June 27, 2016 - Dr. David Chao
Monday Morning MD: Video is the history
Lesson number one in medical school is history is the most important part of a physical examination. Before touching the patient a detailed history is required. History for a traumatic injury is a description of the mechanism. What better description is there than actual video of the injury? Every day, I have at least one patient that shows me how they were hurt by showing me team, cellphone or GoPro video. This is the basis of my video injury analysis which was honed with 17 years of Monday morning visits to the video department to reverse engineer injuries I saw and examined from the day before. When I ran onto the field to tend to a player, my assistant physicians were trained to watch the video board for replays to see the mechanism of injury. Late in my career, sideline injury video was introduced for concussion but found to be more helpful for other injuries as it is difficult to judge head injuries by video. The English Premiere League has now introduced video to the field. Liverpool medical staff now have the injured player on the pitch in front of them, yet still rely on video. This further validates my use of video to assess injuries. Of course, I would be more accurate examining a player than just looking at video. Although I am flattered by some who say I never miss, that is hardly the case. During the 2015 season, I publicly documented 94.3% accuracy. Ten times my video assessment was not accurate, but it was correct on 165 occasions. Some injuries had inadequate visual evidence and I could not opine at all. When Jaylon Smith injured his knee on New Year’s Day, I tweeted my immediate worry about nerve injury. Later, video Smith posted of himself walking confirmed the peroneal nerve injury despite the player's denials. In the offseason there is limited video so I rely on other methods of deduction. A recent photo had Smith still with an ankle foot orthosis (AFO), indicating his nerve is still not functional. I am not diagnosing players on twitter. If I had any role in treatment or access to X-rays or MRIs, I would not be able to comment due to HIPAA privacy laws. I deal in insider knowledge, not insider information. I know the vast majority of medical personnel in the NFL but I never contact them for information, nor would they violate player’s privacy and tell me. When I am treating or have treated a player, I skip commenting specifically. For example, I did not comment on Drew Brees’ shoulder issue last year. On occasions when a team physician colleague discusses an injury with me, I no longer voice a public opinion. I also examined some players in preparation for the Combine and of course I did not comment on their collegiate injuries since I had the insider information. When I do speak about a player that I have treated, I have permission from the athlete or limit my discussion to publicly available knowledge. There is no substitute for an examination, but there is growing use of video on the field to help with diagnosis. The use of video in injury assessments is here to stay. MMMD 1: “Wide receiver” fracture revisited With all the prominent pass catchers who have suffered a Jones fifth metatarsal fracture, I proposed to rename the injury. Bears WR Marquess Wilson re-broke his foot and was announced to likely start on PUP. A second surgery is needed up to 20% of the time as has happened to Dez Bryant and Julian Edelman recently. Bryant has been recently cleared as his second procedure was in January. Edelman’s timeline is tight as his second screw insertion was reported in May. Sammy Watkins had April first-time surgery and may not be ready until the first game. Remember, this fracture happens due to a “watershed area” in the bone where there is limited blood supply. This fact also makes healing more tricky. MMMD 2: ACL mental hurdle Anterior cruciate ligament reconstruction presents physical and mental hurdles. I wrote about this in my MMMD extra: ACL surgery series weekly during the 2014 offseason as I chronicled what the recovery for Von Miller and Rob Gronkowski might be like. Joe Flacco’s admits his biggest remaining hurdle is mental. Until a player gets hit on the knee and momentarily thinks he re-tore the ACL, but gets up to realize his knee is ok, he will always have doubt. Despite many early returns to sport, the mental hurdle to feel the knee is 100% as well as the biology of ACL graft incorporation makes the second year back the better year. The scary thought is that Todd Gurley should be even better this season. MMMD 3: Doctors held to higher standard than lawyers Johnny Manziel’s attorney mistakenly texted an AP reporter violating attorney/client privilege. If a medical professional breached doctor/patient confidentiality, there would be stiff potential penalties. Even if the medical information was leaked accidentally and inadvertently, there are HIPAA penalties up to 50k per single occurrence. Although just as damaging to Manziel, there are no such fines for a legal transgression of this type like there would be for medical leaks of information. In both cases the aggrieved party can take their own legal action, but only medical has built-in penalties. MMMD 4: Offseason program over, injuries still coming Players and coaches are essentially off for a month before training camp begins. The medical work continues as well as the injury announcements. This year just under half of teams lost a significant player to injury this offseason. Add Saints CB Kyle Wilson to the list who has been placed on Injured Reserve with a shoulder labral injury. MMMD 5: Cautionary tale for stem cells All stem cell treatment is not the same. Most stem cell treatments are illegal in the United States due to safety concerns. Unregulated stem cell treatments can have disastrous consequences including developing tumors in your body. Only one’s own un-manipulated stem cells are legal in the US. Any other form is either not truly stem cells or is being performed illegally. There are some legitimate cutting edge clinics outside the US, but many more are dangerous shams than the real deal. MMMD 6: Be true to yourself One of the lucky things from my almost two decades in the NFL is to have met many great people and worked for many great coaches. What I learned is that one needs to be true to one’s self to be successful. I worked under hard line leaders and nice guy players’ coaches. Both styles work if you are real, as players will see thru any false pretenses. Mike Riley was a genuinely nice guy and the players loved him for it. Riley recently made news when he met up with a rape victim who harbored hatred for the coach and instead became a “friend and ally” by genuinely caring. Riley is just a really good human being. Being genuine and true to yourself is the key. Hip hip hooray! (Those who have played for Riley will know what I am referring to.) MMMD 7: ProFootballDoc scorecard When Calvin Johnson posted gruesome pictures of finger surgery, speculation arose of his potentially coming out of retirement. I wrote last week that having the procedure meant the absolute end of Megatron’s football career. Contrary to the thoughts, that type of finger surgery is only done when a player retires due to the long recovery. Johnson indeed has now emphatically confirmed that he is not coming back. The previous 2016 record of 8-0 now increases to 9-0. I will continue to publicly keep track of right and wrong analysis this entire season.