August 10, 2015 - Dr. David Chao
Monday Morning MD: ACL re-tear trend continues
Typically after anterior cruciate ligament (ACL) reconstruction surgery, the chance for ACL tear is higher on the opposite side. That was not the case last year for Sam Bradford or Jake Long, both of whom re-tore the same knee ACL from the previous season. Now the Eagles Travis Long has re-ruptured the same knee ACL two seasons in a row. What is going on here? Although Bradford and Jake Long had the same surgeon, I don’t know the re-tear is related to poor surgical technique. In 2008, Philip Rivers returned to mini-camp practice exactly 100 days from ACL surgery and set a career high QB rating, but that was hardly the norm. That same year, Tom Brady tore his ACL and needed most of the 2009 season to round into form. Recently with the 2012 career performances of Adrian Peterson and Jamaal Charles after ACL surgery, the expectation bar has been raised. Peterson and Charles weren’t the first in sports to recovery quickly. As early as 2003, Shannon McMillan played in an international soccer match 102 days after her ACL tear and at four months played for the USA team at the Women’s World Cup. As the 2012 NFL MVP coming off ACL surgery, the publicity of Peterson’s 2000-yard season has led doctors and patients to more often take chances at early return to play. More players taking chances at quick return, likely leads to more early re-tears. When an ACL is torn, it is not repaired, but instead is reconstructed. Instead of being sewn back, it is rebuilt with graft tissue. That graft needs to incorporate and new tissue must grow up into it like ivy up a lattice. Another way to look at it is the graft is the stake that supports the sapling tree, but ultimately the tree trunk itself must become strong. This process takes well over a year and is why I tell my patients it takes over 18 months after surgery for the ACL to be as strong as you can be. Despite my cautions to them, Rivers and McMillan still chose to push the envelope for early return. It worked for them, but there is risk It is probably safest to sit out up to two years after an ACL but no one has the time to do it. When they see Peterson’s return, everyone thinks it is without risk and pushes ahead. Avoiding the use of a cadaver graft helps lessen the chance of re-tear as it has been shown by the ACL Study Group. However, any early return leads to unavoidable risk. In my experience, the highest risk for re-tear is at 9-12 months and that is when players are usually returning for the next season. That is why I recommend a brace. You can be a freak athlete, have the best surgeon and do the best rehab, but you can’t speed up biology. That means many successful quick returns, and unfortunately a few inevitable re-tears. MMMD 1: Eagles sports science can’t prevent all injuries The Eagles have some of the most progressive monitoring of players for prevention of injury. Last week, DeMarco Murray was held out of a practice because his hydration levels were reportedly high. I applaud the team’s efforts but despite best intentions, the Travis Long ACL re-tear still happens. Now DB JaCorey Shepherd is feared to have an ACL tear. The team doesn’t need the MRI to know the bad news, but will still get it to confirm. [caption id="" align="alignright" width="252"] Michel Floyd in large post-operative splint/dressing[/caption] MMMD 2: Injury rundown Michael Floyd, WR Cardinals, had early reports of three finger fractures, which were later called dislocations. Later an instagram post showed him in a big post-operative dressing saying surgery went well. The team reported that he would be out 3-4 weeks. You can’t judge a book by its cover and one can’t look at the post-operative splint to know exact recovery. However, based on the positioning of his fingers, construction of the splint and what may be the ends of covered pins, Floyd could be out for longer. Most finger dislocations are reduced by trainers on the field and never see a doctor. Floyd had three dislocations severe enough to require surgery, meaning that either the bone was fractured, sticking through the skin or both. Either way, 6-8 weeks seems a more likely return target and head coach Bruce Arians subsequently wouldn’t even put a timetable on it. Dee Milliner, CB Jets, had wrist surgery and will be out 6-8 weeks. Antonio Allen, S Jets, has an apparent Achilles rupture and likely out for season. DeSean Jackson, WR Washington, left the joint Texans practice with a grade 2 AC separation and is reported to be out 1-2 weeks or longer. Fred Jackson, RB Bills, is out nursing a hamstring strain. Star Lotulelei, DT Panthers, out for several weeks with stress reaction in his foot. Hopefully it does not progress to a stress fracture. Patrick Peterson, CB Cardinals, has Type 2 diabetes, but with proper treatment, should not affect his play. LeGarrette Blount, RB Patriots, is out several weeks with a MCL sprain. Jesse Williams, DT Seahawks, had a kidney removed for cancer and has now returned to practice. Jason Pierre-Paul is reported to be in communication with Robert Nunn, his position coach. Nat Berhe, S Giants, tore his calf muscle. Depending on severity, gastrocnemius injuries tend to linger and Week 1 may be in doubt. Brett Urban, DT Ravens, tore his biceps and had surgery. He has a chance for IR/dfr and to return this year. Earl Thomas, S Seahawks was activated off PUP as expected and should easily make the season opener. MMMD 3: NFL’s first chief health and medical officer interview Betsy Nabel had her first sit down interview with CNN’s Dr. Sanjay Gupta and she presented herself well as I would have expected. When her appointment was announced, some were critical that she was a cardiologist and had no ties to football. I felt the fresh look that she would bring could be a positive. Dr. Nabel spoke about her first three months on the job but according to an earlier MMQB interview, it really was her first three days on the job. She formally spends one day a month on the NFL job, but will also spends time on evenings and weekends. With such an important job and with the NFL spending over $2.5 million on the Deflategate investigation, one has to wonder why more formal time isn’t devoted in this health and safety era. MMMD 4: Importance of mental health It goes without saying that Sydney Seau stole the show at the Hall of Fame enshrinement ceremony. However, I hope the message delivered by inductee Charles Haley is not lost. Junior Seau’s legacy is well documented and fellow inductee Mick Tingelhoff has dementia. Haley admitted to bipolar disorder. His message was to seek help with all mental health issues, I hope his fellow players will listen. MMMD 5: Medical timeout rule could be called Edelman rule In explaining the new rule, the NFL cited the Julian Edelman Super Bowl situation where he remained in the game despite the spotter calling down twice. As I pointed out then, despite perception, the Patriots followed the concussion protocol as there was no mechanism to stop the game. The new medical timeout rule is aimed at preventing a re-occurrence of this situation but may raise its own new issues. With the greater power of the spotter, the league recognizes that the appointed “eye in the sky” has to be neutral. The athletic trainer selected can no longer be a former NFL team employee or resident of the home team area. Although this is a good move on the league’s part, I still expect the medical timeout rule to cause its own controversy before the season is over. MMMD 6: Poor field conditions for both Bay Area teams Being the only dual use stadium left in the NFL, the Raiders home turf with the baseball infield dirt has been called a travesty. Levi Stadium field is less than ideal as well. The new 49ers home had problems last year and more turf issues popped up again. The Raiders problem is harder to solve without a move as the A’s signed a 10-year lease in 2014. Hopefully no one is injured by poor footing in the Bay Area. MMMD 7: ProFootballDoc scorecard I thought my 10-0 record on analysis was finally spoiled. Although there was no video, the description of Arian Foster’s groin injury lead me to believe it wasn’t a true adductor avulsion type injury as initially reported by media, but more of a sports hernia type. I was immediately contradicted by reports of surgery to reattach muscle to bone and I thought I would be proven wrong. As it turns out, it was exactly as I thought and sports hernia type procedure was done meaning a much quicker recovery and the possibility of not needing IR/dfr. Ravens safety Matt Elam did turn out to have complete distal biceps tear as anticipated. Bengals defensive end Michael Johnson was carted off for his knee and the worst was feared. Based on media reports of a good physical exam, I correctly surmised that there was no need to worry about an ACL tear on the MRI. Bears first-round wide receiver Kevin White’s absence was anticipated to last weeks, not days as some were expecting. Although he may test out his shin splints running next week, clearly the day-to-day watch for a return has turned into week-to-week with the possibility of reserve/PUP on the table. Quite frankly I am surprised at the now 14-0 record. When a 92.6% correct ratio for last season was quoted, some readers suggested I track it to have vetted numbers. I promise to report when I am incorrect as well, which is undoubtedly coming soon. 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.