May 11, 2015 - Dr. David Chao
Monday Morning MD: 5-11-15
In wake of Pacquiao not disclosing shoulder problem, does NFL hide injuries too? Few sporting events rise to the level of the NFL, but last week’s long awaited Mayweather vs Pacquiao extravaganza was hyped like a Super Bowl and ultimately produced even bigger controversy. After defeat, the Manny Pacquiao camp revealed he fought with a rotator cuff tear and needed surgery. The sports word was abuzz, lawsuits were filed and the Nevada State Athletic Commission postulated sanctions. The reaction was interesting to me as NFL athletes routinely play hurt and hide injuries with little uproar. Sure there are league mandated injury reports but one would be naïve to think that all injuries are disclosed or the magnitude of health issues revealed. We all know NFL players are tough and they play through many small ailments, but I am talking about significant injuries. In Super Bowl XLIX, several starters played hurt and subsequently needed surgery. Seattle safety Earl Thomas stated his shoulder injury was a non-issue going into the championship event, even though it seemed significant to me. After the big game, the Seahawks revealed a labral tear and the need for surgery. New England linebacker Dont’a Hightower made a game saving tackle on Marshawn Lynch immediately before the goal line interception. The Patriots subsequently announced his shoulder labrum repair surgery after the season for this injury initially suffered in the regular season. Even injuries to star quarterbacks are routinely under reported or not reported. For the postseason, official status on Peyton Manning’s thigh were very optimistic, even though I suspected a major problem. After a poor performance and a quick playoff exit, a quad tear was revealed. Tony Romo had a much-analyzed back injury last season, but in December revealed a September/October rib fracture that was never listed on an injury report. I am not suggesting NFL teams break reporting rules. I am simply noting that this is how the game works. The requirement is only for disclosure of a body part and practice/game status. There is no mandate to disclose injury specifics or severity. The type of ailment or even indicating left or right is not required. Lessor injuries are often not reported. If that were mandated, by season’s end, almost the entire roster would be listed, and many with multiple body parts. Players don’t want opponents to know about their ailments. If one sprains an ankle and needs to be spatted (taped over shoe), it is routine to spat both sides to not indicate a side of injury. Like many NFL players, Pacquiao requested Toradol before the fight; however, he was denied. The medication is not on any banned list, but the boxing commission properly denied the shot as there was no declared injury. This is the same standard as usage in the NFL. The strong anti-inflammatory medication is used for a defined injury. If Pacquiao had declared injury, he likely would have gotten the medication. If a fighter had his own doctor there (which is routinely not the case), that physician could have legally administered the medication like in the NFL. The big difference between boxing and NFL is that a game can’t be postponed due to injury. Reports indicate Pacquiao knew of his shoulder injury weeks before and even took a cortisone shot. I don’t know if his shoulder was hurt badly enough where he should have postponed, or if he was right to choose to fight through it. In any case, you know the public relations campaign is on anytime a person physician gets involved to reveal patient information as is the case here. I don’t doubt the injury, but it is unlikely he boxed with a full-thickness rotator cuff tear. Even his surgeon who has spoken extensively publically on the surgery has not indicated that. I am not an attorney, but suing over the Pacquiao non-disclosure of a shoulder injury seems frivolous. We watch sporting events like football games all the time where athletes are less than 100% where the viewing public is unaware. MMMD 1: Third pick in draft tears ACL in first rookie practice Dante Fowler, Jr. was the first non-quarterback selected in this year’s draft. The unfortunate injury occurred in a full-speed non-contact practice. These are changing times with immediate information access. I came out of my day job of surgery to multiple texts from media insiders and tweet notifications with video links of the Fowler injury. Unfortunately, my interpretation of the injury mechanism was ACL tear. Hats off to the club for quick diagnosis, treatment and confirmation. Team physicians are not always at every practice, but the Jaguars have an excellent head ATC in Scott Trulock. He likely knew the diagnosis immediately from on field evaluation but within hours confirmed with doctors and MRI before announcement. Fowler will need ACL reconstruction surgery. Central one-third patella bone-tendon-bone graft is the preferred and common graft choice among NFL physicians. The hope is for an isolated injury without cartilage or meniscus damage in order to have the best long-term knee. MMMD 2: Dante Fowler had not signed contract, but Jaguars will not stiff him Rookies commonly participate in minicamp without signed contracts; however, there is no financial worry. Teams routinely will honor the slotted contract values. If they didn’t, no rookies would participate in practices. Besides teams acting in good faith, typically a rookie participation agreement is signed. This binds the club to negotiate in good faith as if the player weren’t injured. MMMD 3: Star linebacker spring ACL tear for third straight year Dante Fowler is not the first star linebacker to succumb to a minicamp/OTA ACL tear. In fact, it has happened three years in a row. Last May, the Cowboys’ Sean Lee tore his ACL and also had practice video document the injury. In 2013, Chargers linebacker Melvin Ingram tore his ACL in May as well. Fowler has an outside chance to return to play for the Jaguars this season. Ingram returned in December, seven months after injury. However, he was in his second season and his team was in the playoff hunt. It may be wiser to sit the rookie, especially since video shows a likely MCL component to the injury as well. MMMD 4: May injuries unfortunately common Expect more minicamp and OTA injuries to come. Injury is part of the game, but it is even a part of spring football. In my two decades of NFL team physician experience, the vast majority of years, we suffered at least one season-ending injury during the spring. Injuries varied from ACL tears to Achilles tendon ruptures. The key to team success is that it didn’t happen to a key starter. Anecdotally, ever other year, a key contributor went down in minicamp/OTA. It may just seem like there are more injuries nowadays, as there is so much more instantaneous coverage. Mid and late-round picks get extensive coverage now too. (see next) MMMD 5: Call for rules changes? Broncos tight end and third-round pick, Jeff Heuerman tore his ACL in rookie minicamp as well. He was reportedly running on a non-contact special teams play. Immediately combined with the Fowler injury, there were calls for a rookie period of weights and conditioning before minicamp practices. Although honorable in intention, I don’t think Fowler or Heuerman were out of shape or ill-prepared. I have previously pointed out how there has not been the expected drop in ACL tears with the new CBA mandating less practice time and contact. However, ACL tears most commonly happen with cutting at high speed without contact and that is what practices focus on these days. MMMD 6: Projected first-round pick now revealed to have worse injury Former Oregon star Ifo Ekpre-Olomu was a projected first round draft pick until he injured his knee. As a cornerback who needs to react to be effective, an ACL tear already made him a “RED light” issue in my mind. Indeed he dropped to the seventh round. It turns out there is more to the story as his injury is now reported to have been a knee dislocation in addition to ACL tear. With this information, Cleveland is really taking a seventh-round flyer with this potentially career-ending injury. In 2013 San Francisco drafted Marcus Lattimore in the fourth round after his knee dislocation hoping he could ultimately get healthy. Unfortunately, the 49ers' running back never saw the field in two years and retired. We all hope the same fate doesn’t befall Ekpre-Olomu. MMMD 7: Running record I have written about the accuracy of real-time video injury analysis last year. It is far from perfect, but I documented being correct 136 out of 148 times. I have actually adjusted the record to 137-11 as I tweeted real-time while attending the Super Bowl that I was worried about Jeremy Lane’s knee when he left the game. He obviously broke his arm. [caption id="attachment_63314" align="alignright" width="316"] Jeremy Lane's arm break[/caption] However, several weeks after the Super Bowl, Lane was announced to have ACL surgery. Thus I am closing out the 2014 season with a 137-11 record. This year I will keep a running tally here of correct and incorrect video analysis. This way, the public can see how I grade and arrive at my final statistics. It also will provide a forum to critique how I am self-grading my injury assessments. Unfortunately, my initial analysis on Dante Fowler proved correct with an ACL tear and we start 2015 season with a record of 1-0. 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.