September 12, 2016 - Dr. David Chao
Monday Morning MD: Second opinions routine
Week one of the 2016 season was relatively healthy but there still were the inevitable injuries. Despite an opening night victory, Broncos fans fretted about star WR Demaryius Thomas’ left hip and his reported second opinion. Does a second opinion mean trouble? Not really. Getting someone other than the team doctor to evaluate a player is a mantra the NFLPA tells every agent to always do. In almost two decades in the NFL, I witnessed the second opinion rates skyrocket, even for routine injuries. It is not something that I discouraged as a team physician as transparency was important. In this case, there are several additional reasons that Broncos fans can relax. First, Thomas injured the hip in the first quarter and finished the game. Next, he is not technically seeking another examination of his hip, rather just sending his MRI out for review. A true second opinion would involve Thomas visiting with another doctor. That does not seem to be the case here. If the player/agent were worried, Thomas himself would have headed somewhere, especially with the extra time having played on Thursday. The MRI is always read by an independent radiologist anyways and that doctor has usually never met or examined the player. Technically, any further impressions would constitute a third opinion. Some still worry that the MRI would not be sent unless there was an issue. In my experience, over 50% of the time, agents would routinely request sending the MRI to a “players” doctor regardless of findings. By video, the early game internal rotation injury did not seem significant. Thomas finished the game with four catches for 48 yards. In any case, no surgeon operates solely based reviewing a MRI. If there was worry about a hip labral tear, the second opinion doctor would have wanted to see the player. Media and twitter speculation of surgery are very premature. This seems to be a case of over worry. Second opinions are routine. Sending the MRI for an additional set of eyes is extremely common. In this information era, sometimes too much information creates what I think is unnecessary worry. MMMD 1: Chargers lose game and star receiver The Chargers were the week one surprise when they jumped out to a 21-3 lead while dominating the home team Chiefs. Then Keenan Allen went down without contact, was carted off and everything changed. Allen was visibly distraught, but I go off injury mechanism not player reaction. We all hope his ACL was spared but several reports indicate the worst case scenario. Head Coach Mike McCoy said ACL tear was suspected but saying further test with a MRI upon return to San Diego was needed. We can all hope for the best but physical exam is very accurate on the field and I always knew a ligament tear by feel. The MRI was done more to determine associated injury. Last year it was a kidney injury and it looks like this year a knee injury will end Allen’s season prematurely. MMMD 2: How bad is Russell Wilson’s injury? Seahawks fans continue to worry about their star quarterback’s ankle injury. By video, it was a high ankle sprain type mechanism, but appeared to be mild. Wilson was able to finish the game. High ankle sprains are the dreaded type that can have a player out for multiple weeks; however, like all injuries, there are different levels of severity. Wilson was seen in a boot after the game and that is commonly used to control swelling overnight. The fact that he was putting weight on it and out at a restaurant were good signs as well. A more severe high ankle sprain would have necessitated crutches and at home ice/elevation/compression. The worry is how much swelling there will be the next day and this will be the key. Expect Wilson to be limited in practice but I also expect/hope he will be ready for Week Two despite early reports to the contrary. MMMD 3: Cam Newton concussion controversy It didn’t take long for the NFL to have this years “Case Keenum” type head injury controversy. As expected, threats of fines and loss of draft picks have not changed anything. Adding a second ATC spotter makes an impossible role a little easier, yet the process is far from foolproof. The concussion protocol continues to be confusing and the optics of the Newton situation are not good. There was an unsubstantiated report of an on field medical check, but no mention of it by Newton, no video proof, no media eyewitness accounts nor league statement confirming the on field check was done. The NFL should allow the spotters, referees & unaffiliated neurotrauma consultants to speak or release a statement on their mindset. Short of that, it just looks like the league is hiding something. Now the NFL and NFLPA will conduct separate investigations. Lets see if the up to $150,000 fines for a first time event happen. I doubt that it will. MMMD 4: Injury rundown Texans LB Brian Cushing left the game with a knee injury later reported to be a MCL where he is said to miss six weeks. By video, this injury actually occurred on the very first defensive play with friendly fire and Cushing played nine more plays to finish the opening defensive series before leaving the game. This is the other knee from his previous ligament damage. I don’t believe the injury to be severe and fully expect Cushing to return well before six weeks. Patriots TE Rob Gronkowski missed the opener with a four-week old hamstring issue. He has been at limited practice so I expect him to be close to playing, although severe strains could have a player out 8-12 weeks. Playing a road game without Gronk, Brady, Lewis, Vollmer, Solder, Ninkovich and with Chandler Jones trading sides, the minus-2 turnover ratio still didn’t keep the Patriots from winning. Falcons WR Julio Jones re-sprained his same left ankle. Fortunately it is a low (not high) injury and he should be healthy enough to play next week. Browns QB Robert Griffin III injured his left shoulder but finished the game. By video, he likely has a mild AC joint sprain and should not miss time. Viking QB Teddy Bridgewater was confirmed to have a multi-ligament knee injury. Saints CB Delvin Breaux fractured his fibula. No announcement yet but expect surgery and IR as real possibilities. Giants WR Victor Cruz and Ravens TE Dennis Pitta overcame long odds of missing two NFL seasons and returned to play for their respective teams. Packers WR Jordy Nelson and Panthers WR Kelvin Benjamin took advantage of their extra recovery time with their preseason 2015 ACL tears making successful returns. Running backs Dion Lewis and Jamaal Charles who were injured mid-season did not make the opening week bell. Texans DE J.J. Watt kept his streak of never missing a NFL game alive. As expected, he was only minimally effective and not the usual dominant player. Seahawks TE Jimmy Graham overcame odds to suit up after patellar tendon rupture. In limited action, he produced one catch for 11 yards. Cardinals G Evan Mathis injured his left foot, tried to continue playing but couldn’t. This may be a big blow to the offensive line. Seahawks RB C.J. Prosise was in a cast for a wrist sprain despite no broken bones. He will have limited availability. Jaguars RB Chris Ivory was hospitalized for a general medical issue before the game. Here is hoping he is OK and there is nothing related to his calf injury like a blood clot. MMMD 5: Injury reporting confusion Week one saw a big change with the new rules eliminating “probable”. With the help of medical followers, we documented that league-wide “questionable” lists more than doubled for the first week 2016 vs 2015 (82 vs 39). With a player 99% likely to play lumped with someone who is 50-50, this surely will cause confusion. For example, Andrew Luck was described by his head coach as “absolutely” playing yet he was listed as “questionable”. I don’t see the advantage of this new reporting system where less information is given. MMMD 6: Future expansion to London Many speak of the travel being unfeasible for an overseas team. This weekend, the Dolphins travelled to play the Seahawks. A flight from Miami to Seattle is longer than if the Patriots were to fly to London. With some scheduling accommodations, a London based team seems inevitable. MMMD 7: ProFootballDoc scorecard Thankfully, this was a relatively good injury week. Carson Wentz rib injury was not an issue. Kyle Long was reported to play through labral tear issues that likely will require surgery at season end. Teddy Bridgewater was confirmed to have a multi-ligament knee injury. This takes the 25-1 record to 28-1 at 96.6%.