Monday Morning MD: Doctors in the hot seat

In this era of NFL health and safety, the pressure on medical personnel has increased exponentially. Ask Washington’s independent neuro specialist, who resigned after the Robert Griffin III concussion controversy. I do not personally know this doctor, who is jointly appointed by the NFL and NFLPA, nor do I know his exact reasoning for leaving his post. I do know he has been unfairly criticized for “reversing course” or flip-flopping about clearing RGIII as if he was influenced by the team or was incompetent. He anticipated clearing the player based on information he was given, but when he actually examined the Redskins QB, the doctor decided to withhold clearance. What is wrong with that? This is no different than a GM telling an agent he wants to sign a player but after seeing the workout, taking a pass. In this day and age, the neuro specialist probably should be applauded for taking the safe route for the athlete. Instead he has undergone intense scrutiny from media and criticism from a former soccer player/patient. I don’t know what his decision making process was on RGIII but when is being safe with concussions (especially in the preseason) worth being vilified over? With HIPAA privacy laws, the doctor is not allowed to speak up to defend himself on the medical facts of RGIII or the former soccer player, as all medical information is strictly confidential. Judging concussions is a thankless job. The “porridge” is always “too hot” or “too cold”. Doctors are asked to immediately judge what the “temperature” of the brain might be an hour or more later. Concussions are like snowflakes: each one is different. Symptoms don’t always show up immediately. As an orthopedist, I never examined concussions in the NFL. As a head team physician, I always asked my primary care team physicians why they even wanted to do it. There is no winning in evaluating head injuries. Remove a player at the exact right moment to protect him from further injury and when he has no symptoms going forward, he blames you for being too conservative. Properly allow a player to return and he takes a new unrelated hit, suffering a concussion and the doctor is blamed for allowing second-impact syndrome. Rightfully return a player whose exam is completely normal and if he develops symptoms later (which is common), the physician is crucified. It is a no-win situation. Although adjudicating concussions is far more important than making touchdown or penalty calls, I often compared it to refereeing. The regular referees were criticized for doing a poor job and locked out in 2012. When the replacement referees where put in place, we all realized how hard a job it is and the original men-in-stripes were welcomed back. The same is likely to happen with those responsible for judging head injuries. Currently the hot seat is being transferred to independent sideline neuro specialist and the “eye in the sky”. As they have more power, they will have more scrutiny. Even with the new medical timeout rule (which I applaud), I have predicted more controversy to come. Typically, physicians selected for this or any NFL position are respected medical practitioners with booming private practices and their NFL roll is only a tiny part of their income. I am not suggesting the new Washington neuro is not quality but at some point it may not be worth the hassle and public second-guessing for a quality doctor to do the job. I am aware of three situations over the last several years where a doctor has turned down a team physician role just for that reason. It can be a time consuming, thankless job with people criticizing without knowing the facts. On the one hand you have current players pushing you to get them back to play at all costs. On the other, you have former players potentially suing for doing what they asked you to do. No team physician has been sued over the concussion lawsuit or pain killer lawsuit but there is fear among the medical profession that the day is coming. There always will be docs willing to do it, especially because the notoriety can build their reputation and patient volume. However, that may lead to lower quality physicians that might be tempted to do what it takes to keep the job; not ones that are doing the right thing for patients/players. The resigning doctor’s last NFL duty will be to finish his job with clearing RGIII. My guess is he just hopes to return to the normalcy and anonymity of his private practice. (Sorry, I broke my promise from last week to discuss “sports science” and how analytics can or can’t help prevent injuries like ACLs. I will do so in near future. I just felt the timely discussion with RGIII's doctor’s resignation took precedent) MMMD 1: Rosters not set in stone, IR and IR/dfr can free up spots Saturday’s final cut down to 53 is not really final. There are always more moves to be made, especially as teams may covet another club’s released players. A day later, the Broncos released their 2013 second-round pick, Montee Ball, to make room for a rookie tight end. Another way to clear roster space is by utilizing the injured reserve (IR) designation. Rib fractures typically don’t land a player on IR but the Dolphins choose to utilize their only designated for return (DFR) slot on running back Jay Ajayi. He likely would have returned prior to the IR/dfr mandatory eight-week absence with a broken rib (unless he had unreported lung injury), but clearly Miami needed the roster spot to sign QB Logan Thomas, so the decision was made. The Titans choose a similar move with running back David Cobb’s calf injury to create room for healthy running back Terrance West. MMMD 2: How are injury settlements reached? A player released injured is paid by prorating salary based on projected number of weeks he is not able to play football. Contract amounts are already determined. The only negotiation, second opinion and jockeying are performed over the number of weeks a player is projected to be out. An injury grievance can be filed by the player if cut injured or unable to reach injury settlement. MMMD 3: 49ers roster blunder? I am only asking the question and not accusing anyone in San Francisco of erring. Kendall Hunter tore his ACL last year and passed his physical to practice day-one of training camp. Ultimately, he ends up on IR for the same knee. If he had entered camp on the preseason physically unable to perform (PUP) list even for a day, Hunter would be eligible for reserve/PUP and a later season comeback. By practicing the first day, he does not qualify for regular season PUP and was placed on IR with no chance to return. I don’t know if not holding him out for a day was a medical, coaching or front office decision, but doing so would have made him eligible for a second half return. Perhaps his regression was truly unanticipated and there was no preseason worry. However, this is why many teams take the PUP precaution and hold out players coming off injury for a day or two to start, just in case. MMMD 4: If they let me sign Drew Brees… Medical decisions sometimes can change the course of a franchise. Nick Saban said, “I might still be in Miami” if Dolphins team doctors hadn’t nixed the deal. Instead he left for Alabama and the Saints got Brees and a post-Katrina Lombardi Trophy. I am not criticizing the decision of the Miami doctors and I can’t discuss details of the injury or surgery. (As the San Diego team physician at the time, the Chargers already made their choice when they acquired Philip Rivers by trading first-overall pick Eli Manning with Brees already on the roster.) I am only stating that medicine is an inexact science, like drafting is an imperfect discipline. First-round selections doesn’t always end up in the Pro Bowl. Sometimes a medical decision changes a franchise's future as much as a boom or bust high draft pick. MMMD 5: Quick hitters Julius Thomas finger surgery is likely a boney mallet finger that failed conservative care. Expect a 4-6 week recovery. Johnny Manziel is throwing, but not a football yet, due to his tendonititis, but don’t expect this to be a big issue. Kiko Alonso is right. Patella tendonitis is common after ACL surgery, especially when using bone-tendon-bone autograft of the central patella tendon. Typically, it is manageable to play through. Jason Pierre-Paul is reporting to the Giants soon. He expects to play early in the season, but not the opener. I hope that is the case, given all he has been through. MMMD 6: Jarryd Hayne re-ignites rugby vs football debate With the Rugby star making the final 53 for the 49ers, comparisons about the English sport that spawned the American sport abound. For decades, I have been asked about the differences and similarities between rugby and football. In addition to being an NFL team physician, I have the fortune to be involved as a team physician for the USA Rugby 15s and 7s teams. In 2008, the show Dhani Jones Tackles the World had an NFL linebacker playing rugby in England for a week. That spurred a lot of debate in the NFL training room amongst players. In my opinion, Rugby Union (15s) and the Olympic form (7s) are harder to teach a football player than for a rugby player to learn the specialized and compartmentalized game of football. I have seen it first hand with USA Rugby. Football players have attempted and succeeded in the transition to rugby but it does not occur as quickly as with Hayne’s crossover. Of note, Hayne was a Rugby League star in Australia, which is a much simpler game. Football maybe be easier to learn but it is harder to play. There is also the fundamental difference of the aerobic quick burst sport of football vs the anaerobic continuous game of rugby. MMMD 7: ProFootballDoc Scorecard Tom Savage was dumped on his throwing shoulder with a classic AC joint sprain mechanism. With the force of the injury, the bigger worry was clavicle fracture, which fortunately was not the case. He suffered a severely separated shoulder and is now out on IR for the rest of 2015. In early August, John Fox said Alshon Jeffery’s calf injury was day-to-day. I indicated at the time, that was likely “coach speak” optimism. He now has carried the day-to-day label for 26 days without practicing or playing. The hope is the Bears were just being conservative to try and prevent a lingering injury, but in any case it was hardly a day-to-day injury. Last season, Dennis Pitta suffered his second dislocated hip without contact. Medically, that was a bad sign. Hip dislocation typically requires severe trauma with resultant articular cartilage damage. I postulated at that time that Pitta’s career was in jeopardy. Unfortunately, he has now been been placed on PUP with no return in sight. When Arian Foster injured his groin and required surgery, reports indicated the end of his season or three-plus months recovery. Before his announced surgery I anticipated a sports hernia type procedure with quicker recovery as opposed to a true groin tendon repair. Now it seems that there was no need for the doom and gloom and there will be no IR or IR/dfr, as he is reported to return in the first few weeks of the season. Maurkice Pouncey having a high-ankle fracture was already shown to be correct. Now that he has been placed on IR/dfr as postulated, I won’t double count his status. I also won’t score Tarean Folston’s ACL prediction since he is a college player. I suspected ACL, even when Brian Kelly said MCL. Subsequently, Notre Dame made the ACL clarification. Not counting the last two assessments, the scorecard has now risen from 21-1 to 25-1. 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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