What is POTS and how does it impact Kristaps Porzingis’ availability with Warriors?

Kristaps Porzingis was healthy enough to accompany the Warriors on their current road trip, and he took another step in the right direction, returning to the court Saturday night against the Thunder.

Before Saturday, the center had only played 17 of a possible 533 minutes since the Warriors acquired him at the NBA trade deadline. Despite his recent progress, his outlook remains a mystery.

That is the unfortunate reality of living with postural orthostatic tachycardia syndrome, or POTS, doctors who specialize in the autonomic disease told The California Post.

“It is a difficult, difficult thing to deal with,” said Dr. Tom Clennell, a physical therapist who works with POTS patients at UC San Francisco. That said, “I do think he should be able to contribute and be a productive player. … I don’t think it’s unrealistic to think they can get it under control.”

About 3 million Americans have been diagnosed with POTS, Dr. Alba Azola said. Cases in elite-level athletes such as Porzingis are rarer. But the Latvian said last fall that he got an answer to his unexplained absences toward the end of his time with the Celtics: He told The Athletic that doctors diagnosed him with POTS, which deregulates the nervous system.

“It hit me, and it hit me like a truck,” Porzingis said. “The breathing wasn’t good. I did everything I could potentially to feel as good as I could, but my engine wasn’t running the way I wanted. …

“You know how people say, ‘Oh, I’m so fatigued.’ I’ve never used those words. I don’t even like to speak in those terms, but I really was like that. At that time, I could just lay on the couch and be a house cat.”

The prone position — the natural state for many a house cat — is often the only comfortable one for a patient suffering from, as Clennell put it, “a POTS crisis.” 

Without the nervous system regulating things we take for granted — heart rate, blood pressure, etc. — “the heart is not able to adjust to the demands of the body,” explained Azola, who treats patients dealing with POTS and chronic fatigue at Johns Hopkins.

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Typically the body would send a signal upon standing to tighten the blood vessels in the legs and allow the heart to redistribute that blood to other areas, Azola said. The misfiring nervous system in POTS patients prevents that from happening, causing blood to pool in the legs and feet. Lacking blood flow, the brain sends a “fight or flight” signal,” Azola said.

“That, in turn, triggers this response of tachycardia (heart palpitations), sweating, nausea, lightheadedness — all of those symptoms come from that.”

The simple act of standing rapidly increases the heart rate by more than 30 beats per minute, according to Azola. “And it doesn’t normalize. It stays up, just from standing.”

All considered, it might sound like a feat for Porzingis to be playing at all. He has been effective when on the court, too, looking like the Warriors’ missing puzzle piece in his first game with Golden State and averaging 18.7 points over 60 games the past two seasons.

Unlike a broken bone or a torn ligament, POTS “is not an injury you can truly see,” said Clennell, the physical therapist. “He can come out and he can play and look really good, but the issue is … small changes to what’s going on physiologically … can create a kind of crisis.”

Hydration and electrolyte levels have to be closely monitored. Getting sick is a common precursor — 31% of POTS patients suffer from long COVID, Azola said — but environmental changes routine for most NBA players, such as the dry air on flights, can cause complications.

Porzingis’ conditioning as one of the league’s scariest stretch 5s should help him manage the disease, but his 7-foot-3 frame could also predispose him to more frequent disruptions.

“I think it can be hard for fans to grasp,” said Dr. Nirav Pandya, an orthopedic surgeon at UC San Francisco who has treated several patients with POTS. “Because it’s like, ‘Well, you should be able to push through something. You’re sick; you should be able to push through it.’

“But it becomes so debilitating for people that even doing basic day-to-day things can become really hard.”

Warriors coach Steve Kerr described Porzingis’ condition as “mysterious,” and he’s not entirely wrong. The doctors all said POTS was not part of their curriculum in medical school.

Kerr had to walk back a claim that POTS wasn’t actually the problem with Porzingis. He told a local radio station that he consulted Hawks general manager Onsi Saleh, a former Golden State front office employee, and “got confirmation it was not POTS but it was something else that was really difficult to figure out.”

It’s possible Kerr wasn’t misled, according to Pandya. There isn’t a definitive blood test.

“We kind of diagnose it based on your symptoms,” he said. “That’s where I can understand how there can be some confusion around what the actual diagnosis is. … 

“At the end of the day, you have a player that can’t play and you have something that’s not related to a torn meniscus or quad,” for example, Pandya said.

When general manager Mike Dunleavy Jr. acquired Porzingis at the trade deadline from the Hawks for Jonathan Kuminga and Buddy Hield, he said he wouldn’t have done so if the team wasn’t confident that it could keep him on the court — a goal that has, for one reason or another, evaded the medical staffs at all of his five previous stops.

The doctors and trainers in the Warriors’ building are widely considered to be among the best in the NBA, but Porzingis presents a novel challenge. 

Azola treated one high-level athlete at the Johns Hopkins clinic in Baltimore — an Olympic swimmer — whose career she said was “absolutely” impacted by POTS. “It’s something that requires medical management to continue to compete at that level.”

Porzingis is running out of time to prove the Warriors’ return for Kuminga is more than a $31 million expiring contract. When healthy, he gives them the ideal package of size and spacing.

When healthy.