Miami Heat forward Chris Bosh is facing the harsh reality known to many who have been treated for blood clots: unfortunately, a recurrence can be common.

In February 2015, Bosh was diagnosed with a deep vein thrombosis (DVT), a blood clot which formed in a deep vein of his left leg. A piece of that clot then broke off from the wall of the vessel, traveled via the bloodstream up the body, through the right side of his heart, and lodged in an artery of his lung, blocking blood flow through the lung – a very serious, even life-threatening, condition known as a pulmonary embolism (PE).

Pulmonary embolisms can cause damage to the lung tissue, and put increased strain on the heart. This could even cause the heart to become enlarged, or in a worst-case scenario, lead to heart failure.

Bosh was rushed to South Miami Hospital, where he avoided a potential life-threatening situation.

Blood clots can form in people who have a genetic predisposition to them, but most commonly they are caused by long periods of immobility in many cases from prolonged air travel (particularly for players of Bosh’s height, 6-feet, 11-inches, where leg room is more limited), after having undergone surgery, or after having experienced a recent trauma, making professional athletes, who frequently deal with one or all of these issues, particularly susceptible.

Blood clots are treated with anticoagulant drugs (blood thinners), which prevent further blood clots from forming as the body’s normal systems work to break up the existing clot(s). Blood thinners can stop new clots from forming, stop existing clots from getting bigger, or prevent existing clots from travelling to other parts of the body. Treatment is typically continued for three to six months.

Blood thinning medications save lives. But, they also pose one possible and very serious side effect: Bleeding.

Since blood thinners slow the clotting of blood, unwanted and sometimes dangerous bleeding can occur with the use of these medications. Although infrequent, uncontrolled bleeding caused by blood thinners can be very serious. A blow to the head, for example, can cause bleeding on the brain and kill you!

Doctors and teams are therefore hesitant to allow players on blood thinners to return to contact sports, where a potential trauma could have disastrous consequences.

Bosh missed the remainder of the 2014-15 while taking Xarelto, one of a handful of the newer anticoagulant drugs on the market today.

After treatment with blood thinning medications along with adequate rest after treatment, many athletes, including Mirza Teletovic with the Brooklyn Nets this past season and Anderson Varejao with the Cleveland Cavaliers two seasons prior, have been able to resume play and go on with their careers.

Bosh returned to play start the 2015-16 season. He indicated upon his return that, according to testing, he was not aware of any hereditary issues he may have that would increase the risk for recurring episodes, leading to optimism that he could resume his career without further incident.



But that was not to be. Just a year after his first incident, Bosh was diagnosed with a second DVT, this time in his left calf in February 2016. The good news for Bosh was that the second clot was significantly smaller, was caught early, and did not travel to his lungs. He was placed back on blood thinners while the clot resolved itself, and missed the remainder of the 2015-16 season during his recovery.

Such a recurrence is not uncommon.

According to the NIH, more than 600,000 people in the U.S. are diagnosed with DVT each year and roughly 30 percent of those patients develop a recurrence within 10 years, with the risk being greatest in the first two years.

Recurrence is more likely if the initial episode was “spontaneous” – that is, not provoked by transient (often one-time) events such as trauma or surgery, and the recurrence in those who initially presented with a pulmonary embolism, as with Bosh, is more likely to be another pulmonary embolism (as opposed to a DVT alone), leaving Bosh susceptible to a potentially more serious recurrence.

The unfortunate questions for Bosh, his family, his doctors, and the Heat organization now becomes: What is causing Bosh’s blood clots, what lifestyle modifications may be necessary to avoid them in the future, and could those modifications include a potential end to his NBA career?

One of the more difficult concepts for patients to accept is that blood thinners are prophylactic in nature. They don’t dissolve existing clots (the body does that naturally) but rather prevent future clots from forming. Stop taking them, and the benefits also stop.

Blood thinners can substantially decrease the likelihood of a recurrence of a blood clot, but until such a recurrence actually happens, patients can look, feel and even be perfectly healthy. That, in turn, can cause them to want to get off them too quickly. But if a patient stops taking blood thinners too quickly, he is more likely to suffer a recurrence, particularly if he is exposed to such things as contact sports or extended periods of immobility during air travel.

If a patient stops taking blood thinners too quickly, nobody can definitively say that he will suffer another blood clot, or even that such a recurrence would be likely. But studies have shown that the odds do increase.

If a patient plays contact sports while on blood thinners, nobody can definitively say that he is likely to suffer a serious bleeding event. But most experts feel that the odds do increase.

That concept can get quite frustrating, particularly for a professional athlete with a strong competitive drive.

For Bosh, it set off a behind-the-scenes battle with the Heat organization over his status.

Bosh was determined to return to the court this past season. He released a statement in March, just one month after his recurrence, announcing that his DVT had resolved and said he was “positive” he would be able to return this season. He then posted a video of himself on Snapchat shooting at AmericanAirlines Arena and bemoaning how much he misses the game. He then initiated a search for a credible doctor who was willing to clear him. He even presented a scenario in which he would take a newer form of blood thinner which would leave his system within eight to ten hours, theoretically in time to play each game without the thinned out blood that creates the bleeding risk (but also without the protection from the risks of new clot formation that playing would cause).

The medical guidelines for NBA players who have suffered two clotting episodes but aren’t genetically predisposed to them is unclear. Most, but not all, doctors recommend that NBA players take a precautionary approach of remaining on blood thinners for an extended period of time. And most, but not all, doctors recommend that NBA players – who are more susceptible to the types of traumas that could cause bleeding — who are on blood thinners not return to competitive sports.

Bosh playing, no matter the scenario under which he does — whether it be without taking blood thinners, or while taking blood thinners that would theoretically be out of his system before he takes to the court each night — therefore creates a risk.

The Heat is uncomfortable with that level of risk, which, in turn, has set off wild (and uninformed) speculation that the team is attempting to push him toward retirement to reap potential salary cap benefits.

Potential Cap Relief

Bosh has three years, and $75.9 million remaining on his contract: $23.7 million for 2016-17, $25.3 million for 2017-18, and $26.8 million for 2018-19. He will be paid out in full, whether or not he is able to resume his career.

According to NBA rules, any amount a team pays its players is included on their cap sheet (even if the player is no longer playing or has retired). There is an exception, however, whereby a player can continue to receive his salary, but that salary is excluded from the team’s cap sheet — when a team applies for, and is granted, a cap exclusion because its player has suffered a career-ending injury or illness.

To apply for such an exclusion, a team must first endure a waiting period. The waiting period depends on the number regular season and playoff games in which the player played in the season:

If the player played 10 or more regular season or playoff games in a season, the team can apply on the one-year anniversary of the player’s last game.

If the player played fewer than 10 regular season or playoff games in a season, the team can apply 60 days after his last game, or the one-year anniversary of his last game in the previous season, whichever is later.

Bosh played more than 10 games during the 2015-16 season, and his last game was played on February 9, 2016. Therefore, the Heat could potentially apply for the exclusion in regards to Bosh on or after February 9, 2017, but only if he plays fewer than 10 games this upcoming season.

To be granted the exclusion, it must be determined that Bosh’s situation will prevent the player from playing for the remainder of his career, or if it is severe enough that continuing to play constitutes a medically unacceptable risk. That determination would be made by a physician jointly selected by the league and players association.

If the exclusion were granted, the Heat would then waive Bosh in conjunction with the ruling and receive the associated cap relief — instantly wiping away the $23.7 million salary for 2016-17, the $25.3 million salary for 2017-18 and the $26.8 million salary for 2018-19.

Potential Cap Hit Return

If the Heat were to be granted cap relief from his contract, Bosh would not be permitted to play for the Heat ever again. But nothing prevents him from attempting to return elsewhere (even immediately thereafter), if a team is willing to sign him.

If Bosh were to join another team (even at the minimum salary) and play at least 25 regular- and/or post-season games in any one season, effectively “proving the doctor wrong,” the cap hits would be returned to the Heat’s cap for the then-current and any future seasons.

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The question then becomes: If the Heat were to apply for a career-ending injury exclusion, would it be granted?

The answer may well depend upon the circumstances at the time of the application.

SCENARIO 1: Bosh Suffers a Third Clotting Episode Before Training Camp

If Bosh were to suffer a third verifiable clotting episode prior to the start of training camp, he would likely recognize the situation as life-threatening and thus career-ending. Bosh would likely agree to retire, and the Heat would undoubtedly receive the associated cap relief on or after Feb. 9, 2017.

Things get a big more tricky, however, if not.

Before the Heat is even eligible to apply for the exclusion on or after Feb. 9, 2017, Bosh could potentially participate in training camp, play any or all preseason games, and play up to nine regular season games (prior to Dec. 11, 2015) without affecting the timeline for potential cap relief.

Whether the Heat will allow Bosh to participate in training camp, during the preseason or those up to nine regular season games is yet to be determined.

If the Heat does allow Bosh to play, it will be telling.

SCENARIO 2: Bosh Suffers a Third Clotting Episode During Training Camp or Thereafter

If Bosh were to suffer a third clotting episode during training camp or thereafter, Bosh would again undoubtedly recognize the situation as life-threatening and career-ending. He would likely agree to retire, and the Heat would undoubtedly receive the associated cap relief.

If Bosh were to have played fewer than 10 games at that point, the Heat could apply for the exclusion on or after Feb. 9, 2017. If he were to have played 10 or more games, the Heat would be prohibited from applying until the one-year anniversary of his last game played.

SCENARIO 3: Bosh Does Not Suffer a Third Clotting Episode During Training Camp or Thereafter

If Bosh were to participate in training camp, the preseason and/or up to nine or more regular season games and not have suffered a recurrence, it is difficult to see how the Heat would get a physician to conclude that Bosh’s situation is career-ending and, in turn, receive the associated cap relief. He will, after all, have been playing and practicing without incident.

It would be difficult to believe the team would even want to try for such relief in this scenario. Bosh is, after all, perhaps the league’s best perimeter-oriented power forward, a critical Heat need.

SCENARIO 4: The Heat Doesn’t Clear Bosh For Play

If the Heat doesn’t allow Bosh to play, things could quickly get contentious.

Bosh could potentially seek to get the players association involved. But neither he nor his agent Henry Thomas nor the players association would have the authority to dictate to the Heat how it chooses to manage its own fully compensated player. Teams have the right to determine if a player practices or plays. The player has no remedy if he doesn’t like the decision. The team can DNP him the entire season, for any reason. They’re under no obligation to play him.

But things could either prove easy or challenging, depending upon how Bosh handles the situation.

If Bosh wants to make things difficult for the Heat, he could.

The physician that would ultimately make the determination as to whether Bosh has sustained a career-ending injury would need to be jointly selected by the league and players association. In other words, the league and the players association (presumably, in coordination with Bosh) would need to agree upon such a physician. There are physicians who have cleared athletes in similar situations to Bosh for play while utilizing blood thinners that leave the system before each game (including for NHL player Tomas Fleischmann). Bosh and the players association, knowing that, could push for one of those physicians to be selected.

Even if a physician could be jointly selected, whether a doctor would actually rule his situation is career-ending is less clear (even if it is in the mutual best interests of Bosh and the Heat organization). It seems likely that most doctors would consider Bosh’s situation is career-ending. But there are several athletes who have successfully returned to play professional sports after enduring multiple blood clots (several by utilizing the strategy of taking blood thinners that leave the system before each game that Bosh is pushing). Bosh has made it perfectly clear he intends to return. And if he does, once he plays in 25 games in any one season, the doctor will have been “proven wrong.” No doctor presumably likes to be proven wrong, particularly not in such a high profile situation. The determination that a player has suffered a career-ending injury should be, after all, a very high standard.

If Bosh wants to make things easy for the Heat, he could.

Bosh could comply with the process and act as if he has no intention to return to the game. This would make it much easier for the Heat to get the relief.

Why would he do this? Because he too would benefit from such a ruling. While the Heat would get the associated salary cap relief, Bosh would get the freedom to attempt to resume his career elsewhere — something he would not have in Miami. The desire to play could be a powerful motivator.

***

If, in consultation with the league office, the Heat were to feel confident that they would receive cap relief from Bosh’s contract, there would be two more decisions that would need to be made.

Decision #1: When to Waive Bosh

Miami would seemingly have three primary options for when it could waive Bosh.

First, the Heat could waive Bosh now. That would free up one of the team’s 15 roster spots. But it would also provide Bosh with an entire season in which to find employment with another NBA team. If he did, it would essentially wipe away any chance for the Heat to get cap relief.

Second, the Heat could waive Bosh after the career-ending injury determination is made, as early as Feb. 9, 2017 or shortly thereafter. Doing so could allow the Heat to leverage its $16 million of cap room at the Feb. 23, 2017 trade deadline. But it would also expose the Heat to the potential that Bosh could play 25 games elsewhere. The decision to take this approach, therefore, would likely come down to whether it has an immediate alternative need for that cap space that would outweigh the potential risks.

Third, and perhaps most likely, the Heat could waive Bosh after Mar. 1, 2017. By delaying until after March 1, the Heat would lose its ability to use the $16 million at the trade deadline, but would ensure that Bosh would be ineligible for post-season play. By that time, no team will have 25 games remaining on its regular season schedule either. While it remains decidedly unlikely that Bosh would return to play for any NBA team this season anyway, the Heat would therefore ensure that Bosh cannot “prove the doctor wrong” and return his salary to the Heat’s cap until, at the very earliest, the start of the 2017-18 season. By that time, the Heat will have potentially already have capitalized on the $25.3 million in freed-up summer of 2017 cap space. The most it could do at that point is create a massive luxury tax bill, something of which the Heat will surely be cognizant.

Decision #2: How to Protect From a Massive Tax Bill if Bosh Were to Play 25 Games With Another Team

To mitigate the consequences of such a possibility, the Heat would need to carefully consider whether it would want to “stretch” his remaining cap hits when it waives him in conjunction with its potential salary cap relief.

If the Heat were to elect to “stretch” his cap hits, his salary would be returned at his full $23.7 million salary for 2016-17 if he were to reach the 25-game threshold this season (which the Heat could render impossible by waiving him after March 1st), and $10.4 million for each season thereafter through 2021-22. If he reaches the 25-game threshold in any future season, only the $10.4 million would be returned to the Heat’s cap from such season through 2021-22.

If the Heat were to elect not to “stretch” his cap hits, his salary would be returned at his full $23.7 million salary for 2016-17 if he were to reach the 25-game threshold this season (which the Heat could render impossible by waiving him after March 1st), $25.3 million in 2017-18 if he reaches the 25-game threshold this or next season, and $26.8 million in 2018-19 if he reaches the 25-game threshold this, next or the following season.

The decision would basically come down to whether the Heat would want to reduce Bosh’s annual cap hit if he were to “prove the doctor wrong” by stretching his salary over a longer period of time, or if it would want to endure the larger cap hit for a shorter period of time.

It is also very possible that, when the new Collective Bargaining Agreement to come is negotiated, it will contain a similar amnesty provision as has the current agreement, which would allow the Heat to re-wipe away Bosh’s cap hits (this time permanently).

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This remains a complex situation – a balancing act between a player’s desire to pursue that which makes him happy and the risk that allowing him to do poses. There are no easy answers. The hope is that he is perfectly healthy, and will remain that way for the entirety of his remaining career.

Notes:

(A) The injury exclusion described in this post differs from the Disabled Player Exception, which allows a team which is over the cap to replace a disabled player who will be out for the remainder of that season. This exception is granted by the league, based on an application from the team and a determination by an NBA-designated physician that the player is substantially more likely than not to be unable to play through the following June 15.

If this exception is granted, the team can acquire one player via free agent signing, trade or waiver claim, to replace the disabled player:

The team may sign a free agent for one season only, for 50 percent of the disabled player’s salary or the amount of the Non-Taxpayer Mid-Level exception, whichever is less.

The team may trade for a player in the last season of his contract only (including any option years), who is making no more than 50 percent plus $100,000 of the disabled player’s salary, or the amount of the Non-Taxpayer Mid-Level exception plus $100,000, whichever is less.

The team may claim a player on waivers who is in the last season of his contract only (including any option years), who is making no more than 50 percent of the disabled player’s salary, or the amount of the Non-Taxpayer Mid-Level exception, whichever is less.

Teams can apply for this exception from July 1 through January 15, and cannot apply after January 15. Once granted, the exception expires when a player is acquired, when the disabled player is traded or returns to the team, or on March 10 of that season, whichever comes first. This exception is granted on a season-by-season basis — if the player will also be out the following season, the team needs to apply for this exception again the following season.

For Bosh, the amount of the exception would be $5.628 million for 2016-17.

However, the Heat would not be allowed to apply for the injury exclusion if it has applied for a Disabled Player exception that season, whether the Disabled Player exception was granted or not. That, in turn, makes it unlikely that the Heat will apply for one.

(B) The Heat’s ability to collect on insurance is a completely separate issue. There is a league-wide policy that insures the contracts of around 150 players each season. Generally speaking, the five most expensive contracts on each team, of which Chris Bosh for the Heat is one, are included. However, the carrier has the right to exclude 14 contracts per season, such as when they consider a player with a very large remaining contract to be a medical risk. The list of excluded players changes each year, so a player who is not covered one season might be covered the following season. However, once a player is covered the carrier can’t exclude the player for the remainder of his current contract. It is unclear as to whether the carrier named Bosh as one of the 14 excluded, or if the terms of his coverage excluded any specific conditions, but it is likely he is covered.

If he is covered, there is a 41 regular-season-game waiting period before coverage kicks in. Bosh has already missed 29 consecutive regular season games. After potentially missing 12 to start the 2016-17 insurance would kick in. It would pay out $175,000 per regular season game thereafter missed, or approximately 60 percent of his per-game salary. If Bosh were to miss the entire 2016-17 season, assuming he has not been excluded from coverage by the insurance provider, the Heat would be obligated to pay $11.5 million of his $23.7 million salary, while the insurance provider would pick up the remaining $12.3 million.