September 26, 2016 - Dr. David Chao
Monday Morning MD: MCL and high ankle combo
What do the injuries to Russell Wilson, Dez Bryant & Brandon Marshall have in common? They all have a similar mechanism of being pulled to the ground in a “horse collar” type fashion. Wilson’s tackle was flagged as a penalty. Bryant was pulled to the ground legally by the jersey. Marshall was illegally yanked down by his facemask last week. All three tackles are dangerous and have the same injury patterns. They all are at high risk for knee MCL injury and same side high ankle sprains as the tackler’s body pins the ankle while the knee is rolled up upon. Fortunately all three only had mild MCL sprains. Wilson continued to play before being removed for a coaching decision based on the lopsided score. Bryant was injured the second play of the game and returned to catch a touchdown pass. Marshall surprised people when he finished the game last week and proved doubters wrong by starting this week. When the defender’s body traps the leg as the ball carrier is pulled to the ground, either the medial collateral ligament (MCL) and/or the syndesmotic ligaments (high ankle sprain) are injured. Sometimes it is both. In these cases, there may have been some ankle symptoms but all three were primarily knee injuries. The good news of all three are that by video, they appear to be mild. Marshall’s injury is known. Wilson and Bryant will have the prerequisite MRI that will confirm the mild MCL sprain. Contrary to some internet fears, I am sure there is no additional ACL tear or bigger injury looming for either player. Pulling a player to the ground by the collar, facemask or jersey is dangerous as the tackler’s body often pins the leg. Fortunately, Wilson, Bryant and Marshall escaped with minor injuries; however, this can cause ankle fractures or more rarely tibial plateau fractures as well. Players need to take care of each other. Football is dangerous enough and no one should suffer a preventable injury. MMMD 1: The dreaded non-contact injuries beginning with “A” Everyone knows anterior cruciate ligament (ACL) tears end seasons. Achilles tendon tears are second only to that in landing players on injured reserve. As players get bigger, faster & stronger, the ACL and Achilles do not get larger, thicker or stronger, thus a weak point exists. By video, DeAngelo Hall tore his right knee ACL. The Redskins officially called it a “knee sprain” during the game, which is technically not inaccurate; however, an ACL tear is a severe form of a knee sprain. Ironically, Hall tore his Achilles in 2014. Manti Te’o was announced to be out with an Achilles. There was no official mention of tear yet but the bad news is expected with the formal announcement of tendon rupture, surgery and IR. This marks the 3rd Achilles tear for the Chargers (RB Brandon Oliver & TE Jeff Cumberland). This is also the 3rd week in a row that San Diego has lost a key player for the year. Keenan Allen and Danny Woodhead tore their ACLs in Week 1 and Week 2. MMMD 2: Walk-through injuries Injuries in games, practice and preseason are bound to happen, but injuries during walk-through practices? The Browns kicker injured his knee during the lightest of practices and was later placed on injured reserve. Sammy Watkins had his foot stepped on in walk-through and missed Sunday’s game. His pain predated the stomping injury and my hope is that he won’t need a second Jones fracture surgery as happens up to 20% of the time with this problem fracture. MMMD 3: Weather delay in Tampa A thunderstorm delayed the end of the Rams at Buccaneers game by just over an hour. The delay was not just about player safety but fan safety too. Lightning is dangerous for both fans and players. Reports of danger in football are usually in high school fields without large structures like stadiums; however it pays to be smart when the chance of a potentially deadly injury is preventable. MMMD 4: Several medical timeouts It seems that referees have gotten the message after the season opening Cam Newton potential head injury incident. A medical timeout was not called and the league underwent criticism. This week, several medical timeouts were called by referees. Cardinals WR Michael Floyd was sent off for a play. So was Browns QB Cody Kessler. Both were not diagnosed with concussion. This is a good step forward. Now let’s hope the system works this well the next time a big star QB in the final two minutes takes a significant head blow. MMMD 5: UNC needs to watch the action I feel bad for the elderly gentleman on the Cowboys sideline that got run over. He was clearly mesmerized by the video boards and not watching the action as it came towards him. I hope he wasn’t hurt. This does bring up a different question. The gentleman was on the sidelines working as the official unaffiliated neurotrauma consultant (UNC). His job is to watch the action and protect players. It is the spotter’s job to watch video and sideline personnel’s job to watch the field. Certainly it would be appropriate for the UNC to watch the video boards after the whistle for replays but not to miss the live action. Lesson number one on the sidelines is to watch the action. With this incident, I wonder about the experience of UNC doctors. Last week, I was told by a NFL doctor that the assigned UNC had never worked a football game in his/her life and had no specific football training. Recently, Jenny Vrentas was allowed access to observe a sideline neuro doc in action and he admitted to only having 10 games experience in 3 years. In contrast, up to half of team doctors have 10 plus years of experience. Since the UNC plays an important role, perhaps there should be some formal training mandated before stepping onto the sidelines to help give players more protection. MMMD 6: Injury rundown The Steelers had multiple players leave the game. LB Lawrence Timmons (shin - hospitalized and quickly released), G Ramon Foster (chest), S Rob Golden (hamstring), WR Eli Rogers (toe) and LB Ryan Shazier (leg) were all nicked. Their status will be determined this week. Redskins WR Josh Doctson was a surprise late scratch with Achilles tendonitis. This injury has lingered from preseason and hopefully will not hamper him all year. Teammate CB Bashaud Breeland suffered a high ankle sprain. Bears RB Jeremy Langford left with an ankle injury. Contrary to some reports of Achilles injury, by video, his tendon is not torn. His return to play is yet to be determined but fears of his season being over are premature. Packer TE Jared Cook left with an ankle injury. Video was not clear as to diagnosis or when he might return. Giants CB Eli Apple left with a hamstring injury and his return is to be determined. 49ers CB Jimmie Ward strained his quad/thigh muscle and left the game. DeSean Jackson and Morris Claiborne both suffered different contusions and were able to return to play. Tony Romo helped warm up Cowboys with throws during pregame. At five weeks after L1 compression fracture, I expect to see him at practice at any time now in a red jersey. Romo is not ready to take a hit but he is ready to practice with a red jersey. Jay Cutler did not play with his UCL thumb injury as expected. Even though he doesn’t need surgery, expect his absence to continue as his ability to grip and spin the ball is affected. Patriots QB Jacoby Brissett’s thumb sprain has not been confirmed as an UCL and thus still has a chance to play next week. Either he or Jimmy Garoppolo (AC) is likely to be available for Week 4 before Tom Brady returns. Browns QB Josh McCown was announced with a hairline clavicle fracture in addition to AC sprain. His estimate to return is pegged at 2-4 weeks. WR Corey Coleman broke his hand in practice and will not need surgery but will miss 4-6 weeks. Jimmy Graham appears to be rounding into form after his patellar tendon tear last year. Titans G Chance Warmack's season is over after finger tendon surgery. The reason for IR is the post-op recovery protocol is extensive, thus making it impossible to play through, even thought it is just a finger. MMMD 7: ProFootballDoc scorecard Josh Mcown does have an AC sprain but he also has an unanticipated hairline clavicle fracture, so even though video was right, it was also wrong, so it will be counted as a mistake. Adrian Peterson did have a locked knee with bucket handle meniscus tear. He did end up with repair, which is better long term but longer recovery. There was much misleading info but scope and repair were always the likely outcome. DeMarcus Ware did have surgery for an ulna fracture and returns in a month. DeAngelo Hall confirmed ACL tear. Manti Teo will have Achilles tear announced soon. Jay Cutler did miss due to his thumb. Mo Claiborne and DeSean Jackson continued through contusions. Eddie Goldman was confirmed with high ankle sprain. Chance Warmack will miss the season with flexor tendon finger injury. The 39-1 record moves to 48-2 for a 96% average.