If a player gets hurt and the medical staff says he’s “medically clear,” does that mean he or she is pain-free and ready to play? Absolutely not. Being medically cleared simply means that the injury is physically healed. It’s bearing on whether the player is pain-free and ready to return is nebulous, at best. The longer the injury has lingered, the more nebulous that association becomes.

This contrast between medically cleared to play and able to play without pain or hesitation has come up in the last year with two prominent NBA examples: Markelle Fultz and Kawhi Leonard.

For Kawhi Leonard, he was diagnosed with a knee problem (a “quadriceps tendinopathy” to be exact) in the summer of 2017 that led to him missing all but a handful of games last season. He tried to come back in December, still had pain, and then was shut down for more rehab. In March, the Spurs’ medical staff deemed him as “medically cleared,” but he didn’t suit up again last season.

Markelle Fultz was diagnosed as having a scapular imbalance prior to his rookie season but was medically cleared to play in November of 2017. However, he’s never been able to regain his standstill jumper form, even with the Sixers’ shooting staff on the case around the clock and Fultz working with renowned trainer Drew Hanlen over the summer.

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Here’s what his standstill jumper looked like at the University of Washington:

And here are some iterations we’ve seen in the pros:

In each case, the medical staff deemed the player “medically cleared” to play, but in each case, the player was unable to play that season. This led to speculation ranging from “this is just really weird and unexplainable” to “totally faking it.” Additionally, each of these situations has resulted in discord between the team and player, with Leonard being traded to the Toronto Raptors and Fultz now involved in trade discussions, with recent reports that he isn’t in the long-term plans for the Sixers, particularly after their acquisition of Jimmy Butler.

I can understand why both of these cases would cause consternation. Our Western medical model focuses on diagnoses and physical ailment. If something is broken, you fix it good as new. If a player is injured, heal the injury and off they go.

However, humans aren’t cars (or are we dancers?). It’s not as simple as “fixing” the physical injury. There have been multiple studies done on injuries in which one group had a real procedure done while the others had a sham procedure done. For example, in one study of individuals dealing with a meniscus injury, group A had actual knee surgery to repair their meniscus while group B was simply under the pretense that they had surgery (went into the operating room, anaesthesia, the whole nine but no surgery). The long-term outcomes were the same, with both groups having the same level of improvement in their knee pain and functionality.

HOLD UP—one group had their injury physically fixed while the other was simply under the impression that they had their injury physically fixed. Yet both had the same results. How can that be?

Say it with me and say it with your chest: “Pain is a multi-factorial experience.” Our perception of something as dangerous or not colors whether we perceive it as painful or not. That’s because the ultimate role and function of pain is an alert signal sent by your brain to warn you of danger (“DON’T MOVE THAT”).

Have you ever been poked in a spot where you’ve been dealing with injuries or pain for a while and nearly jumped out of your shoes? Whereas if that same poke was applied somewhere else, it would barely even register. In the former case, the brain is already on red alert and highly sensitized, trying to protect that area. In the latter, it’s the lazy “guard dog” who licks the hand and wants a tummy rub from potential thieves.

That red alert, high sensitivity focus can still exist far after an injury has healed. This is the basis of chronic pain and a key reason why some providers, including myself, are trying to move away from intense focus on constantly explaining and focus on diagnoses. The person “becomes their diagnosis,” leading to an inherent sense of danger, hyper-vigilance, and self-reinforcing pain loops.

Pain is a very useful and necessary tool in the short term because it protects the area but over time there becomes a mismatch. It’s like if you lived in a crime-stricken area and you made sure your car’s alarm was extremely sensitive, but then you moved to the suburbs and the car alarm was still extremely sensitive. Ms. Jacky and her schnauzer were just coming over to say hello and the alarm started blaring. How rude.

That’s why a player being medically cleared with no physical ailment doesn’t mean they still aren’t having pain or that they have confidence in their movement. The alarm bells can still be going off far after. In fact, kinesiophobia (fear of movement/re-injury) has shown to be one of the last obstacles overcome after injury, especially for ACL injuries.

The real issue becomes when we don’t recognize or educate patients on this reality of pain. For example, using an educational video like this one (I made this but I first learned this from Seth Oberst):

Without any education on pain science or understanding the dangers of playing through pain, athletes who are medically cleared but still in pain or not fully confident in their movements will continue to push through because “it’s all in my head” (everything is in our head), which leads to even more severe and complex problems like developing a hitch on their jumper, slapshot, tennis serve, and so on. I’ll dive deeper into that topic next time.