Monday Morning MD

The most anticipated medical evaluation for this year’s Scouting Combine was Todd Gurley. As a top draft prospect coming off ACL surgery, draft boards could change based on the results. Initial reports indicated the running back refused the physical, but that is just not the case. In 19 years of attending Combine and performing orthopedic examinations, I have never encountered or heard of a player that refused the physical. The medical evaluation is the main reason for the Combine and is the only chance for all teams to perform full medical testing. It would be silly for any player to refuse the physical examination and Gurley did not do that. He completed all other parts of his physical but simply requested to delay hands-on knee exam for the medical rechecks to be held in six weeks back in Indianapolis. Usually 40-50 players with pending health issues will return. Typically these are players coming off of surgery or ones with recent injuries. Gurley participated in all parts of the medical evaluation except he did not have manual tests on his reconstructed knee where surgery was only three and a half months ago. He likely also refused Cybex and KT1000 testing as these physical maneuvers could stress the graft. A MRI was performed on the knee. He completed the orthopedic physical in all other ways. He also completed the standard medical evaluation where heart, lung, abdomen, EKG, blood tests etc. are done. Gurley’s request was not unusual or unreasonable. In my experience, each year there would be several players that would make similar requests. Repeated physical stress on a recently reconstructed ACL can cause soreness and could stretch the graft. In addition, recent shoulder labral or rotator cuff repairs also fall in this same category. These players will be re-evaluated in six weeks. In the orthopedic exam, Gurley could have more than 32 doctors tugging forcefully on his knee. Some teams will have more than one doctor examine a player. During an anterior drawer test for ACL stability, a doctor will sit on a player’s foot and pull forcefully on the knee with both hands. The ACL exam can be performed gently. I actually feel it is more accurate done that way and one can feel subtleties. I teach my fellows to examine gently but old habits die hard. The majority of doctors still perform it as they were originally taught in residency, which is quite rough and can make a knee sore if done repeatedly. Another way around this problem could have been to designate one doctor to perform a gentle knee exam at Combines and share his findings while other doctors could witness the process. Gurley has chosen to just wait and let all teams have a chance at the same time at the medical rechecks. Other testing is sometimes also deferred by players. Prospects have refused MRI evaluations due to claustrophobia. Putting big guys in a small tube can be disconcerting. Typically there are open scanners available or medication can be used to calm anxiety if really warranted. Gurley’s surgeon put out a supportive words touting how the ex-Georgia player is recovering ahead of schedule. He may indeed be doing quite well but these personal physicians letters mean very little. A doctor can only comment when allowed to by the patient; therefore, you will never see a personal doctor saying his player is doing poorly. Last year, a Washington team doctor wrote a support letter for Cyrus Kouandjio’s knee to other team physicians. The Redskins were in need of lineman and had the first pick on day two when Kouandjio was still available but traded out and did not select him even though their own doctor had written a positive letter. At this point teams will have to wait as they only have partial data on Gurley. The recheck Combine that is for medical personnel only will complete the picture. If he refuses manual knee testing in six weeks (which I highly doubt), that would then become a big story. MMMD 1: Jameis Winston throwing shoulder issue Jameis Winston’s shoulder is a relative non-issue. It is the job of team doctors to go over every player with a fine-toothed comb. Players commonly have multiple MRIs. If there is any question, the body part will be tested. If any single team doctor requests a further evaluation, that test is ordered. Winston apparently had an electromyogram (EMG) study that confirmed his nerves to his shoulder were ok. He also had a MR arthrogram where die was injected into his shoulder. He complained on NFL Network about that needle stick being the only thing that made his shoulder a little sore and he had no issues. It is rare to find something that disqualifies a player but it is common to find an issue that downgrades a player’s medical grade. Winston appears to have a common thrower’s suprascapular nerve traction syndrome and doesn’t have a neurogenic or structural cause to his minor shoulder weakness. The EMG ruled out nerve issues and the MRI ruled out cysts, labral and rotator cuff tears. In this case, rehab to keep the shoulder muscles strong should easily take care of Winston’s minor issue. He certainly quieted concerns by throwing well at the Combine workout. MMMD 2: Amari Cooper did remove his shirt for examinations There was some initial rumor that Amari Cooper refused to take his shirt off for the physical examination process. I believe this was a misunderstanding and not a case of an athlete refusing to cooperate. Cooper did remove his shirt and was very cooperative in most of the six examination rooms where teams are grouped. Apparently there was a minor misunderstanding when he started the process in one room. The seems to be an issue of high scrutiny for a top draft pick more than a player being difficult or defying authority. MMMD 3: No major surprises at Scouting Combine So far this seems to be one of the healthiest Combines in recent memory. There appear to be no big health surprises. No one was medically disqualified from participating in drills like Star Lotulelei was in 2013. Last year, Austin Seferian-Jenkins was discovered to need foot surgery and was held out of Combine workouts. Also, Cyrus Kouandjio fell out of being a top-ten pick into the second round due to concerns about his knee. Expect more Combine medical information to leak out over time. It is certainly not my role to call up my team physician friends to get them to spill the beans on players with medical issues. I wouldn't ask them to betray confidences and they wouldn't do it anyways. But when private health information becomes public knowledge, it becomes fair game and I will do my best to interpret that information. MMMD 4: Players do get injured at Scouting Combine B.J. Dubose injured himself during the 40-yard dash. He was reported to have torn his hamstring. Certainly that is tough luck and hopefully he can recover for his Pro Day. It does seem like every year someone is injured at Combine even though it is shorts and t-shirts with no contact. Previously, players have torn their ACL doing drills. Recently, a prospect tore his pectoral tendon during bench press testing and needed surgery. MMMD 5: Giants GM contradicts Odell Beckham medical claim Odell Beckham Jr. stated he played with two hamstring tears all last season. Giants general manager Jerry Reese contradicted that information by saying if his player were hurt he would have known about it. “I think he’s trying to be a hero.”  I don’t know if ODB was hurt or not. He certainly played well late in the year. There is no way he had complete tears but it is possible he played through minor partial tears. I am not saying he is embellishing his injury. Patients interpret what a doctor says to them differently. A lay person’s lack of full understanding sometimes leads to false impressions. What is unusual in this case is that his GM seemed to call out his player. Once a player (name purposely withheld due to privacy) claimed that he played all season with a broken hip. That was not the case but my team never corrected him. They let the player’s interpretation stand. MMMD 6: DeAndre Hopkins has major wrist surgery DeAndre Hopkins revealed his wrist surgery in a radio interview. By his description, it seems to be major surgery as he reported a ligament repair and still has pins that need to be removed. The most likely injury is a scapholunate ligament tear. That is an injury where he could play through to have it fixed in the offseason. If left alone, it would lead to long-term arthritis and loss of motion. Although this is major wrist surgery and he still needs pins removed, I don’t see it affecting Hopkins much for the 2015 season. MMMD 7: Blood flow restriction training Blood flow restriction (BFR) training has been around for decades. It is quite popular in Japan and is called KAATSU. Currently it is finally gaining some traction in the United States as the Texans are reported to use it. BFR training is also currently being tested in the military and by the US Swim team. US Ski team member Bode Miller is an early adopter. To oversimplify what BFR is, I call it poor man’s altitude training. Instead of thin atmosphere robbing muscles of oxygen, a tourniquet temporarily restricts blood (and thus oxygen). I have looked into this technology for years and met with Dr. Sato the founder of KAATSU on multiple occasions. I think there is promise with BFR training, especially in early post-op or acute injury patients to preserve muscle when someone isn’t in a position to do heavy exercise. BFR causes quicker fatigue and thus potentially increased benefit with much lower weight resistance. 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.
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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