November 23, 2015 - Dr. David Chao
Monday Morning MD: Medical timeout rule fails to work
This season’s new medical timeout rule was supposed to prevent another Julian Edelman Super Bowl situation. Sunday we see that rule failed Case Keenum as he appeared dazed, was not removed from the game, but later found to have a concussion. The play should have never have happened anyways. Elvis Dumervil was standing well across the line of scrimmage when he thought there was a false start. It seemed like some of the players didn’t even play on the snap as they anticipated an unabated to the QB or false start call. During the free play, the back of Keenum’s head hit the turf. Immediately, both of Keenum’s hands go to his head. Right tackle Garrett Reynolds goes to help pull his somewhat limp QB up, but is unable to as Keenum slumps back to his side and then rolls onto all fours. Center Tim Barnes comes to check on Keenum as well but the QB slowly gets up and walks off to the side. The next play, Keenum throws high to Wes Welker. The following play, Keenum drops back to pass and is nonchalantly holding the ball in one hand at his waist and fumbles when his arm is hit. Ironically, staying in the game is likely what cost the Rams the game. To me, there was clear visual evidence of potential head injury; however, a medical timeout was not called. When the rule was ratified, I wrote how that was not going to solve all concussion detection issues. [caption id="" align="alignright" width="427"] Screenshot from TV broadcast immediately after hit and before next play[/caption] Here the system failed Case Keenum. I am not blaming any one person, but the spotter, referee, ATCs, team doctors, unaffiliated neuro consultant (UNC), coaches and players all share in the responsibility. I doubt there was a conspiracy to keep Keenum in the game, rather a confluence of factors that lead to his not being removed. The “eye-in-the-sky” has gotten the most criticism but that may be fair. Visually there was enough to call a medical timeout but perhaps the spotter saw team medical personnel come onto the field to tend to Keenum so the spotter saw no need to stop the game. During the referees adjudication of the offsides penalty and explanation of the in the grasp call, the Rams head Athletic Trainer speaks to Keenum on the field including pointing to his own head. I know the Rams to have a quality head athletic trainer. He saw enough to come onto the field to check on Keenum; however, had he seen the video as the viewers at home and the spotter did, I am also sure he would have removed his QB from the game for further evaluation. The concussion happened on the 30-yard line in the open and not away from the play or in a pile of bodies. Clearly coaches saw enough to have Nick Foles warm up and put his helmet on. They could have removed Keenum from the game. The team doctors and sideline UNC could have seen it as well and stepped in. Rams offensive linemen saw their QB struggle after the hit and players need to take care of their teammate by notifying medical staff or pointing their signal caller to the sideline. Referees have the ability to send a player off but here the head man was too busy doing his main job. The referee hurried right past a struggling Keenum to spot the ball for “in the grasp” rather than an incomplete pass, determines the pre-snap penalty and makes the public announcement. I guarantee the league will look into this. In my NFL experience, it is common for New York to call medical personnel and spotters to discuss what happened. Although I doubt there was a conspiracy to keep Keenum in the game, it still is not a good look for the NFL and something must change. Everyone on the sidelines, field and booth need to step up. [caption id="" align="alignleft" width="272"] Navarro Bowman's injury[/caption] MMMD 1: Joe Flacco done for season The Ravens QB was rolled up on his lead leg on the first play of the game winning mini-drive after a late turnover. Flacco limped but stayed in the game for three more plays before the game-winning field goal. After the game, head coach John Harbaugh announced ACL tear and likely MCL tear. Based on video analysis, Flacco does not have a true mutli-ligament knee injury. His MCL may be sprained but this is not like the ACL and MCL tear that NaVorro Bowman suffered where he missed the entire next season. Because Flacco’s ACL/MCL is much less severe than Bowman’s ACL/MCL injury, I believe Ravens signal caller will have an excellent chance to be under center for the first snap of the 2016 season. [caption id="" align="alignright" width="265"] Forsett on the ground after the injury[/caption] MMMD 2: Justin Forsett breaks forearm In more Ravens bad luck, their starting RB suffered an obvious radius and ulna fracture. He will need surgery that will likely consist of plates and screws. Recovery is a minimum of six weeks so his season is done. The good news is Forsett should make a full recovery (barring infection like Rob Gronkowski had) for the offseason program. He can play with the plates in his forearm as they will usually stay in for his playing career. MMMD 3: Marshawn Lynch likely surgery When Beast Mode was reported to have abdomen and groin issues weeks ago, I worried about sports hernia despite reports of a normal MRI. Now the Seahawks RB is headed across the country for a second opinion and probable surgery. Even Pete Carroll admits “the surgery thing is always an option in there.” Athletic pubalgia and core muscle injury are other names for sports hernia. Physicians have moved to use other names as there is no true hernia in this injury. The issue is with muscle insertions from the abdomen and groin on the pubic bone. Look for the surgery to be done immediately as typical recovery is six weeks and the hope would be a playoff return for Lynch. MMMD 4: Colin Kaepernick surgery signals the end in SF The 49ers demoted their starter and he will now be on injured reserve for a shoulder surgery. There may be more to this story than meets the eye. In my NFL experience, a QB could play through a non-throwing shoulder labral tear and have offseason surgery. He apparently played with it since the October 4th Packers game. The 4-6 months recovery leaves time for that. This likely means that one or both parties are done with each other and just looking to move on rather than stay available if Blaine Gabbert is hurt or performs poorly. It will be interesting to see whether a trade will happen or if Kaepernick will be released. I do not believe this procedure will reduce his market values since it is his non-throwing shoulder. MMMD 5: QB updates Andrew Luck was on the sidelines with his team but that doesn’t mean he is ready to go soon. The short end of the Colts initial 2-6 week timeline was never realistic. Kidney lacerations are kept out of contact for a minimum of a month or longer. Peyton Manning did not travel to Chicago with the team. If his foot bothered him to be on the sideline, he could have sat in the box with headset on. Afterall, everyone says he is essentially an on field coach. In any case, his plantar fasciitis could be improved but will not heal with just one week’s rest. It will be interesting to see how long Manning will be held out. Tony Romo had no issues with his clavicle and lead the Cowboys to a much needed victory. Jerry Jones said he had six fractures; however, medically we would say one fracture with comminution (multiple pieces). He played Sunday nine weeks after injury and should continue to do well but his collarbone will not be as strong as the other side for months. MMMD 6: Medical potpourri Charcandrick West injured his hamstring and is said to be day-to-day. Hamstring injury severity is hard to determine by video so we will just have to go by the team reports. Glen Dorsey is feared by the 49ers to have torn his ACL. I did not see the play but a MRI is pending. Rodney Hudson re-aggravated his high ankle sprain. Although the mechanism seemed mild, re-injury likely means some missed tine for the Raiders center. Nick Mangold was seen on the sidelines with a splint that is normally used for metacarpal fractures. Turns out he suffered a laceration not a fracture. Must have been significant as one can usually play through cuts even on the snapping hand. I hope his underlying tendons were sparred. He could move to guard if the injury is an issue with snapping. Devonta Freeman and Zach Ertz left with head injuries. In 2015, with concussions seemingly being held out longer, it would be surprising if both returned next week. Ryan Fitzpatrick appeared dazed after his touchdown run but after the game he said he was checked for concussion and cleared on the sidelines. He did play without missing time as expected after his thumb ulnar collateral ligament repair. Jordan Reed was reported to have a MCL injury. Severity is not known as I did not see the video, but it will be hard for a skill player to retrun in one week. Carlos Hyde missed a third straight week with stress fracture. I still suspect Jones fracture and would not be surprised if eventual surgery was announced. Julian Edelman had his Jones fracture surgery. Recovery is typically 6-8 weeks but the Patriots WR may have a harder time with early return due to his style of multiple quick cuts and underneath routes. Reggie Bush did not have ACL or MCL injury as initially announced. He had meniscus surgery. By the timeline, he likely had repair rather than trimming, which takes longer to return. Breshard Perriman confirmed PCL injury only in his first comments to media after he was placed on IR. No additional surgery is needed. I just hope he doesn’t have associated cartilage injury. Victor Cruz said he needed surgery for his calf and was placed on IR. The procedure has not been done yet. I am curious as to what will be done. Typically, one does not do surgery to fix calf strains as muscle doesn’t hold suture, making repair difficult. MMMD 7: ProFootballDoc scorecard I was fooled by the splint Nick Mangold had on. Without seeing the injury video, I made the wrong assumption of fracture based on the splint he wore on the sideline. It was reported after the game to be a severe laceration. This makes five misses for the year. Marshawn Lynch does indeed have sports hernia symptoms. Despite going down non-contact and pointing to his Achilles, Byron Jones injury seems to be mild as the video indicated. Tony Romo did well with his clavicle fracture as expected. Ryan Fitzpatrick did have Friday thumb surgery and return to play as predicted. The 2015 season started the week at 94-4 record. Adding in this week, the tally is now 98-5. 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.