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A Dissection of Jrue Holiday's Problematic Tibia

And a discussion of where he needs to proceed from here.

Derick E. Hingle-USA TODAY Sports

As you've already heard by now, Jrue Holiday is going to miss at least another 3 weeks due to his troublesome right tibia. Nearly one month ago, he was diagnosed with a stress reaction that was supposed to sideline him anywhere from 2 to 4 weeks.

Before yesterday's news, everything appeared to be favorably pointing towards a return following the All-Star break. The Fox Sports New Orleans broadcast team noted Holiday's increase in on-the-court activities prior to several of the Pelicans previous games. Remember when Eric Gordon rejoined the active roster? Joel Meyers and David Wesley were the first to alert us to his increased activity just prior to his eventual return.

Thus, unless the broadcasters are in on the take, let's do away with those conspiracy theories that claim Holiday was never close to returning over the course of the last week or so. The Pelicans organization tending to not offer quick nor thorough updates never helps matters, but let's not confuse that with deliberate deception. Besides, we've got a more important issue to deal with: the team's second best player, once a perennial iron man, has fallen victim to an injury in the same part of the body in back-to-back seasons.

Defining Holiday's stress reaction

Jeff Stotts of In Street Clothes broke down Holiday's stress reaction very well this past January.

Nearly every bone of the human skeleton endures some sort of stress during everyday movement. The amount of force applied to the bones increases with strenuous or repetitive activity. To keep up with these high-energy or constant demands, the stressed area of bony tissue is continually remodeled. In the process, new bone tissue is created and used to fill any developing gaps while damaged and worn out bone is absorbed and broken down. However occasionally the body’s natural remodeling process is unable to keep up with the demands placed on the area and a stress injury develops.


Stress reactions and fractures are a common occurrence in the NBA as the players endure a strenuous schedule that often leaves little time for rest. The most frequently involved areas include the bones of the foot, the back, and the lower leg bones, the tibia and fibula. The tibia is the bone most likely to experience a stress fracture, due to the fact that it bears a higher percentage of the body’s weight during activity.


Unfortunately this isn’t the first time Holiday has suffered a stress injury in his right tibia. Last season Holiday was diagnosed with a stress fracture in his tibia that prematurely ended his season and ultimately required surgery. Now almost one year to the day, the problem has resurfaced.

Reoccurrence of a stress fracture in a one of the lower leg bones is relatively higher than most injuries, though Coach Monty Williams insists the two injuries are not linked. However a quick look at other lower leg stress injuries in the NBA reveals the likelihood of a future problem is noticeably higher in individuals who underwent surgery to treat a previous stress-related injury. The most recent example is Denver big man JaVale McGee who has missed 29 games this year with lingering soreness in his surgically repaired tibia.

Reoccurrence Theory

Contrary to Monty Williams belief, it appears quite possible that Holiday's recent stress reaction was a reoccurrence of last year's injury. Normally, tibial surgeries require 4-6 months to heal. Considering, Holiday had his surgery to repair his fracture back in February of 2014, he should have been ready to go by the time training camp opened this season.

However, 7 months later, during media day, he declared himself only at 75%. Not a week later, Jrue participated in the Pelicans first preseason game. Well, according to retrospective studies, players who are not fully healthy are more susceptible to problems, ranging from shin splints to stress reactions to stress fractures.

One of the intrinsic risk factors that contribute to susceptibility of injury is muscle weakness. If Jrue Holiday claimed he wasn't close to 100% by the time he was training and playing in games, there existed a chance his body wasn't able to repair itself at the rate necessary to remodel his tibia.

A further possible complication, Holiday may have had calf atrophy stemming from his surgery. Although it was never specifically announced what type of tibial surgery Holiday underwent, intramedullary nailing is most commonplace.

The current most popular form of surgical treatment for tibial fractures is intramedullary nailing. During this procedure, a specially designed metal rod is inserted from the front of the knee down into the marrow canal of the tibia. The rod passes across the fracture to keep it in position.

One of the long-term complications of this type of surgery is calf atrophyAccording to one study, smaller muscles can result in underdeveloped bones.

The reason is that bone responds to the demands put on it—and if you have small, weak muscles in your lower leg, you won’t be able to put much force on your tibia during exercise.  As such, you won’t develop very thick bones.

Thus, the odds of Holiday suffering a re-injury at some point during this season, despite being close to a year removed from his surgery, appear quite feasible. Amid the pounding activity of the NBA, the constant flexing of his tibia in his weakened right leg might have finally succumbed to injury.

No Reoccurance Route

On the other hand, let's say Monty was right and that last season's fracture and subsequent surgery had nothing to do with Holiday's stress reaction. Now, the team must examine a whole slew of risk factors that come into play:

  • inappropriate or excessive training (particularly on hard or uneven surfaces)
  • poor foot posture (particularly excessively high arches or flat feet)
  • poor biomechanics
  • muscle weakness
  • muscle fatigue
  • muscle tightness (particularly of the calf muscles)
  • joint stiffness (particularly of the ankle)
  • inappropriate footwear
  • inappropriate running technique
  • inadequate diet
  • leg length discrepancies
  • being overweight
  • In essence, questions need to be asked ranging from the simple stuff like Holiday's footwear (bad orthotics) or his diet (possible vitamin D deficiency) to more complicated factors like loading rates, knee stiffness and stride frequency. A whole lot of Greek sounding jargon, huh?

    Going Forward

    Probably the best method of prevention is through the use of biomechanics and nutrition. Many of you have probably heard of P3, the most advanced sports performance conditioning in the world company. They aim to study all of an individual's movements through motion capture and then look for inconsistencies to help reduce the odds of injury.

    There are a number of NBA players and teams (UTA, SAS, ATL) who swear by it but probably none more adamant than Kyle Korver.

    At the more inquisitive end of the spectrum is Korver, the Hawks’ 6' 7" sharpshooter and one of Elliott’s most devoted NBA clients. When Korver arrived at P3 in 2008, the initial assessment zeroed in on his left knee. It had troubled him for years. "When I looked at myself on the camera and they showed how I loaded and jumped, I almost threw up," says Korver. "My left knee bent and almost knocked into my right knee." He thought, I’ve done that every time I’ve shot a jump shot, thousands of times. The prescriptive work wasn’t easy. "I had to totally reprogram my body," Korver says. "I was putting all the pressure on my knees, not using my glutes." Slowly he learned how to leap differently.

    There was another problem, though: Korver has unusually long legs, making it difficult for him to get low. So Elliott focused on increasing Korver’s lateral quickness, as he has with Favors. Now Korver’s "rate of force development is 30% faster," Elliott says, "so he creates space he couldn’t create before." Korver believes his work at P3 is responsible for his unusual career trajectory. At 33, an age at which most NBA athletes are in decline, he is putting up the best numbers of his career for the second straight season, as measured by both traditional and advanced stats, shooting 54.1% on three-pointers through last Friday. "My body feels better now than it did at 23," Korver says, "and that doesn’t happen in pro sports."

    Naturally, there are a lot of skeptics, similar to Charles Barkley and all those who sneer at analytics. Many teams may prefer to keep their information in-house, or worse, they don't believe the information gleamed from biomechanic studies are enough to make reliable judgments.

    Just as the Sports Illustrated article argues, the data, at the very least, has a wealth of potential begging to make use of it. In this day and age where players contracts are well into the millions, where an injury or two can derail a season and an owner's deep pockets could be significantly curtailed, all professional teams should be placing their faith (and money) into these new avenues...if they haven't already.

    Although many fans have already gone this route, the Pelicans head athletic trainer, Duane Brooks, is hopefully making plans on ensuring the Pelicans investment in Jrue Holiday isn't prematurely deemed a failure. With this week's setback in his recovery from a stress reaction, there needs to be an impetus by the New Orleans Pelicans medical staff to get this one right. The technology exists to find out whether Jrue's issues stem from a lack of nutrition, muscle weakness, improper movement or from a host of other factors.

    Let's nip it in the bud guys.