DeMarcus Cousins’ return: Cousins’ doctor shares his journey

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The man witnessed DeMarcus Cousins through a lens that gives him a distinguishable perspective on how he managed his injured left Achilles tendon.

Dr. Richard Ferkel, the Director of Sports Medicine Fellowship of Southern California Orthopedic Institute, performed surgery on Cousins’ left Achilles tendon five days after he injured it with the New Orleans Pelicans. Ferkel saw how Cousins weathered the initial frustration with his season-ending injury. And Ferkel remained encouraged with Cousins’ subsequent rehab.

So nearly a year later, Ferkel expressed cautious optimism about his patient’s expected return when the Warriors (31-14) play the Clippers (24-20) on Friday in Los Angeles.

“We anticipate he’ll help the Warriors a great deal as their starting center,” said Ferkel, who is also an assistant clinical professor of Orthopedic Surgery at UCLA. “When you come back, though, initially it does take time.”

The pressing question: how much time will it take? Ferkel and a handful of outside doctors familiar with Achilles injuries admit that remains a difficult question to answer. The Warriors and Cousins have conceded the same thing.

According to a 2013 study published by the American Journal of Sports Medicine, six of 43 NBA players (14 percent) that had a major Achilles injury between 1988 and 2011 did not return to the league. For the 37 players that did return, the study concluded that those players mostly showed “a decreased level of performance.”

Dr. Douglas Cerynik (CEO of Stabiliz Othopaedics) and Dr. Nirav H. Amin (sports medicine specialist at Loma Linda Universiy), the co-authors of the study, stressed various circumstances that make each recovering NBA player unique. That includes the age (younger is easier), length and quality of rehab (anywhere between six to 12 months), the players’ role, the players’ talent level and evolving medical technologies. Ferkel and Dr. Jonathan Kaplan, a foot and ankle surgeon with the Hoag Orthopedic Institute, echoed similar sentiments.

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All the outside doctors stressed they do not have access to Cousins’ medical records and rehab regimen as Ferkel does. Nonetheless, all parties anticipate Cousins experiencing various bumps after the four-time All-Star had prolific numbers in points (21.5), shooting percentage (47 percent) and rebounds (10.7) in a combined eight NBA seasons with Sacramento (2010-2017) and New Orleans (2017-18). They suspected those numbers will not just drop because Cousins will adjust his role playing with four other All-Stars in Stephen Curry, Kevin Durant, Draymond Green and Klay Thompson.

“I doubt you’re going to see him doing what he did in New Orleans,” Cerynik said. “But he’s a great player. He’s going to do well. I think you have to be realistic, especially with that first year.”

What is realistic?

“We look at his return as the final phase of his rehabilitation,” Ferkel said. “He needs to start playing in some games to finish his rehabilitation. He hasn’t quite completed it yet. This will be part of it as he gears up, plays some limited minutes and gets used to the pace of play in an NBA game.”

Will age make a difference?

Still, Ferkel and outside medical experts sense that Cousins will experience relatively better success because of his circumstances.

One of them: Cousins’ age (28). Before injuring his left Achilles tendon on Jan. 26, 2018 with the Pelicans, Cousins had not suffered a major season-ending injury. According to their 2013 study, Cerynik and Amin concluded that “players with Achilles tendinopathy have a better chance to return if they are younger in age and early in their professional career.”

At 25, Warriors forward Jonas Jerebko strained his right Achilles tendon during a 2010 preseason game with the Detroit Pistons. After missing the rest of the season, Jerebko played 14 months later and has since had a productive career as a role player in Detroit (2011-2014), Boston (2014-17), Utah (2017-18) and Golden State (present). At 29, Wesley Mathews ruptured his left Achilles tendon with Portland (2014-15), had surgery under Ferkel and signed with Dallas the following summer before having mixed success with his role and efficiency for the following four seasons. At 31, Rudy Gay tore his left Achilles tendon with Sacramento (2017) and then accepted a reduced role with the Spurs the following two seasons.

At 34, former Lakers star Kobe Bryant tore his left Achilles tendon in 2013, returned eight months later the following season and then needed season-ending surgery on his left knee after playing only six games. He then absorbed a season-ending right shoulder injury (2014-15) and overlapping ailments with his knees, shoulder, back and right Achilles during his final season (2015-16). Both at 35, Hall-of-Fame point guard Isiah Thomas tore his right Achilles tendon (1994) and future Hall-of-Fame point guard Chauncey Billups tore his left Achilles tendon (2012). Thomas had already decided beforehand he would retire, capping a 14-year NBA career with two championships and a Finals MVP. After missing the final 35 games in 2012 with the Clippers, Billups remained hobbled by injuries in 2012-13 with the Clippers (22) and 2013-14 with Detroit (19) before retiring.

“In older patients and older athletes, the tendon often has something going on even before it ruptures,” Kaplan said. “Then when it ruptures, it’s harder to heal. In a younger person, their body heals quicker.”

But what about NBA Hall-of-Famer Dominique Wilkins and former NBA forward Elton Brand?

At 32, Wilkins ruptured his right Achilles tendon, returned nine months later, and increased his scoring average from 28.1 points per game to 29.9. He made two more All-Star appearances before retiring seven years later. At 28, Brand ruptured his left Achilles tendon and played only eight games the following season. He then faced statistical declines in his last eight NBA seasons in Philadelphia (2008-2012), Dallas (2012-13), Atlanta (2013-15) and Philadelphia (2015-16).

“In Dominique Wilkins’ situation, he adapted his game post-injury. He had the skill and ability to adapt his game,” Cerynik said. “Not everybody has that kind of ability.”

Medical experts envision Cousins having similar ability considering his various skills as a post player, outside shooter and passer.

“He is a more athletic player than traditional big men who have had this injury,” Kaplan said. “For athletic players, their bodies tend to heal well. Since he’s more athletic, he’s more likely to modify his game.”

How much will Cousins’ prolonged rehab aid his return?

The other variable that could ease Cousins’ transition: he will return nearly a year after injuring his left Achilles tendon. Medical experts pin a recovery time on an injured Achilles to last anywhere between six to 12 months, with factors depending on the medical technology, the players’ age and how aggressive each training staff allows that player to rehab.

In Cousins’ case, he progressed in the opposite way the Warriors usually play on the court. He rehabbed at a deliberate pace. The reason: the Warriors already won two NBA championships in the past two years with their four All-Stars. They considered it a bigger priority to integrate Cousins for a playoff run than worry when he would return in the regular season.

“He had a little bit more of a luxury to make sure he could take as much time as he needed to be back to as close to 100 percent as he can,” said Ferkel, who also treated other current and former NBA players, including Curry, Joel Embiid, Terrence Ross, Ricky Rubio and Ray Allen. “If he was on a team where he was the best player and they weren’t committing too many other players at his level, obviously he’d feel a lot more pressure. Sometimes, the difficulty is when that pressure is so high that you try to get back and return before you are quite ready. That’s not always optimal.”

That is because doctors consider the Achilles, which connects the calf muscle to the heel bone, as the body’s most important and strongest tendon. With the tendon connecting all muscle tissue, that allows a person to cut in various directions, land off of a jump and move with explosiveness. A basketball players’ success significantly hinge on those three skills.

When the Achilles tendon is not healed properly, not only does it become more difficult to complete those moves. It can also lead to other injuries because of imbalance with other body parts.

Therefore, Cousins, Ferkel, Cousins’ personal trainers and the Warriors training staff mapped out five phases of rehab without any formal timetable for any of them.

Ferkel did not outline the timetable for each stage. But Cousins initially spent his time in Los Angeles with frequent checkups with Ferkel and at his Las Vegas home with his personal trainers. Then, Cousins wore protective devices on his left Achilles tendon that included a cast, a boot and a tennis shoe. Once Cousins’ left Achilles tendon healed, he spent months on strengthening it through pool therapy, weights light jogging and jumping as well as gymnastic exercises. All of those drills reduced the scar tissue on his left Achilles tendon, improved his range of motion and tested his explosiveness.

After Cousins completed various conditioning and skill work, the Warriors then cleared him on Oct. 22, 2018 to participate in team non-contact drills and to travel with the team when his rehab allowed it. After completing games of 1-on-1, 2-on-2 and 3-on-3, Cousins then scrimmaged with the Warriors’ G-League team in Santa Cruz for a full week in mid December. Cousins then scrimmaged with the Warriors in late December and early January.

Warriors coach Steve Kerr and Dr. Rick Celebrini, the Warriors’ Director of Sports Medicine and Performance, became comfortable enough to outline his expected return after seeing Cousins improve his conditioning during two scrimmages last week.

How did Cousins handle such a long recovery process?

“Like any player, it was a struggle for him at first,” Ferkel said. “He wasn’t used to being injured and being out for so long. Physically and mentally, it was very hard on him. But once he understood how to deal with those issues and turn that into positive energy to move forward, he has worked very, very hard in his rehab.”

Will being a big man help or complicate his comeback?

And with Cousins advancing in his rehab, he faces a question that even doctors concede they cannot fully answer.

Is it a bad thing that Cousins plays at the center spot with a 6-foot-11, 270-pound frame and will match up against physically imposing big men? Or is it a good thing that Cousins does not have to run around to keep up with mobile and fast guards?

“That’s a good question. There is a little bit of debate on that,” Kaplan said. “We think bigger players and centers may not come back as easily because of how much force it takes for them to jump as opposed to someone that is smaller. But the data is all over the board.”

Amin said that he and Cerynik “didn’t find too big of a difference” in their study between how well frontcourt and backcourt players return from Achilles tendon injuries. Instead, they said it depends on that persons’ playing style.

“A smaller person like a point guard or a shooting guard has to move quicker, cut more and explode a little more from their position. In some ways, being smaller can be a disadvantage and in some ways it can be an advantage,” Ferkel said. “The taller guys don’t have to explode quite as quickly and don’t have to jump quite as high because of their height. So in that way, it’s not quite as difficult to return as it would be for a point guard. But it’s unique to each individual.”

In Cousins’ case, Kerr said he has not formally mapped out his role beyond that he will start with the team’s four other All-Stars. Still, Kerr has left some clues.

Cousins will likely serve as a facilitator, decoy and rim protector in the starting lineup. With the second unit, Cousins will likely both assume a playmaking role and command more shots. Kerr plans to limit Cousins’ minutes, but he has not divulged the exact number or to what degree it will increase each game. The Warriors will lean on Cousins as a rim protector, but it appears unclear if they want him to switch out on the perimeter to account for the influx of 3-pointers taken throughout the league.

Ferkel and other doctors pinpointed the team’s pace as the most instrumental and potentially challenging part that Cousins will face. The Warriors currently rank 10th in the NBA in pace (101.68), which is the number of possessions per game. That marks a sharp increase from the pace the Sacramento Kings played in 2016-17 (27th at 95.05) before trading Cousins to New Orleans. Yet, the Warriors have played at a similar pace that New Orleans did last season before Cousins’ injury (fifth at 100.64).

“The pace is going to be an issue, the amount of quick movements and jumping and all the twists and turns,” Ferkel said. “We’ll be watching that carefully with him and see how he’s adjusting.”

Cousins’ doctor became encouraged with his mindset

Despite all of their research, Cerynik and Amin said their data could not provide any definitive clues on how players became mentally affected with their Achilles injuries. They also could not chart if any initial hiccups stemmed from any psychological impact from the injury as opposed to lingering issues from the injury itself.

Ferkel anticipates Cousins’ mindset helping him after initially experiencing frustration on two fronts.

When Cousins injured his left Achilles, he immediately was ruled out for the season and missed the chance to make the NBA playoffs for the first time in his career. Once free agency started in July, Cousins could no longer command a max contract on the open market amid concerns with his injury. Because of Cousins’ depressed interest and their championship equity, the Warriors agreed with Cousins on July 3, 2018 to a one-year deal at their taxpayer midlevel exception ($5.3 million).

“Once he signed with the Warriors, that took a lot of stress off,” Ferkel said. “He knew he had a team he wanted to shoot for to join to become very successful. He knows the players well and their success, and thinks he can really contribute a great deal to the team’s success.”

Since then, Ferkel observed Cousins stayed disciplined and confident with his recovery. Sure, Cousins may have wished to return sooner than Friday’s game against the Clippers. When Cousins felt upset with the delay, though, Ferkel saw that did not stifle Cousins’ determination. It only emboldened it. The Warriors also became pleased with Cousins’ attitude, including his sense of humor as well as mentoring their team’s young frontcourt players in Damian Jones, Jordan Bell and Kevon Looney.

“Some of the key points for him were getting his mind mentally into the place we felt his physical body was at and making sure he felt comfortable,” Ferkel said. “Those are the key bumps to overcome — the mental aspect of getting back.”

And now that Cousins is back, Ferkel stressed this will mark the beginning of another test. That explains why Ferkel, the Warriors and outside medical experts believe it is important for Cousins, teammates, coaches and fans to stay patient with whatever transpires.

“Most serious injuries like that, usually the athlete is better the following year than their first year,” Ferkel said. “It takes time after missing that much time just to develop confidence in your body again and not worry about the injury or reinjury and get back to that extremely high level of being an elite athlete. That is very difficult to get to and maintain when you have an injury.”

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