Monday Morning MD: What does it mean when a player enters camp on PUP?

As training camps around the league start, often players with any minor injury issue will start on the Physically Unable to Perform (PUP) list. The Steelers opened camp with a surprise in center Maurkice Pouncey and four others starting on PUP. This designation sounds ominous, but what really is the significance? The knee-jerk reaction for the rabid fan is to freak out when your favorite player is placed on the PUP list. After all, there has been an entire offseason to get healthy. The reality is that most players pass physicals and are activated very quickly, usually within days. Teams freely use the temporary PUP designation to get some future roster protection in case an injury lingers or regresses. There are actually two categories of PUP (active and reserve) with different implications. Active/PUP is utilized in the preseason when a player doesn’t pass a physical from a football related injury. The player remains on the active 90-man roster during this time. He can pass a physical at any time and come off the list and start practicing. Reserve/PUP is saved for the regular season. Here the player does not count towards the then 53-man roster. This designation requires missing a minimum of six but a maximum of 12 weeks. Once activated, there is up to a three-week grace period for practice before being the roster spot counts. Check-in physicals are performed upon arrival at every camp and a player must pass before any conditioning tests or practice starts. If there is any question on an injury or the possibility of a setback, the player is typically failed on physical and the active/PUP designation is used to preserve the right to later enact the reserve/PUP status in the regular season. If a player passes the initial physical and practices for even one minute without having been on active/PUP first, a team loses the ability to use the roster spot saving reserve/PUP designation. This is why you will see teams freely apply the active/PUP status as training camps open. This is also why you will see many players pass a physical a day later and begin practice. If the original injury flares up, this allows the team to save the roster spot later. However, it can’t be used if a new unrelated injury occurs. Expect Jadeveon Clowney (Texans/knee), Earl Thomas (Seahawks/shoulder), Sam Bradford (Eagles/ACL), Dont’a Hightower (Patriots/shoulder), Brandon Albert (Dolphins/ACL), Dennis Pitta (Ravens/hip) and more to be placed temporarily on active/PUP. They all are coming off known injuries and it means very little to start camp on PUP, as long as it is temporary. It is more telling when a player with known injury does not start on PUP than if he does. Le’Veon Bell starting camp day one not on PUP is much more meaningful. Evan Silva of Rotoworld asked me about Bell earlier this summer and I indicated little concern about the knee injury that kept him out of the playoffs. The Steelers leaving him off PUP indicates they have no worries about any possibility of lingering injury or risk of missing games and indeed he has had a strong early showing already. Expect the Rams to open with Todd Gurley on the Non-Football Injury (NFI) list, which is essentially the PUP equivalent, except it is for a non-NFL injury. Players with illness, fireworks injuries or those injured in college football fall under this category. For a full listing of PUP, NFI, IR and IR/dfr, see last year’s column here. MMMD 1: Jadeveon Clowney “looks spectacular” The Texans team physician says last year’s first pick of the draft has very little muscle atrophy after his microfracture procedure due to use of blood flow restriction (BFR) training. The surgery necessitates non-weight bearing initially and limited physical exercise for at least six months. This typical leads to significant muscle loss, whereas Clowney’s is minimal. Although the Texans have a top team surgeon and his use of BFR puts him ahead on rehab, expect Clowney to still start camp on active/PUP. BFR helps muscle girth but it has yet to be shown to help articular cartilage regrow and that is the main issue. Despite this report of great progress, my earlier comments still stand and the hope is for a small lesion. Even in the best hands, needing microfracture is not a good sign. The likelihood is that Clowney will not have a 10-year NFL career. If he gets to a second contract or is just productive throughout the first one, that would be deemed a huge success. The bottom line is Articular cartilage is the Holy Grail. MMMD 2: Impossible to have someone else’s kneecap When Danny Trevathan made the comment about having “someone else’s kneecap”, I indicated that just was not possible. Now the truth has come out. Trevathan now says he was just joking. He admits to reconstructive surgery but the kneecap is his. I still think the injury bears watching as anytime articular cartilage is involved, it leads to concern. MMMD 3: Why is Junior Galette still listed on Saints roster? New Orleans decided to part ways with Junior Galette due to character issues. Because Galette had a recent pectoral injury where surgery was contemplated, the team can’t actually cut him until he reports and passes a physical (or reaches an injury settlement). Passing a physical shouldn’t be an issue as this recent video proves the pectoral issue behind him. However, Galette still needs to report to do so before he can be released. That may be the bigger obstacle based on reports of his anger at the Saints. MMMD 4: C.J. Wilson stepping away from football Most of the attention has been on Jason Pierre-Paul, but the other NFL player injured by July 4th fireworks has decided to step away from football after he lost his index and middle fingers. We all wish him well. Meanwhile, Justin Tuck says he spoke to JPP who realizes he made a mistake, but his spirits are up. Hope he can put this behind him and return to play. It all depends on what damage there is beyond the index finger. MMMD 5: Cardinals rookie WR wounded by gunfire Damond Powell Jr. was shot in front of his own house and fortunately the injuries do not appear to be life-threatening even though he was hit in the face. When I was team physician, our second-round pick was an innocent bystander and shot at a mall in the July offseason in his hometown as well. He subsequently needed surgery. The team immediately had me reach out to his treating physicians to get updates. I am sure this is the case here with the Cardinals just like the Giants also reached out when JPP was hurt. The job of professional sports is not limited between the white lines. MMMD 6: NFL plotting response to movie Concussion A movie about two doctors at the forefront of the CTE issues will be released on Christmas day. Apparently owners have already begun to meet to deal with the response. I hope the movie is accurate and continues to bring further concussion awareness rather than being sensationalist. No one should be afraid of an honest discussion of the issues. MMMD 7: ProFootballDoc scorecard As we restart the regular season column format, I will resume the self-assessment of correct/incorrect injury prediction/analysis that left off at 6-0. The goal is to have vetted numbers this year instead of just reporting 92.6% accurate at season’s end. The vast majority of the Jason Pierre-Paul analysis has been accurate. Even though my breakdown turned out correct on multiple aspects, it will count as only one in the plus column. Add to it the correct assessment that Trevethan did not “have somebody else’s kneecap” and that Le’Veon Bell would start the season healthy and that leaves the score at 9-0. I am sure a miss is 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.
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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