Monday Morning MD: Youth movement in pro sports

The NFL has always valued youth, and with the current CBA it really seems like any player approaching 30 becomes expendable. Fueled by analytics, the youth movement has reached coaches and management across all sports leagues.
This week, the NHL’s Arizona Coyotes hired a 26 year-old analytics expert as their general manager. Examining the current roster, the new GM is younger than over half of his players.
In MLB, Theo Epstein was 28 when the Red Sox hired him. His success may have encouraged other owners and leagues to hire young Ivy League brainiacs. The Browns have gone that route with young Harvard educated executives Sashi Brown and Paul DePodesta who then in turn hired 28 year-old fellow Crimson Andrew Berry for the top personnel job.
The NFL has long embraced the youth movement. Howie Roseman was 36 when he became the Eagles GM. The Bears Ryan Pace was 37. At 31, Lane Kiffin was the youngest NFL head coach. Bill Cowher and Mike Tomlin were both only 34 years old when they each started their long Steelers tenures.
I am not against this youth movement. In fact, I was part of it. There is no official record keeping of age for medical personnel, but I was likely the youngest head NFL team physician ever. Being 32 when I first started as a team doc, the first 8 years I was younger than at least one active player on the roster. William Fuller was older and when he retired, we acquired Jim Harbaugh who was three months older. When Jim moved on, I thought my streak was over; however, Doug Flutie joined the roster and he was two years older.
There was nothing significant about being younger than a player except it made me feel more part of a peer group all trying to achieve the goal of a championship. I related and cared personally about the guys off the field, which made it easy to do the best thing possible for them to keep them healthy and on the field.
The last nine years of my 17-year NFL tenure, players were all considerably younger than me but many felt like my little brothers. This camaraderie made it easy to spend time on the road and enjoy going the extra mile to help out my teammates.
The youth movement eventually caught up to me too. When my GM and head coach became younger than me, it was a sign of how the times have changed. I will always feel lucky to have been in a position to have these special friendships that extended beyond the traditional doctor/patient relationships.
It meant a lot to me when players accepted me into the special fraternity made possible by age. My biggest compliment was when Philip Rivers called me a teammate saying I “wasn’t a doctor that also happened to be a team doctor. He was a Charger all the way. He’ll be missed.”
Time marches on. Many say the NFL stands for “not for long” and that has never been more truthful. The only seemingly constant is the owners.
MMMD 1: Unprecedented suspension reversal
The NFL has long enforced the policy that a player is responsible for what is found in his own body, no matter what. The league seems to have shown some compassion when Duane Brown proved his positive test was related to eating meat in Mexico.
Brown’s Texans teammate once claimed “over trained athlete” syndrome for his positive test, but Roger Goodell did not buy that excuse. The league has never accepted tainted supplement arguments either. In an unusual but positive step, the NFL overturned Brown’s suspension. As a result, warnings about eating too much meat in Mexico and China was issued to players by the league. My guess is this will be a one-time exception to the hardline policy of being responsible for what is in your body regardless of the circumstances.
MMMD 2: Will Jaylon Smith play?
Owner/GM Jerry Jones said Smith will not start the season on injured reserve (IR) for 2016. Some interpreted that as optimism for the knee and nerve recovery. In reality it is just wordplay as Smith undoubtedly will start the 2016 season on the non-football injury (NFI) list. NFI refers to any injury not happening in a NFL season, so collegiate injuries qualify.
The Cowboys were in a unique position to draft Smith as the GM is the owner and the trusted team physician (and Smith’s surgeon) has enough political capital with the team where his job will not depend on his being right about nerve recovery. The Patriots were reported to covet Smith late in the 2nd round but I would be surprised if that were the case. Certainly Bill Belichick doesn’t worry about answering to the owner; however, New England has a new team physician this season. I find it hard to believe that any new doctor would put his job on the line to clear a player with a nerve injury with unpredictable recovery.
Smith has a multi-ligament knee injury plus a nerve issue. Ifo Ekpre-Olamu was a projected early pick last year and fell to the seventh round after dislocating his knee. The Browns released him without playing a down and he is now with the Dolphins. Marcus Lattimore had two years of rehab with the 49ers but retired without ever being activated. Navarro Bowman had an ACL/MCL injury, missed an entire season and returned to play last year, but his knee is far from normal. Willis Magahee did return after his severe injury to have a productive career.
Not all of these severe knee injuries are similar. The point is a multi-ligament injury without nerve issues already is career threatening. Adding nerve recovery makes it even more daunting. Here is hoping Smith beats the odds to make it back. With some luck and lots of hard work, he could be a quality player, but it would be unprecedented to have 100% recovery and reach all of his pre-injury potential.
MMMD 3: Medical analytics
Much has been written about Myles Jack. Some argue he needlessly dropped. Other say his knee is a time bomb. I think he was drafted in the expected spot. Jack can play football today but the question is for how long.
The general manager makes the final decision but he relies on his team physician’s input. Many thought the Packers should have selected Jack with the 27th pick. An inside look at how draft decisions are made show why he wasn’t. Analytics may be new to the NFL, but medical analytics is exactly what team physicians have been doing at draft time for decades.
MMMD 4: Sports science seems to work for soccer
Coincidence or cause and effect? Leicester City has been transformed from bottom feeder to Premier League champions. They certainly aren’t the only European team that embraces sports science but they are among the leaders in integrating its use.
Chip Kelly, now with the 49ers, aggressively brought sports science to the Eagles with modest success. Other teams have adopted some new age medicine techniques. I don’t think just sports science is solely responsible for Leicester City’s championship, but it certainly was a factor as they were among the leaders is lowest injuries. The question now is how might this translate to football.
MMMD 5: Cold weather games cause more injuries?
In my 17 years in the NFL, I often noted that wet or snowy games made for poor footing and made for less traumatic injuries. Now a study comes out that claims cold weather leads to more concussions and ankle injuries.
Although I applaud the authors for their work, calling a warm weather game 70 degrees Fahrenheit and marking a cold weather game at 50 degrees Fahrenheit, may skew the data. 50 is probably the average temperature of an NFL game. The increased injuries seen might simply correlate with games played later in the season as the weather happens to be colder. Much more research needs to be done and this is a good start.
MMMD 6: BFR at NFL course
Last week the NFL had its bi-annual course with the American Orthopedic Society for Sports Medicine. I have been fortunate enough to be invited to lecture several times as team physicians present the latest breakthroughs to other sports medicine practitioners. Being asked to speak at this meeting is an honor and means the topic is being endorsed by NFL physicians.
The latest on blood flow restriction (BFR) was presented. This is another indication that this new rehab and workout technique is reaching the mainstream. KAATSU is the world-wide leader in BFR and I have meet with the inventor in Japan over five years ago. As I predicted, BFR is catching on as shown by its inclusion in the NFL course. Over half of pro teams now incorporate BFR techniques.
MMMD 7: Genetics matter
The QB lineage of the Mannings is well documented. Both Peyton and Eli have successfully followed in father Archie’s footsteps. There are plenty of other famous football families.
Three recent examples involve the city of San Diego. Third overall pick Joey Bosa’s dad played in the NFL. Fullback Derek Watt was drafted and will face brother J.J. Watt this season. Ian Seau was signed by the Rams and will always face comparisons to his Hall of Fame uncle Junior Seau.
I hope all of these legacy players can make their own names in the NFL.

Monday Morning MD: 2016 NFL draft dominated by medical

Medical always plays some role in the NFL draft; however, the 2016 version would have a completely different look without two “red light” knee issues on two top players. If linebackers Jaylon Smith and Myles Jack were healthy, they would have been selected at the beginning of the first round, instead both fell out of the first day into the top of the second and the “dominos” fell differently as a result.
The Cowboys gambled on Jaylon Smith out of Notre Dame who has been described as a generational linebacker. If he fully recovers from the multi-ligament knee injury and his peroneal nerve wakes up, he could be the steal of the draft. On the other hand, if he becomes the next Marcus Lattimore and doesn’t play a down, Dallas fans will surely lament the pick.
It is hard not to root for Smith, who has done everything right, except have a bad luck horrific knee injury during the Fiesta Bowl game. He couldn’t have found a better landing spot as the Cowboys team doctor performed his surgery and he will be reunited with his older brother who is a running back on the team.
Smith is still using an ankle foot orthosis (AFO) due to his persistent foot drop. It would be unprecedented to have someone play his career with an AFO, much less make a Pro Bowl while wearing one. His surgeon has shown great optimism for a full nerve recovery going against others who were more pessimistic. The Cowboys exhibited a lot of faith in their team physician by selecting Smith so high.
His doctor knows best if the nerve will wake up, but no one knows for sure as nerve recovery is unpredictable. Even if the nerve recovers, the chance is small that it will return to 100% function. Without the nerve issue, an ACL, PCL and posterolateral corner injury is still career threatening. With the nerve issue, the odds are stacked against Smith.
It takes three things to recover from any major injury. First, the injury has to be amenable to recovery. Second, one needs good surgery. Third the player needs to be motivated and have good rehabilitation. I compare it to needing a good snap, hold and kick to make any field goal. Smith certainly had good surgery as his doctor is tops. No one can question his work ethic in rehab. The remaining issue of the nerve is really out of Smith’s or his surgeon’s hands.
Smith remains optimistic saying he “absolutely” could play in 2016, but there is no guarantee he will ever play at all, much less perform to his potential. The best hold and kick may not be able to overcome a bad snap.
Myles Jack is the other top linebacker with medical issues and his situation is the opposite of Smith. Jack is healthy and able to play today, but the question is for how long? The Jaguars were rumored to be interested in selecting Jack with their number one pick and overall 5th selection. With the medical issues, they nabbed him at the top of round two.
Jack reportedly has an osteochondral defect (osteochondritis dissecans – OCD) lesion involving his knee articular cartilage and the underlying bone. This is essentially a separate issue from his meniscus tear and is likely congenital. The irony is the OCD may never have been discovered by teams absent the meniscus issue. There would have been no reason to X-ray or MRI the knee if there was no knee injury history.
No one knows how long Jack will play. If, or some say when, the OCD lesion breaks off, microfracture type surgery with up to a one year recovery is needed. Regrowing articular cartilage is the “holy grail” of orthopedics as typically the new cartilage is not as strong as the original.
If healthy, these two linebackers would be the stars of this draft. Jaylon Smith is the proverbial “start up company” with huge potential that may never get off the ground, Myles Jack is the “newspaper” that is popular today but needs to retool to the internet age to stay relevant. Best of luck to both.
Here are some more draft medical observations:
MMMD 1: No false medical info leaked
There was suspicion that teams were leaking false information to drive down the values of Jaylon Smith and Myles Jack. Many teams leak false information about their interest in a player, but I have never seen a team tell lies about a player’s medicals. It just would be unethical. As it turns out, both of these players have real knee issues.
MMMD 2: Jaguars defense to add three top-five players
Dante Fowler, last year’s first round pick, tore his ACL at the first mini-camp and missed the season. Myles Jack is a first round talent who dropped to the second due to medical issues discussed above. No one questions the top-five talent of Jalen Ramsey.
Fowler, Jack and Ramsey could turn Jacksonville’s defense into a force. When is the last time a team added three top-five level players at one time?
MMMD 3: Shaq Lawson still says no surgery
Despite my analysis, and a report from Adam Schefter that surgery is needed, Lawson still denies it. No one is panning the pick or saying he can’t play this year, but he will need a brace.
In the end, the Bills are likely to recommend labral repair surgery after this season to give more time for recovery. If Lawson plays well with his shoulder brace, stabilizing the shoulder should make him an even better player as the harness keeps the shoulder in the socket but limits his range of motion.
MMMD 4: Raiders top two picks with medical questions
First pick Karl Joseph is coming off ACL surgery. Second pick Jihad Ward is said to need a knee scope.
Joseph appears to be recovering well from October ligament reconstruction but don’t be surprised if he is not activated with the start of training camp. He will contribute this season but may not be in full form until the middle of the season.
Ward has denied the need for surgery but his potential knee surgery should not prove to be a big deal. Anticipated recovery should not be more than four to six weeks and look for that to happen after mini-camp breaks.
MMMD 5: Top 2 picks overcame throwing side injury
An injury to anywhere on the throwing upper extremity of a quarterback is a cause for concern. This year the first and second overall picks beat their injuries.
Jared Goff had shoulder surgery on his AC joint after his freshman year and has done well since. Carson Wentz missed the second half of last season with a scaphoid fracture. Both should be healthy. In the end, this is football. Players will get injured. What type of injury determines if there are any potential future problems. No issues with that on these two top picks.
MMMD 6: 49ers follow recent tradition
In the Trent Baalke era, there has been a penchant to get value by drafting players coming off ACL injuries. This year was no exception when the 49ers selected cornerback Will Redmond who tore his ACL in October. That makes a seventh player since 2013, which is essentially a normal full draft class.
MMMD 7: End of the magnet era.
There is no official count, but the day of draft magnets is ending. The small custom player magnets loaded with info were ubiquitous in war rooms for decades. Now most teams are in a hybrid system or switched entirely to an all-electronic draft board.
The picture was from Mike Silver’s 2014 war room visit with the then St. Louis Rams. Images shared from this year’s Los Angeles Rams show a much different 100% electronic video board system. Things do change in the NFL

Monday Morning MD: Biggest deal for schedule release is the bye week

Why is the schedule release even a big deal? After all, opponents and home/away locations are already known. Much is made of strength of schedule but only two games are variable based on position of finish. Six within division, four vs rotated AFC division and four vs rotated NFC division are fixed for years to come. Just two in-conference opponents in another division with same place finish are variable. Besides divisional rivals, the Cowboys have long known they were playing the NFC North and the AFC North in 2016. Only their 4th place division finish has them matched with 4th place 49ers and Buccaneers.
Despite already knowing opponents, everyone eagerly looks at the NFL schedule as soon as it is released. Fans get excited, circle big matchups, note night games and perhaps schedule a road trip. Media pundits start picking wins and losses and prognosticate season records.
Schedule release is also a big deal for everyone employed by the NFL. What do medical staffs and those who work for clubs look at?
General managers, coaches, staffers, players and wives all look for different things, but the common thread is that everyone, including doctors, looks for the bye week. In the regularity of the NFL, any schedule alteration is looked at first.
Chargers GM Tom Telesco said the bye week “is the only thing I look at right away”.  It is the extra week to work with when it comes to pre-existing or new injuries.
As a former NFL team physician, I would agree. The bye is the first thing I looked at. Not because it was my only free weekend during the season, but it was important to know when the bye is to use the off week to your advantage. Often we might ask a player who needed an in-season procedure to hold on until the bye week to have surgery in order to not miss any games. It also provides the extra week to rest/rehab injuries.
A team never wants its bye week too early or too late. In 1999, my team essentially did not have a bye as it was the first week of the season. Currently, the bye weeks are between weeks 4-13. The Packers and Eagles have to feel their Week 4 bye is too early for their liking. They finish with 13 straight games without a break.
The next thing team doctors look at is how the schedule affects their medical practice. Friday departures, weekday games, and late returns impact patient schedules. Yes, team physicians have “day jobs” and the travel affects them. Contrary to popular belief, no NFL doctor solely works for the club. In fact, typically less than 5% of their income is derived from the team. The weekday disruption is a major factor. A Thursday night game meant I had to clear my Thursday afternoon to be at the stadium at least three hours before the game and then move my Friday morning surgeries to be available for the routine day after game player injury check. A Sunday night game makes for a very late return home and could wipe out the Monday workday.
Head coaches make their team’s daily schedules and they too look for aberrations to the regularity of the NFL. Bye week, Monday/Thursday games, Sunday night games, London and coast to coast travel with late night/early morning returns all disrupt the routine that is the NFL. When a team plays Monday, the Friday practice is called a Thursday schedule. West coast teams have to decide on when to make it a three-day road trip and depart on Friday. East coast teams have to deal with getting home at 4am from a routine Sunday day game on the west coast. For example, the Patriots are known for staying on the west coast for the week if they have back-to-back cross-country travel.
Players peek at the bye week to see when they can get home to visit family. However, in their “one game at a time world” the opener is the first thing that comes to mind. Then perhaps they peek at contests with special meaning: primetime, rivalry, hometown return, former club, etc.
The wives look at the bye week as well but then go straight to the holiday schedule. Is daddy home for Christmas? How will the family adapt Thanksgiving plans?
Equipment guys look forward to seeing the bye week as they work with expanded rosters throughout training camp and the bye is their first and only break. Their attention then turns to which games will be in cold weather as they make their special preparations.
The bye week is the common thread that everyone looks at when the schedule is released. Team medical personnel is no exception.

Monday Morning MD: Game changing rehab/workout technique

Athletes have long searched for a shortcut to success. Blood flow restriction (BFR) training may be that answer. Yesterday, ESPN featured BFR training on Outside the Lines and how it is catching on in professional leagues.
BFR training involves light workouts with tourniquet bands to control blood flow to the extremities. It can be overly simplistically described as a convenient way to altitude train in a lower oxygen state, but that would be short-changing the muscle hypertrophy and potential systemic benefits.
Modifying circulation to the extremities allows the body to use up the oxygen carried in blood. This creates an environment where light activity can reproduce the gains of heavier workouts. BFR is the recent American term that is catching on. The Japanese were the first to popularize it decades ago. BFR
I first learned of and reviewed this cutting-edge technology over 10 years ago in the form of KAATSU training. While traveling to Tokyo with the USA Rugby Sevens team five years ago, I sought out Dr. Sato and spent a day with the inventor of this specific form of BFR training. He refers to it as blood flow modification (as opposed to restriction). This blood pooling technique has been popular in Japan for over two decades.
Decreased blood flow equals less oxygen available to limb muscles allowing light resistance exercises to equal that of heavier workouts. There is local effect of lactic acid buildup but there is a claimed systemic effect as well.
Where BFR training has taken off is in the rehabilitation world. In the United States, its roots began with use in the military in treating severe limb injuries. Among the first NFL users was Jadeveon Clowney as he “looked spectacular” in his recovery from 2014 microfracture knee surgery. ESPN injury analyst Stephania Bell has been a proponent of BFR training and reported that 20 NFL teams were now using the technique. It has been presented at the NFL Physicians Society meetings during the Combines.
I have believed in this technique for years and currently am using it on three USA Rugby players as they recover from surgery (2 ACL tears and a tibia fracture) and hope to make the short timeline of the Rio Olympics this August. Athletes lose muscle girth when not able to workout in the post-operative period. BFR training allows one to keep muscle mass and fitness when you are limited in workout abilities.
Muscle gain at lower loads has many implications beyond making middle-aged Americans looking for a workout shortcut happy. If one can put less stress on the body to maintain fitness, that potentially leads to career longevity for a professional athlete. It may even lead to reduced late season injury and breakdown from cumulative stress. An NFL player with articular cartilage wear essentially has limited “tread on his tires”. Imagine if he could workout at lower loads and still stay in shape while not “burning more rubber”.
The potential systemic benefits of BFR type training is even more exciting. In theory, BFR training also stimulates the pituitary gland to produce natural and legal human growth hormone (HGH). In addition, this type of HGH is more effective than the synthetically produced kinds. Also VO2 max (oxygen usage or a measure of aerobic fitness) is said to be improved with even light bike riding.
Safety is a natural concern when limiting blood flow. However, BFR training has been proven over time to have few complications. KAATSU, the most vetted type of BFR training, has shown an excellent safety profile over more than two decades. When used with proper medical supervision or training, there has not been reports of nerve or vascular injury. After all, in surgery, we routinely will use tourniquet for up to two hours, whereas this total training here is targeted for under 30 minutes.
BFR training/rehab makes intuitive sense. Athletes feel the burn with light exercise and early results are encouraging. With more and more NFL, MBA and MLB teams jumping aboard, this type of training has definite potential to be revolutionary. Who wouldn’t be excited to train at lower loads with less stress and get the same benefit?

Monday Morning MD: How 2016 NFL rules changes will affect safety

At the recent NFL owners meetings, a total of 10 new rules were announced for the 2016 season. The league often touts its health and safety improvements. Four of the new rules were enacted with player welfare in mind; however, did the league go far enough?
Four rules changes for safety

  1. All chop blocks are now illegal

In my opinion this is long overdue rule change helps prevent ankle and knee injuries. The old rulebook with some chop blocks being legal was confusing. In addition, whether a player is engaged or not, diving at a player’s planted leg increases the chance of high ankle sprain/fracture, medial collateral ligament (MCL) knee injury and sometimes even anterior cruciate ligament (ACL) tear. As a team physician in 2002, I witnessed Jamal Williams suffer a season ending ankle fracture from a legal chop block and felt that play should have been outlawed for over a decade. Many defenders and coaches have complained about it as well. Thankfully, all forms of the chop block have now been eliminated.

  1. Horse collar tackle expanded to include the area “at the nameplate and above

This is another good rule, but does it go far enough? Horse collar tackles from behind were outlawed over 10 years ago due to the propensity to cause eversion ankle fractures and other knee/leg injuries when a runner is folded back onto his leg. This rule expands the definition of “collar” to the nameplate area and jersey up high. However, tackling by a player’s long hair that often covers the nameplate and collar is still legal. Hair is considered part of the body. Pulling a player to the ground from behind by his dreads is still legal, but that maneuver is just as dangerous as a true horse collar or tackling by grasping the nameplate area. I understand that some will say the player should cut his hair, but my point is that dangerous type of tackle from behind is still legal.

  1. Retroactively designate IR player as “designated to return”

I think this is another great rule change that may not go far enough. A team no longer needs to designate a player for return off injured reserve (IR) with the initial roster move. The club can move players to IR as before and then wait to see which player recovers quickly enough or perhaps becomes more valuable to the team to return. The same eight weeks absence is required as before, but this solves several issues. Teams have sometimes used the old IR/dfr designation on a player that subsequently has a setback in recovery and the player never makes it back. Other times, clubs wish they had saved the spot or used the spot as their roster situation changes as the season progresses. This way all IR players can stay “alive”. Only one can practice as early as six weeks and return to play in eight. This rule is still limited to a one-time use and perhaps the NFL should think about adding more short term IR slots since players are getting paid anyways and many want to return.

  1. Moving the touchback on kickoffs to the 25-yard line

The theory behind the rule is to entice more touchbacks and thus decrease collisions on kickoff returns. In reality, this may have the opposite effect. Strategically, kickers may now add elevation to the kickoff and attempt to pin a returner into a corner of the playing field forcing a return. The unintended consequence may be that we see more kick returns. Thankfully, this is just a one-year trial and the league will re-evaluate before it becomes permanent.
The other six rule changes were adopted outside of a safety focus. Players are now ejected for a second unsportsmanlike conduct penalty, the extra point conversion is permanently at the 15, offensive/defensive play callers can use headsets form the field or the booth, no more 5-yard penalty for illegal touching when out of bounds (just loss of down) and multiple spots of enforcement for double fouls after change of possession are eliminated.
The final rule change adds a delay of game penalty for calling a timeout when not allowed. The rule is fine but I feel the NFL should never penalize a team for a medical timeout. If a doctor or athletic trainer feels there is a chance their player has a head injury, they should be allowed to go onto the field and stop play without waiting for the referee or “eye-in-the-sky”. When someone is acting for safety, there should be no risk to being penalized or being charged a timeout. If this rule were in place, the Case Keenum situation with the Rams last year might have been avoided.
The league is making an earnest effort to make the game safer. Perhaps it would be even better if the NFL would add a medical person to the competition committee where the vast majority of the rules change proposals come from. Another option is to start a separate player welfare rules committee that would be specifically charged with coming up with new safety rules. This group would be made up of mostly medical personnel. Since almost half the rule changes have to do with health and safety issues, why not involve medical personnel. This new medical rules committee might have been more expeditious in suggesting to outlaw all chop blocks, adding hair as part of the dangerous horse collar tackle or coming up with the next good player safety rule.
Follow David on Twitter: @profootballdoc
Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.

Monday Morning MD: The NFL should "Let it go"

I never thought I would relate the theme of the children’s movie “Frozen” to sports. Then again, Disney does own ESPN.
“Let it go” should be the mantra for the NFL as it should stop trying to defend its defunct Mild Traumatic Brain Injury (MTBI) committee. The media and concussion critics should also “let it go” and stop looking backwards to critique the league’s decade plus old research.
We all know the NFL attitudes toward concussion are historically far from idea. The league has essentially admitted the errors of the MTBI committee by disbanding the group years ago. There is a new Head, Neck and Spine committee in its place. The new committee is no longer run by the NFL’s often criticized medical advisor. It was a bad look to have a rheumatologist who is a league employee head the MTBI group and the league has seen the error of its ways. The chair of the MTBI committee being the lead author on head injury studies invited criticism based on qualifications and conflicts of interest.
Even thought the MTBI papers have already been discredited, the recent New York Times article rightfully points out specific study errors. Publishing data with one team not reporting any concussions for six years clearly makes no sense. Add that during that time period, the team’s star QB Troy Aikman was publicly reported to have four concussions and was thought to retire because of head injuries makes the research look even worse.
I have participated in NFL research as a team physician. Yes, it is hard sometimes to get busy team doctors to respond to questionnaires and surveys. However, this was a study performed on behalf of the league. The NFL has required all head team physicians and athletic trainers attend certain concussion symposiums in person and there are frequent directives for conference calls. It would have been simple to mandate that all teams carefully report concussions for the MTBI studies.

Lead Author on the field tending to Wayne Chrebet after concussion

Undoubtedly, there is recollection bias and it is difficult for a team physician to remember every concussion across a six-year span. However, the authors should have at least gotten their own team’s head injury data correct. Not reporting at least two concussions on the team for which the lead author worked seems inexcusable. Jets receiver Wayne Cherbet’s career ultimately ended over head injuries, yet his two concussions during the research period were not listed in the study by the authors which included Chrebet’s team physician.
The MTBI committee said it analyzed all concussions diagnosed by team medical staffs during 1996-2001. All players were said to be included as well as all concussions, no matter how minor. That clearly was not the case as at least 100 additional concussions were identified by cross-referencing public reports. It is embarrassing that the NFL’s own injury reports were used to contradict and prove the underreporting in the NFL studies.
The research was at best sloppy or at worst fraudulent. One member of the MTBI committee indicated he was unaware of the omissions but agreed: “If somebody made a human error or somebody assumed the data was absolutely correct and didn’t question it, well, we screwed up. If we found it wasn’t accurate and still used it, that’s not a screw-up; that’s a lie.”
The NFL looks silly when trying to defend the research of the long ago disbanded MTBI committee when one of the authors has called the omissions a mistake. The excuse that the research was “necessarily preliminary” rings hollow. The paper is based on data up to 20 years old, the scientific community doesn’t put much stock into it and it is pointless to defend it.
The NFL justifying the shoddy research perpetuates the criticism of its attitudes towards head injury. However, linking the NFL to big tobacco seems quite a stretch. Yes, some attorneys and lobbyists overlapped the two industries, but that hardly warrants the headlines of “ties to tobacco industry”. More accurately, the NFL had ties to some people who in turn had ties to the tobacco industry. If the New York Times is going to hold the NFL researchers to the highest scrutiny, the paper should do the same for its headline writers. The league official statement on the concussion research correctly refutes the ties.
Media and critics should move on. We all know the NFL mishandled and underestimated concussions. Overall, the medical community has been slow to point out concussion dangers. However, it’s time to stop beating a dead horse. The best team doesn’t win every game. The best player misses a tackle now and again. Peyton Manning started his Hall of Fame career with 28 interceptions his first season. The NFL has made some early mistakes but has since done better; however, Jerry Jones calling any concussion link “absurd” doesn’t help the situation.
The NFL should let it go and stop defending the research of a defunct MTBI committee. They already admit the new Head, Neck and Spine committee doesn’t rely on that previous research. Media should let it go and stop sensationalizing the story by bringing big tobacco into the headlines. I want to let it go and no longer write columns about the finger pointing and defensive posturing. Lets all let it go and work forward to find solutions.
Follow David on Twitter: @profootballdoc
Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.

Monday Morning MD: Did the NFL flip-flop on a link between football and CTE?

If you believe the headlines, the NFL has reversed field and finally pulled its head out of the sand. If you listen to critics, this is the “smoking gun” plaintiff attorneys have been searching for. While it is true that the NFL has acknowledged a link between football and chronic traumatic encephalopathy (CTE), this is hardly equivalent to big tobacco’s late admission in 1997 that smoking causes cancer and heart disease.
In reality, this was another round of politics and semantics. My hope is the NFL and its critics both stop the gamesmanship and get to some real answers. What happened in Congress last week did not get us closer to prevention, treatment, cure or a living diagnosis of CTE.
This week, a senior NFL official did seem to contradict what the league’s own appointed medical personnel recently said during Super Bowl week. In fact, this league vice president was sitting on the same stage when the neurosurgeon denied a link between football and CTE just a month ago.
Although the refutation and now admission of a link appear at odds, I do not think they really are. The recent acknowledgement of a link does not signal a big NFL policy shift. This is not the “gotcha” moment that some have made it out to be. Let’s examine the context of both statements to see why.
Just before Super Bowl 50, Dr. Mitch Berger, the head of the NFL medical subcommittee on long-term brain trauma, denied any definitive link between football and CTE. Having attended that health and safety press conference where he said this, it was my impression that the neurosurgeon was answering the question as a medical professional using strict scientific guidelines of proof. He was indicating that there is no medically proven link of “cause and effect” for football and CTE.
When Jeffery Miller, NFL senior vice president of health and safety policy, answered affirmatively that there was a link between football and CTE, he gave the obvious answer as a lay, non-medical person. If you watch the House of Representatives roundtable discussion, it seems clear that Miller is using the word “link” in the vernacular, acknowledging there is an association. Given the autopsy findings in former football players, colloquially no one can doubt there is some sort of relationship between football-related head trauma and CTE. Miller even tries to clarify his answer to that effect. The key is to find what that link truly is.
This news was incorrectly heralded as the first time the NFL acknowledged a link. In 2009, an NFL spokesman told the New York Times that it is “quite obvious from the medical research that’s been done that concussions can lead to long-term problems.”
To me, Miller’s opinion does not seem at odds with Berger’s earlier statement. This is not an axis shift coming out of the NFL. Medically speaking there is currently not conclusive scientific evidence of a direct link between football and CTE. On the other hand, common sense tells us that there has to be some associative relationship that links football related head trauma and CTE.
The latest statements are not surprising at all. I don’t believe the NFL is flip-flopping or even has changed its stance. Of course, I don’t know how attorneys may use the latest statements and how it might impact the legal proceedings of the concussion lawsuit settlement.
I have said many times, there is so much more we don’t know about concussions than what we do know. We are in our absolute infancy of knowledge and medicine needs to catch up. Lumping together all head injury as concussion is like diagnosing every knee injury as a sprain with no distinction for ACL, MCL, meniscus, articular cartilage, tendon, muscle or dozens of other specific structures. It would be silly to group all knee injuries as the same, yet that is where we are at with head injury. We know less about concussions today than we knew about treating ACL tears in the 1960’s
Conventional thinking is that cognitive rest in a dark quiet room was the best treatment for a concussion and now some scientists say using your brain after a head injury is the better way to go. Not only is there no treatment for CTE, there is no way to conclusively diagnose it except by autopsy. We have come a long way in the last decade but we are just starting the quest for knowledge.
The NFL has been the lightening rod for criticism from concussion and CTE advocates. They may have been slow to the party or let down by their medical advisors back in the day. Currently, the league is no longer in denial.
The many rules changes have produced a new safer game. Just look at the recent ESPN 30 for 30 film: The ’85 Bears. The vast majority of the plays shown highlighting their defense would be penalized, fined and/or suspensions today. However, this protection does not apply to running plays or limit the routine head contact on every play. Why did Dave Duerson, who killed himself, have CTE and why does Jim McMahon have brain injury symptoms? Meanwhile, teammates Mike Singletary and Ron Rivera seem to be fine.
New York Giants owner John Mara said Sunday that the long-term effect of concussions on players and the link between football and CTE represent the most serious issues confronting NFL owners at the league meetings which start today, “and I don’t think anything else comes close.”
Let’s stop the rhetoric and focus on a solution. It doesn’t matter who first found or said there is a link between football and CTE. The focus should be on finding ways to diagnosis, treat, cure and prevent progressive brain disorders.

Monday Morning MD: The new trend

There is a new injury rehabilitation trend and it has nothing to do with actual medicine. As social media continues to blossom, posting video of one’s recovery workouts has become the norm.
Le’Veon Bell, Jason Pierre-Paul and Jamaal Charles are just a few examples of NFL players who recently have joined the injury update by social media movement. Draft eligible players, like Butkus Award winner Jaylon Smith, have also participated in the “check out how well I am doing” posting craze.
Athletes who share these updates typically are trying to make the point of how hard they are working or how great the rehab is going. What is usually highlighted is the best snippet of their recovery, which may not be reflective of their actual status.
When news is leaked to the media, the information needs context and interpretation. Rarely is the message taken at face value. The same should be said about the injury updates. The videos need analyzing to determine their true meaning as well.
Self-released Vines should be looked at with a critical eye. I am not saying the postings are staged or faked, just that they need context and interpretation.
Le’Veon Bell, coming off MCL and PCL surgery, tweeted “clear to run” with a video link to prove it; however, what it showed wasn’t exactly running. Medically, it is more accurately described as jogging on an anti-gravity treadmill. Yes he was performing the running motion, but it was partial weight-bearing as the machine unloads body weight. In reality, it was a good sign of progress for Bell, but hardly as advertised.
JPP has used social media to post his own hand X-rays from last year’s unfortunate July 4th fireworks accident. Yesterday, he tweeted “they said I wouldn’t be able to grip the bar and lift weights anymore” with a video of him bench pressing. Others may have questioned his ability to bench press, but I never did. Power grip is mostly provided by the 4th and 5th fingers, therefore it is no surprise that he can bench, but that doesn’t mean he will be the same dominant player.
Jamaal Charles took to Twitter to counter naysayers that claim he is too old and can’t come back from a second ACL surgery. His assertion of quick recovery seems to be accurate as Charles looked good to me with his agility on jump rope and balance board. I never doubted that he would make a successful comeback as Charles has done it before on the other side.
Jaylon Smith has released several videos after ACL and LCL surgery. His pre-Combine post that was meant to show off his knee progress unintentionally alerted the world of his nerve issue. He continues to post rehab video, this time doing squats. I applaud his dedication and wish him the best; however, peroneal nerve function is not required when performing squats. The key for Smith will be his nerve status at the Combine medical rechecks two weeks before the draft.
The previous trend was to have personal physicians make statements or write letters espousing support for an athlete’s recovery. Those letters had very little influence and were understandably taken as biased. Due to HIPAA confidentiality laws, a physician can’t reveal medical information without permission from the patient. What player will allow a negative report to be released? What doctor would publically claim the outcome of their surgical work wasn’t positive? With social media, the workout videos seem to have replaced those physician letters.
“Selfie” rehab videos are not just limited to football. Even Tiger Woods posted a video of hitting into a virtual golf machine in response to articles that said his career was over.
The new trend of rehab video is interesting and can be informative. It provides a small window into the recovery process. Like all data, there needs to be context and interpretation before extracting great meaning from the posts.

Monday Morning MD: Peyton Manning's greatest feat

MMMD 3.7.16
Peyton Manning’s greatest feat
In a career of great accomplishments, it is not the two Super Bowl victories, five league MVPs, 200 victories or the single season and career record for passing touchdowns that stand out to me. In a first ballot Hall of Fame career, Peyton Manning beating Mother Nature in his recovery from four neck surgeries is his greatest feat. Having success playing with a grandma-like triceps muscle is what is most unbelievable to me.
Peyton ManningA
How does anyone play quarterback in the NFL with an arm that looks like this? With nerve issues leading to multiple neck surgeries, his arm was significantly atrophied as he joined the Broncos. His triceps waggle resembled that of an octogenarian. There were also reports of his fingertips being numb. If a sure-fire top college quarterback prospect showed up at Combine with similar neck and arm findings, he would not be drafted at all based on his medical exam.
Manning not only had a successful post-Colts career, he passed for an NFL record 55 touchdowns and 5,477 yards in 2013. His triceps strength seemed to improve but there was no question that his entire Denver tenure was played at less than 100%. Manning proved a quarterback’s most important attribute is intelligence, not arm strength.
During his time with the Broncos, his throwing was so limited that any lower extremity injury unmasked his arm strength issues. We all saw that with the 2015 plantar fasciitis; however, also recall last season’s poor performance during a home divisional round loss to the Colts when he had a quad tear and resulting in the firing of John Fox.
Having examined the neck and the arm, the Colts knew the bleak medical situation with the nerve issue. Owner Jim Irsay took the percentage play by bidding farewell to Manning and drafting Andrew Luck in 2013. In the end, Manning was able to beat the injury and Father Time to play four more years and gain that second ring.
Atrophy and strength loss from nerve compression typically never returns. Through Manning’s hard work, the triceps atrophy seemed to improve some.
Peyton Manning
While it may be true that Manning’s wife was shipped HGH, it is a medical fact that human growth hormone does not help with nerve issues, thus it would have made little medical sense to use it.
To me, Manning’s greatest accomplishment was to play well returning from the neck and arm issues. A close second is how he was the consummate professional.
Before I had the fortune to meet Peyton, I was not particularly a fan. After all, as the Chargers head team physician, the Colts were our rivals in the mid-2000s. After meeting Manning and serving as his team doctor at the Pro Bowl, I was proven wrong. There was absolutely nothing not to like about Manning on or off the field. I came to have the utmost respect for him.
Manning took his Pro Bowl selections as an honor and duty. He felt obliged to accept every invitation and never bowed out due to injury. At our first AFC team meeting, Manning took charge of the room and showed off his sense of humor and leadership. On the sidelines, he was the leader of the pranks. Loosening tops off water bottles and handing them to first time Pro Bowlers saying to stay hydrated due to the Hawaii sun. My now wife became a life long fan when three days after briefly meeting Peyton, he made a point to say hello remembering her name as they crossed paths on the way to the hotel pool. I have previously chronicled how while Manning was making time for a Make-A-Wish visit, he was still concerned about the athletic trainers and doctors being able to enjoy our time in Hawaii.
Manning is famous for hand writing letters to players on their retirement. He is known for touching lives away from the camera or media. I witnessed Manning (and GM John Elway) quietly attending the “celebration of life” for Junior Seau while turning down media photo and interview requests saying they were just here for the family.
As Manning makes his retirement announcement, this is his time. Yet, he took the effort to personally text former and current teammates and coaches to thank them and let them personally know about his impending retirement.
Whatever happened in the Tennessee training room two decades ago was regrettable. Mooning (or more than that) was an unacceptable act even for a college student. Judging Manning on his body of work has to have him in the plus column even with that blemish.
I was lucky our paths crossed. I only wish they had crossed sooner. The Chargers unfortunately had the second pick as Manning and Ryan Leaf were coming out of college and the Colts made the right decision.
To me Manning’s greatest feat is giving us four more successful years with a terribly weakened arm. The NFL is better for having him for 18 years. The league would be even better if all players acted more like Peyton. There is no better ambassador for the game.