowly shave the wedge down until his foot is back in neutral.

MT: Has any athlete – or just, anyone – ever had a shoe created for them for such purposes?
Vitti: Usually, people just put wedges – heel lifts – in the shoe. As I understand it, Kobe called Nike with advice from Dr. ElAttrache and our own head physical therapist, Dr. Judy Seto, to get this specially lifted shoe created. The reason this shoe being designed specifically for Kobe is better is because it does not change the relationship of the foot to the shoe.

MT: Where is Bryant in terms of his rehabilitation? Do you think he can play in the season opener, as is his hope?
Vitti: We don't know yet. Kobe looks exactly the way he's supposed to look at this point in time. Kobe makes you look good as a training staff … we always feel good about how he's going to recover from anything, and that's a credit to him. He gets all of it. He's the one that has to do it. He's going to be great no matter whom he works with, and right now he's working with the best, in my opinion, Judy Seto.

MT: Where as Kobe's injury happened suddenly, Pau Gasol battled tendinitis in his knees throughout the entire season, issues he's had in the past few years. He recently had what we were all informed was called a FAST technique procedure to try and help. Can you fill us in on the details?
Vitti: Whenever you have 'itis' on the end of a word, it refers to inflammation. Tendinitis is inflammation of the tendon, and it's very common in the NBA. Pau's tendinitis eventually became tendinosis, which is basically a diseased tendon where the tendon doesn't function properly any more. There's a technique called the FAST technique where they make an incision with a scalpel, a very small hole, and insert a probe to use an ultrasonic wave length to break up the scar tissue, the diseased part of the tendon, and aspirate it (suck it out). After they do that, they take another needle, put it into your hip and take out some bone marrow and inject that into the tendon. To give you an idea, since everyone knows what PRP (platelet rich plasma) is today, there are about half a million platelets in PRP and over a billion in bone marrow. And so you inject the bone marrow in there, let the whole thing calm down and let the body heal itself. So when Pau left for Spain last week, he had zero pain in the left tendon, and the right tendon was almost pain free. He's coming along really, really well. We also expect his plantar fascia to completely heal by next season. There's a small gap right now, but it's filling in nicely. Having said all that - it's a testament to the toughness of Pau. He's never been regarded as a 'tough guy' on the court, meaning a someone who bangs around out there – he's a skilled, finesse player. But he's always shown a level of toughness to play injured. A lot of times, Pau has been playing through tendinitis throughout different times in his career and he deserves some credit for that. He is the consummate professional. He did everything we asked him to do on the court, whether or not it was good for him individually.

MT: You mentioned how Jordan Hill's playing style could have contributed to his hip injury. How's he doing right now?
Vitti: Jordan is still rehabilitating. We have a few physical therapists that work with him in South Carolina, where he lives, and we expect him to be fully functional by the start of the season.

MT: Finally, I expect that Nash is in Canada working on his body?
Vitti: Yes, he's working with his longtime therapist in Vancouver and is getting better every day. Steve did everything we asked him to do all season, but as I mentioned, the fibular fracture along with the neurological component just disrupted his kinetic chain and he started compensating, which creates dysfunction. Part of what has made him great is his ability to know his body and compensate for movements on the court. But getting hurt so early and being out so long kept him from getting to that point, as he was chasing young guys like Ty Lawson and Russell Westbrook around the court. Teams were running him around picks, smashing him into the floor – he really got beat up last year.

But I think he's going to come back in great shape, and then it's all about how he's used. You don't want to beat him up in practice. Save it for the game, figure out the appropriate minutes that put him in a successful situation. The example I use is Robert Horry, where we played him a lot of minutes, and it was difficult for him to recover and be productive at his age. But he goes to San Antonio, plays 18 minutes a game, and the guy was an unbelievable force off the bench for them. I think if we figure out how best to use Steve, he can be the same way.