Monday Morning MD: PUP watch is on

After an offseason of speculation of who will be healthy and who will not, the PUP watch is on. The eagerly anticipated news of the week will be who is placed on the Physically Unable to Perform (PUP) list, but what does it really mean? As previously explained, there are two types of PUP, Active (for the preseason) and Reserve (for the regular season). The other designation is Non-Football Injury (NFI) which is used for injures not occurring during NFL football, which includes collegiate injuries. One needs to be on Active/PUP even first, if only for a day, to be eligible for Reserve/PUP . Thus, is it not the end of the world if your favorite player is placed on PUP. For example, the Jets signed Muhammad Wilkerson to a big free agent contract but fans should not freak out, rather expect his appearance on PUP initially in case his ankle doesn’t respond as expected. It says more when a player is not on PUP than when he is. The Ravens announced six players were not ready for training camp, including Steve Smith (Achilles), Terrell Suggs (Achilles), Elvis Dumervil (foot), Breshad Perriman (“partial” ACL), Trent Richardson (knee scope, hamstring) and Jumal Rolle (Achilles). Notably absent from this PUP list was Joe Flacco coming off ACL surgery. This speaks volumes to the team’s confidence in their QB’s recovery. The Lions placed three players (WR Corey Fuller, TE Brandon Pettigrew, T Corey Robinson) on preseason PUP. The key is not that a player begins on PUP but when he comes off. Jordy Nelson is reportedly doing well and had almost an entire calendar year to recover from his ACL tear; however, don’t be shocked if the medically conservative Packers start him on PUP. Sometimes, it is just the team taking the precaution and leaving the worst case option of Reserve/PUP open if there is a setback. The Cowboys reportedly will start TE Gavin Escobar on PUP after a Week 15 Achilles rupture. The Bills will undoubtedly start Shaq Lawson on Active/PUP and convert him to Reserve/PUP to save the roster spot and get him back this season after shoulder surgery in May. There are some big names coming off injury: Jamaal Charles (ACL), Dion Lewis (ACL), Jimmy Graham (patella tendon), Thomas Rawls (ankle fracture), Sammy Watkins (Jones fracture) and Julian Edelman (Jones fracture). Don’t be surprised if many of these names at least start training camp on PUP. The key will be how long they stay on the list and unable to practice. The annual PUP watch is on. MMMD 1: J.J. Watt's back surgery isn’t the issue, rehab is Although back surgery is nothing to scoff at, the herniated disc procedure for the two-time reigning Defensive Player of the Year is relatively straightforward. The rehab of the core muscles for this injury is more unpredictable. While it is possible that Watt will play Week 1, it is very unlikely that he will be 100% until mid-season. The Chiefs’ Dontari Poe had a similar surgery and a late July 2015 time frame and indeed returned to play Week 1 but was not himself until much later. The disc procedure was undoubtedly in the lower lumbar spine at L5-S1 or L4-5 level meaning it affects the player’s base. In my NFL experience, it is harder for a power player like a defensive lineman to return to full effectiveness than a skill position. After all, playing on the D line is like wrestling a bear (or two). The Texans medical staff didn’t miss the injury and Watt didn’t delay surgery. Yes he played with a herniated disc (many players do) last season; however, it likely got worse, or extruded, leading the team and player to decide to be aggressive. Pulling the trigger now on surgery assures Watt being 100% for the critical parts of the later season. MMMD 2: Bell suspension minimal real effect on Steelers Le’Veon Bell is still recovering from his multi-ligament knee injury. In reality, the four-game suspension will just give him more time to recover and might not really be costing additional game time. Combined PCL/MCL injuries are harder to recover from than an ACL tear. Bell was likely to start training camp on active/PUP and work his way back in anyways. The biggest significance is that he will have to find his own rehab and workout place as he will not be allowed to be with the team during the first four weeks of the regular season. The Steelers are likely to factor in the suspension in deciding when to activate Bell. This is not illegal, as when Bell is ready to play is a subjective decision anyways. The bigger worry for Bell is that this counts as a second strike. A third violation would mean a one-year suspension. He needs to continue on random testing and this potential jeopardy could cost him in his pending contract status. MMMD 3: A change in stance on Jaylon Smith? The Cowboys have always expressed confidence in their high second-round pick’s nerve recovery. Has that now changed? Jerry Jones remained steadfast in his comments that Smith is not behind in his recovery; however, he did say “if it comes around” not when. This is the first acknowledgement from the team that it might not. Let’s all continue to hope that it does. MMMD 4: New IR/dfr rule The amended injured reserve-designated for return (IR/dfr) rule should benefit clubs and players. In the past, a team needed to designate the single slot with the initial roster move. Last season, the Steelers wasted their only IR/dfr slot on Maurkice Pouncey, as he was unable to return after his ankle fracture as he ended up with seven additional surgeries due to infection. This year, teams can place players on IR and not make the decision on which player they want to return until the player is ready to come back. This removes the worry of teams of using the designation too early in case a star player gets injured later or holding the spot and wasting it in the end. It also prevents using it on the wrong player, as in the case of Pouncey. This rule change is a good improvement. MMMD 5: NFL medical director “retires” Elliot Pellman, the longtime Park Avenue medical voice, has been asked to step down by the commissioner. Pellman and the NFL have made their share of mistakes over time. No one is going to shed a tear in his departure. People seem to want a “scalp”, rather than focus on a solution. Now they have Pellman’s so lets focus on fixes. Hopefully this signals a new era where the NFL, NFLPA, concussion researchers and media stop playing politics. The bigger issue is perhaps the NFL will now be forced to have a real medical advisor. I am not at all knocking current chief health and medical advisor, Betsy Nabel. However, working on a part-time basis one day a month is hardly enough time to tackle all of the health and safety issues in the NFL. Hopefully the new medical director can have the time and resources to truly lead the NFL where it needs to go. MMMD 6: Dennis Green passes away One of my early experiences as a NFL team physician was with the Dennis Green coached Minnesota Vikings in 1994. I had the fortune of taking my first NFL road trip with that special team. Besides Green, there were some great coaches on that staff including Brian Billick and Tony Dungy as well as future head coach Jack Del Rio who was playing at the time. Four players on that squad, Warren Moon, Randall McDaniel, John Randle and Cris Carter, would later be inducted into the Hall of Fame. I will remember Green fondly and may he rest in peace. MMMD 7: ProFootballDoc scorecard When Desmond Bryant of the Browns was announced with a pectoral muscle injury, I immediately indicated it was likely a tendon tear and surgery would be needed, essentially costing him the season. Unfortunately, this has come true, but the good news is he will recover 100% for 2017. When Muhammad Wilkerson broke his leg last season, I tweeted he would recover well and it would not have a negative effect on his pending free agency. Indeed, the Jets resigned him to a big contract as expected. This takes the 2016 record from 10-0 to 12-0.
Dr. David Chao
Two decades of NFL team physician experience including two Super Bowls and two Pro Bowls. Providing unique perspective to injuries and the NFL sideline/locker room. Successful orthopedic surgery and sports medicine practice in Southern California.

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