Fatigue Likely Contributed to DeMarcus Cousins' Achilles Injury

When DeMarcus Cousins crumpled to the floor on Friday night late in the fourth quarter, medical professionals around the NBA suspected one of the worst injuries a player can suffer: the torn Achilles tendon. 

The signs were there. An awkward landing with strain on the back of the ankle. The sudden look of confusion down at the foot (those who suffer a ruptured Achilles often report feeling like someone kicked or hit the back of the ankle). Then, Cousins collapsed after trying to push off his foot.

It’s a devastating injury for any person or professional athlete. It requires surgery, a walking boot and grueling, sedentary rehab. Throw in the fact that Cousins had so much to look forward to as a player: starting in the All-Star Game in Los Angeles, a potential playoff run with the New Orleans Pelicans and a possible max contract this offseason.

That it occurred at the end of the fourth quarter isn’t a total surprise. According to a 2015 study by Jeff Stotts of InStreetClothes.com, a site specializing in sports injuries, 64 percent of in-game ruptures in the NBA since 2005 happened in the second half of games. That finding follows this report: Fatigue or overuse contributes to Achilles tendinitis and ruptures, according to the Cleveland Clinic and other studies.

Cousins was coming off the best stretch of his career, but his minutes totals indicate it was also perhaps the most taxing. On Monday’s phenomenal 44-point, 23-rebound, 10-assist performance in the double-overtime win over the Chicago Bulls, the 6’11”, 270-pound center played a career-high 52 minutes. No player on either team played more than 47 minutes. Cousins tied for the highest total that any player has clocked in a game this season (along with Russell Westbrook and Ben Simmons).

Cousins was clearly gassed after the game.

"My strength coach had the nerve to ask me, do I want to lift after this game? I almost lost it,” Cousins told the Associated Press’ Brett Martel after the game. “If I had some energy, we would have fought.”

The marathon outing may have been particularly grueling because he had been pushing his body into uncharted territory. Heading into that game, Cousins had been averaging a whopping 39.8 minutes per game in his previous 10 contests. He played in four overtimes in a nine-day span.

In sum, January was Cousins’ most taxing month of his career (in months with at least five games played)—he registered a career-high 38.3 minutes per game. Friday’s game was Cousins’ fourth in seven days.

Of course, through the annals of NBA history, plenty of centers at Cousins’ enormous size have averaged 40 minutes per game. If they could take it, why can’t today’s big men?

But minutes only tell half the story. Tim Duncan averaged 40.6 minutes per game in 2001-02 for a Spurs team that averaged 92.6 possessions per game. When you do the math using the NBA’s official data, Duncan played an estimated 78.3 possessions per game. Cousins this month? He was playing approximately 80.2 possessions a night when you factor in that the Pelicans have averaged 101.5 possessions, one of the speediest in the league. Such a pace would blow the doors off any Duncan team of the early 2000s.

What gets lost in the injury discussion is an appreciation of today’s high-octane pace of play and its effect on larger, heavier athletes like Cousins. The 27-year-old was in the midst of one of the most all-around dominant seasons in recent NBA history. He’s averaging 25.2 points, 12.9 rebounds and 5.4 assists per game. But he’s also leading the Pelicans in three-point makes and steals.

Only three other players have averaged at least 25 points, 12 rebounds, 1.5 steals and 1.5 blocks in a season, per Basketball Reference: David Robinson, Kareem Abdul-Jabbar and Hakeem Olajuwon.

But they were not nearly as good as Boogie from beyond the arc. Their total three-pointers combined in those seasons? One (granted, the three-point line didn’t exist in Kareem’s 1977-78 season). Cousins has 104 this season. And none of them averaged at least five assists like Cousins.

Losing someone of Cousins’ caliber will be devastating for the Pelicans’ playoff hopes. It’s hard to know what kind of player he will be when he returns from his torn Achilles. But according to NBA medical professionals, his sheer size will make it more difficult to make a full recovery. History corroborates that thinking. After his Achilles rupture in 2009, 7’0”, 300-pound Knicks center Jerome James never played in the NBA again (though his career was already in a precarious position at age 33). In 2010, Mehmet Okur, a 6’11”, 249-pound former All-Star, ruptured his Achilles—he was 30 years old—and played just 30 games the rest of his career.

The closest comparison for Cousins might be Elton Brand (275 lbs). After averaging at least 20 points per game for four straight seasons with the Los Angeles Clippers, Brand suffered a torn Achilles and missed all but eight games in 2007-08. And he never averaged more than 15 points per game in any full season thereafter.

Ultimately, the Pelicans hope that Cousins can return to the player he was prior to the injury. According to ESPN Insider Kevin Pelton, 18 players have come back from an Achilles tear since 1990, but only three have met or surpassed the pre-injury projection the following season. Spurs small forward Rudy Gay is on target to become the fourth. The somber tenor on Twitter and around the NBA echoes the hard data.

What makes matters trickier is the track record of the New Orleans medical staff. Last August, the team retained head physician and director of medical services Dr. Misty Suri, an orthopedist who had been fired from his other job with the New Orleans Saints for misdiagnosing a player’s broken leg as a contusion. Dr. Suri was seen following Cousins to the locker room after he was carried off the floor by teammates. The Pelicans medical staff will be tasked with caring for Cousins until free agency begins July 1.

The Pelicans have been dealing with injury after injury after injury in recent years. In 2016-17, according to Stotts’ record-keeping, the Pelicans finished with the third-highest total of games lost due to player injury. And that was a drastic improvement. In 2015-16, the Pelicans underwent an awful season in the health department; players missed a league-leading 351 games due to injury or illness.

The road ahead for Cousins and the Pelicans this season will be undoubtedly tough, despite such a strong start. Cousins was in the midst of the finest stretch of his career. We may never know what prompted his ruptured Achilles. But after a grueling stretch of high minutes and fast play in a breakneck NBA, Cousins’ body certainly reached its breaking point.