October 26, 2015 - Dr. David Chao
Monday Morning MD: Why Achilles are ACL more common
The high profile injury of the week happened to the Texans star RB. Arian Foster, in the process of motioning out to the slot and turning up field, fell to the ground untouched. By video, he had a clear right Achilles tendon rupture. Houston announced Achilles injury but expect formal confirmation of tear, which means surgery and injured reserve. Why do these non-contact Achilles and ACL tears seem to happen more frequently? Certainly there is more media coverage making it seem more prevalent, but there is another reason. As players get bigger, faster and stronger, the size of the Achilles tendon (or ACL) does not increase. The Achilles of the 227-pound Foster is not proportionately thicker, wider or stronger than that of a 150-pound office worker. There are two ways Achilles tendons rupture. The first type involves a weakened Achilles with tendinosis in a middle age or older individual. The second involves a completely healthy tendon where the muscle of a younger athlete is actually strong enough to tear the Achilles when it contracts quickly. Foster’s tendon didn’t have a chance to accommodate the sudden forces of an eccentric load. The Texans immediately knew the severity as Achilles tears are easier to diagnose than ACL tears. MRI is usually obtained but not needed as the Thompson (calf squeeze) test, loss of plantar flexion strength, defect, ankle position and increase dorsiflexion are all ways to confirm complete rupture, Typically, the players feels like someone kicked the heel but when the player turns around, no one is there. Partial tears are uncommon as the tendon is usually completely torn when it gives out. The injury could be related to his groin; however, in this case I don’t think so. Foster hurt it in a classic way with a simple linear force that didn’t likely involve the groin. The injury could be considered career threatening as Foster will turn 30; however, his Achilles should return to full strength after surgery and nine months of rehabilitation. DeAngelo Hall, Robert Mathis and DeMeco Ryans are some high profile Achilles ruptures from 2014 who have recovered for this season. In a show of determination, Foster insisted on getting up and walking off the field despite the pain. No additional damage was done as the tendon is already completely torn. In my NFL experience, many players refuse to be carted off the field. Once on the sidelines, they relent to being transported to the locker room. Achilles is the new ACL. Both are typically season-ending non-contact lower extremity injuries. As players get bigger/faster/stronger, the Achilles and ACL remain the same size and unfortunately tears will continue to happen. MMMD 1: Tony Romo will be healthy before he is eligible to play Jerry Jones says his star QB will be ready Week 10 versus Tampa. With the IR/dfr designation mandating an eight-week absence after the Week 2 injury, Romo has to sit out until Week 11. When the injury occurred, I questioned the wisdom of using short term IR. Now with the Cowboys in a tailspin, losing all four games since Romo’s injury, even one week earlier return for the star QB would be a big deal. The team might have been smarter to use the single IR/dfr spot on Dez Bryant who has now missed six weeks and still might not be ready for a week or two. MMMD 2: Three quarterbacks with MCL injuries sit as their teams lose Ben Roethlisberger, Tyrod Taylor and Marcus Mariota all were inactive Sunday due to MCL sprains. The Steeelers, Bills and Titans all posted losses. Look for all three to play at the next opportunity as the tide of coaching decisions swing. The knees of all three were stable enough to throw from the pocket this week, the issue was mobility and avoiding the rush. Steelers will play Big Ben next week as they host undefeated division rival Bengals. The Titans at 1-5 are not out of the sub-.500 AFC South and play division foe Texans. The Bills have a bye, which will give extra rest before their division game versus the Dolphins. MMMD 3: Chewing tobacco or shrimp? Adrian Peterson vomited on the team bus after the short flight to Detroit. The Fox broadcast claimed it was due to accidentally swallowing chewing tobacco when the team plane hit turbulence. The Vikings RB claimed it was due to eating bad shrimp. Peterson has a known shellfish allergy and carries an EpiPen with him; however, allergic reactions don’t usually involve vomiting. Whatever the case may be, a medical staff’s job extends well beyond the field. Kudos to the Minnesota staff for getting Peterson ready to play. This undoubtedly involved intravenous fluids as he was seen with the tell tale post IV bandage on his right antecubital fossa (elbow) as he exited the locker room heading for the field Sunday. MMMD 4: Carlos Hyde stress fracture? The 49eers RB told a sideline reporter his left foot issue was a stress fracture before the Thursday game. Hyde played but only rushed 11 times for 40 yards. When asked after the game if he had a stress fracture, he replied “something like that”. The most common foot stress fracture is a Jones fracture of the 5th metatarsal like Dez Bryant has. Hopefully Hyde only has a stress reaction, but even that can be dangerous as continuing to play on it can lead to a fracture. The bottom line is any bone stress issue takes weeks not days to heal. This injury could very well linger. This week he dropped out of the top three in rushing attempts league-wide. With any stress injury, even if he plays, his carries will drop him out of the top ten soon enough. MMMD 5: Panthers linebackers show toughness No one questions Thomas Davis as he has recovered from three ACL tears in three years. However, when Davis was spotted reducing a dislocated finger during a play as he continued to make the tackle he set an even higher bar. Fellow linebacker Luke Kuechly upped the toughness ante by apparently dislocating his shoulder, having it reduced and returning to finish the game in a shoulder harness. Earl Thomas and Dont’a Hightower each finished the season in a brace and had post Super Bowl labral repair surgery. With the Panthers undefeated at 6-0, will Keuchly be the latest player with an unstable shoulder to play thru and lead his team to the Super Bowl? MMMD 6: Medical Potpourri Todd Gurley RB had a Week 3 debut of only 6 carries for 9 yards. Since then, the Rams rookie RB has been sensational in three starts with 433 yards rushing and a 6.0 yards per carry average. In a show of further confidence, he did not wear a knee brace for the first time. Josh McCown QB exited the final minutes with a shoulder injury. By video, there was no dislocation or severe injury. If this were his non-throwing shoulder, it would be a no-brainer to play next week. Caution here but I don’t expect a prolonged absence. More concerning was being down for 10 seconds after a hit with his hands on his head yet no medical timeout was called for concussion check. Matthew Stafford QB had hand X-rays post game that were apparently negative Louis Murphy WR left the Buccaneers game with a non-contact knee injury that by video is ominously an ACL tear. Phillip Dorsett WR, by video, went down with high ankle mechanism of injury. He was later reported to have a fibula fracture and back in only 4-6 weeks. Unfortunately, that seems optimistic. Don’t be surprised if surgery or IR comes into play for the Colts first-round pick. Ryan Kerrigan LB exited with a hand fracture. Hopefully he can return with a cast or other protection. Jason Peters LT, exited the game with a back injury that does not appear to be significant by video, although he was carted off. Jeremy Maclin WR was a surprise scratch for the Chiefs after he was apparently cleared for concussion. In 2015, it has become the norm not to return from head injury in one week, and that may be a good thing. Eric Berry S celebrated his first interception since his return from beating cancer. MMMD 7: ProFootballDoc scorecard The season total from last week was 61-4 for a 93.8% correct rate. Once again, I keep track only to have meaningful vetted numbers. I continue to emphasize that video analysis and insider knowledge is powerful but far from perfect. Unfortunately, Arian Foster’s Achilles rupture and Phillip Dorsett’s high ankle type injury is correct while Louis Murphy’s ACL is likely torn. Dion Lewis’s abdominal injury now has cost him a game and I feel like this Thursday will be tough too. Fortunately, Allen Robinson injury was minor and Jason Witten continued after his minor ankle sprain. It looks like Jason Peters back injury is simply spasms. By the way, I don’t count the weekly “will he” or “won’t he” play scenarios into the scoring as a) coaching decisions play into the equation and b) it would be too easy to inflate statistics by saying a player like Dez Bryant is out for each of the last six weeks. As is, the 2015 running total is 68-4. 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.