June 22, 2015 - Dr. David Chao
Monday Morning MD: Articular cartilage is the Holy Grail
Injury to articular cartilage has ended more NFL careers than any other physical ailment. Solving this medical problem would mean the Nobel Prize in medicine. Broncos LB Danny Trevathan said he “got somebody else’s kneecap” to solve this problem. That is hardly the case, although damage to articular cartilage of the patella is especially difficult to treat as it responds poorly to microfracture. Likely, he has a cadaver bone/cartilage plug (osteochondral allograft-OATS) that has been placed into his own kneecap. Whole-patella transplants don’t work and are just not done in the NFL or in regular patients. It is too difficult to anchor a floating bone to the tendon and get blood supply to regenerate in the kneecap. In medicine, anytime a first-time procedure is done, that means either it is a new condition that has never been seen before (highly unlikely) or there is no good solution to the problem and a new technique is attempted. My formal entry into the league involved performing a new cartilage regrowth procedure. In the mid 1990’s, I performed the first Genzyme Carticel surgery on a NFL player. After harvesting some of his cartilage and growing these cells in a laboratory, it was re-implanted. He did return to some football, but the procedure certainly cannot be termed a long-term success or we would all be doing the procedure routinely today. Articular cartilage is also Jadeveon Clowney’s problem. He had an initial knee scope to treat the meniscus tear and then had to have a subsequent microfracture procedure. By definition, the need to regrow cartilage indicates a down to bone lesion. I certainly hope he goes on to a productive career, but a full-thickness cartilage defect in a 22 year-old is ominous. The good news is Clowney is expected for the start of training camp. Despite being treated by his team physician who is one of the best in the country, the question is how long his new surface will last. The knee heals with fibrocartilage that fills in the defect and is never as strong as the original hyaline cartilage. I hope I am wrong, but even if Clowney lives up to his number one overall pick promise this year, he would have to beat the odds to make it to a second contract. Limited results with microfracture lead us to try new techniques. I hope Trevathan is the first, but in my two decades involved with the NFL, I am not aware of long term success of osteochondral allograft of any kind, much less in the patella. Despite medical advances, the orthopedic profession just doesn’t have the final answer yet MMMD 1: Additional Broncos health woes Last year’s injuries are not behind them and there are already new ones. Both inside linebackers, Trevathan (above) and Brandon Marshall (lisfranc, playing with screws in foot) are not past last season’s injuries yet. Left tackle Ryan Clady tore his ACL and is done for the year. Add to that first-round pick Shane Ray’s quad injury, when he already came in with a turf toe type injury that he is forgoing surgery on. Then, there is Peyton Manning’s quad tear (which should be fine) and his chronic neck/arm issues. If the Broncos don’t reach expectations this season, pre-existing and new injuries will likely be the culprit. MMMD 2: No surgery needed for Saints leading pass rusher Junior Galette was reported to have a pec injury and surgery was contemplated which would have meant injured reserve. I postulated that a report of split decision on surgery and early delay was potentially a good sign as there is no indecision with a complete pec tendon tear. He also was not too sore to wear a backpack with straps right across the anterior axilla where the tendon is located. It was reported that no surgery will now be needed at all, just time and rehab. Physically, Galette will be available to the Saints for the start of the season. However, he may face discipline for a brawl on a beach. MMMD 3: Will Todd Gurley be ready to go? When asked if his first-round pick coming off ACL surgery would be ready for training camp, Rams head coach Jeff Fisher said, “It’s hard to say right now.” A key to whether he plays early season will be if he starts the year on the PUP list. Everyone cites Adrian Peterson’s quick return after his ACL tear. That is an unfair comparison for Gurley. First, not all ACL injuries are the same. The associated cartilage, meniscus and ligament damage is rarely reported so we don’t know the true extent of injury. Second, in orthopedics, data shows that up to 95% of athletes can return to their same level. Gurley is not being asked to return to his same collegiate level, but make the jump to the NFL. He has two hurdles to clear in his rookie year. MMMD 4: Is any sport with contact safe from brain injury? Chronic traumatic encephalopathy (C.T.E.) has been diagnosed posthumously in other sports. Now it has been found in a 24 year-old soccer player with three concussions over 14 years. Whether his pain killer overdose is related to head injury is not conclusively proven. However, it only serves to heighten concern. There is still more we don’t know about concussions than what we do know. The ongoing research findings can’t come fast enough. MMMD 5: Is minicamp all that important? What does one really get out of minicamp? It is a mandatory assembly of all players, but practice is conducted in shorts. How important is it when teams like the Patriots, Dolphins, Chargers and others cancel the final practice? The big key is to avoid injury and most clubs seem to have done that. Minicamp concludes the offseason program. The training camp grind will come soon enough. MMMD 6: Slowest month of the NFL season As teams finished minicamp, the annual hiatus before begins. This is truly the slowest month of the year-round NFL. Players are off until reporting for training camp. Many team officials and coaches take their vacations. Last year, I continued to write the Monday Morning MD column to prove a point that there is never a lack of injury and health topics. After 80-plus straight weeks of full-length columns, I too may take a partial hiatus. The plan is to provide abbreviated weekly updates these next four weeks as opposed to the usual 1500 word treatises. MMMD 7: ProFootballDoc scorecard Last year, I had a successful prediction rate of 92.6% by being correct 137 out of 148 times. This year I will give a running tally to allow readers to perform an ongoing audit of my injury opinions. Based on reports of a split decision on surgery and an instagram picture. I correctly deduced that pec repair surgery and a spot on injured reserve would not be needed for junior Galette. Add to the Dante Fowler, Carson Palmer, Sam Bradford, Derek Carr and offseason injury correct analyses, that puts the 2015 season record at 6-0 to date. This is not gloating, as I am sure I will be wrong soon enough. This is simply a way to keep a running tally to allow for vetted statistics by 2015 season end. 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.