Pro Football Doc Podcast – Episode 4

In Episode 4 of The Pro Football Doc Podcast, Dr. Chao talks with Alex Marvez who has covered the NFL as a writer since 1995. They talk about everything from Marvez’s tour of training camps to solutions for Preseason problems. Afterwards Dr. Chao goes position by position and talks about injury concerns at each of the major offensive positions.

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Monday Morning MD: New formula to extend Tom Brady's career

Despite being hated by Patriots fans, the commissioner may have actually helped New England win this and more future Super Bowls.
How did a 39 year-old quarterback outlast a young defense that in the first half was flying to the ball and applying pressure without blitzing? The Patriots had more than twice the offensive plays as the Falcons. The lopsided time of possession difference was even worse than the stats indicated (40:31 vs 23:27) as New England’s 14 more incomplete passes added little clock time but substantial real time on the field. Atlanta defended for an unprecedented 93 plays. Brady passed more times than Matt Ryan even touched the ball. By the fourth quarter, the pass rush seemed to wear itself out and the tight coverage began to trail.
Don’t forget that the offense led by Brady was on the field the same number of plays as the “rise up” young defense. Why did the aging quarterback not seem tired? Brady is dedicated to his training regimen but there may be more to it.
The four-week forced hiatus where he not only missed games but had to be away from the facility and could not practice may have helped the veteran QB and his team in the long run. The Patriots with Brady only playing a 12 game season still ended up with the playoff bye and home field advantage.
The early rest and shortened season may have helped Brady during the playoffs and Super Bowl. He certainly doesn’t need the added reps. Perhaps it played a role in his strong 4th quarter as the Falcons defenders ran out of gas.
Bill Belichick used a boxing analogy at the MVP ceremony this AM saying “the mark of a true champion is winning after getting knocked down.” Staying in fight game analogies, this contest seemed like the famous rope-a-dope fight during the 1974 “Rumble in the Jungle”. The young George Foreman came out strong and punched himself out as Muhammad Ali conserved energy and stayed strong to finish the fight in the end.
During my time with the Chargers, LaDainian Tomlinson never played in preseason games. He didn’t suit up his rookie year due to a holdout. The newly announced Hall of Famer played so well his rookie season and became so valuable, the team decided to not mess with success. During his illustrious career, he always sat out preseason games. Perhaps this season will set the new precedent for the Patriots.
Father Time catches up to all of us. Perhaps the shortened season model is something Brady and the Patriots will adopt going forward to combat the effects of age. Inadvertently, the most hated man in New England may have helped the Patriots to their fifth Super Bowl and perhaps extended the career of Brady into winning more.
MMMD 1: Did injury play a role in who ultimately won?
By video, it was clear that Alex Mack would not be 100% even before the news of a broken/chipped fibula. He played surprisingly well but did give up the key sack to Trey Flowers that prevented the Falcons from icing the game with a late field goal.
Julio Jones was also still hampered by his turf toe injury. He made a spectacular catch but had a subpar performance for him with only four catches. Jones is reportedly still undecided on offseason surgery.
The lengthened pre-game and halftime made it harder on both Dwight Freeney and Chris Hogan who were playing through muscle injuries. Freeney recorded a sack but missed a short portion of the game with his calf and undoubtedly was not 100%. Hogan recorded 4 catches with his thigh issues but was not nearly as productive as during the AFC Championship Game.
Dont’a Hightower played through a likely left shoulder labral tear and has been using a harness/brace. He effectively used his left arm to make the pivotal strip sack resulting in the key Falcons fumble.
MMMD 2: Athletic trainers and doctors deserve rings too
The medical staff plays a vital role in not only health and safety, but also in a team’s winning. It is right that they too will be awarded with Super Bowl rings.
There is no better example of medical helping a team win than this year’s Super Bowl. The key play was Dont’a Hightower’s strip sack fumble. Despite a likely labral tear (which will need offseason surgery), he made the game-changing play with his injured arm. Doctors and athletic trainers had him safely on the field with a shoulder harness that provided stability yet did not restrict his motion to prevent reaching Matt Ryan to cause the turnover that launched the Patriots to victory.
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This is nothing new for the Patriots ATCs as they have enjoyed many Championships. The head team doctor is a rookie this year, as was the lead physician two years ago when New England last won it all. In my 17+ years in the NFL, my team never even made it to the big game. But trust me, I am very happy for them as I know how much work is put in and how special it is.
MMMD 3: NFLPA agenda
Each year at the union players press conference, there seems to be a main agenda push. This year, the call is for teams to follow the concussion protocols exactly. For years, the mantra has been changing and advancing the head injury rules. Now, the players seem happy with the rules and want them strictly enforced.
Recall only two years ago, there was controversy over a big hit on Julian Edelman. That was the genesis of the medical timeout rule. Last year a second concussion spotter was added. Sideline replay, neutral independent physicians, standardized testing, mandatory rules for going to the locker room are just some of the many changes.
It is noteworthy that no new rules are being requested. Last year the commissioner announced a structure for penalties to teams of fines and/or draft picks for violations. To date, no one has been penalized.
The Dolphins were recently warned over their handling of Matt Moore.. The Chiefs are being investigated now over their handling of Chris Conley. I know Kansas City has a quality medical staff and the head athletic trainer is the current President of the Pro Football Trainers Athletic Society. I do not know the specifics of their care during the Division Round game in question. However, don’t be surprised if penalties are assessed for the first time as that is the push of the NFLPA.
MMMD 4: Pain medication lawsuit
News broke during Super Bowl week that the Falcons were worried about their reliance on painkillers in 2010 and how the team spent nearly three times the league average on narcotics. I am not an attorney and I do not know details about the pending lawsuit but I don’t believe this story is not nearly as explosive as it sounds on the surface. In fact, it is my understanding that some teams, including the Falcons, have been dropped from the legal action (although they could be added back in).
To me, the emails show that Atlanta executives acted as soon as they realized their team used more pain medication than the rest of the league. Medical staff changes were made to make sure this problem didn’t go forward.
The Falcons should be applauded not criticized for their actions. In medicine, there is something called peer review. Any internal criticisms and actions to improve medical care are exempt from attorney discovery. The purpose is to encourage the process of improving patient care and to remove the fear of plaintiff attorney discovery. Here it seems like the Falcons found a problem and then acted to correct it.
MMMD 5: Medical Mike Pereira
As most of you realize, I am not a trained professional writer or full-time media member. I have a “day job” as an orthopedic surgeon. I hope this and my almost two decades of experience as an NFL team physician gives me the unique perspective that you enjoy. Hopefully, I can be as good at analyzing injures as Pereira is at breaking down the rules.
I have written a 1500 word article for over three straight years with a one main and seven subtopic format including through the offseason. Add in watching games, keeping up with news, speaking to other reporters, my SiriusXM sport medical analyst duties and my Real Football Network work. It is almost a 40 hour a week second job..
I enjoyed my time at Radio Row and the game. I especially enjoyed taking the media bus all week long. Every ride provided a nice opportunity to randomly meet a fellow media member that we have been mutually following. I was so surprised and flattered that a few fans recognized me and even asked to have their picture taken with me.
MMMD 6 Mrs. ProFootballDoc
I have to thank my wife as she has been so supportive. She takes the kids every Sunday so I can do football. This past week she was single parent for the week as I attended Radio Row and the Super Bowl. She is eight and a half months pregnant and still managed to take the kids to Disneyland for her birthday. There is NO ONE like her.
I also want to thank my co-stars on the Periscope broadcast, Davis and Dylan. My weekends are free again so more Daddy time on the way.
MMMD 7: ProFootballDoc scorecard
This marks the end of my tally of initial impression right/wrong for this season. There may be adjustments as new information is revealed but any subsequent injuries will not count to this total.
This year concludes with a 95.1% record (203-10) of correct injury predictions. Last year the final record was 94.3% (165-10) and the year before that was 137-11 (92.6%). The number of first impression assessments have gone up slightly as well as the percentage correct. With a three-year track record, I am not sure if I will track it again next year as the concept seems to be proven. Using video and insider medical knowledge is at least 90% accurate.

Monday Morning MD: "Witch hunt" season is on

As the numbers of games dwindle, there is more time to deal with unfinished business. Thus the administrative “witch hunt” season is on.
The Dolphins were admonished (but not penalized) over their handling of Matt Moore during the Wild Card round. There was no criticism of the care he received. The Unaffiliated Neurotrauma Consultant participated and agreed with the treatment and return to play process. Bear in mind it was a road game where the UNC is local to the Pittsburgh area and probably a Steelers fan. The purpose of the UNC is to first hand witness and provide player protection. Despite the UNC not requiring a locker room evaluation and agreeing with care, the team medical staff was still criticized for not following the concussion protocol.
There was the perception of rushing Moore back into the game since he only missed one play. With the referee and TV delays, I timed that Moore was out for exactly five minutes before he returned, which is the equivalent of seven or eight plays of real time. A sideline screening exam takes two to three minutes. Blood in the mouth is considered by the league to be a sign of concussion requiring locker room evaluation. Apparently there was a trace amount on Moore, but not enough to concern the Dolphins or independent doctor. Of course the slight blood could have come on a different play but on this technicality the Dolphins were criticized and warned of future penalties.
Now attention is focused on the Chiefs for their handling of Chris Conley in the AFC Divisional Round. With last year’s announcements of potential team penalties/fines for medical staff transgressions, it seems the NFL and NFLPA are destined to find someone to punish. The Chiefs head ATC is the current president of the Pro Football Athletic Trainers Society, which makes him a high profile target. Add to that the fact that he has been in the news this season and previously related to head injury and sets the Chiefs up to be a prime candidate to become a scapegoat.
I do not know the details of what the Chiefs did or did not do in their evaluation of Conley. This is why I have advocated for transparency. Why not let the UNC describe what happened on the field, sideline and locker room? Referees talk to a pool reporter after the game to help explain what the officials were thinking. Allowing the UNC to do this might clear up the perception that players were not cared for and might even apply more pressure to do the right thing with the doctor knowing he/she will have to answer publicly for it.
Currently the NFL does not have a full-time medical officer. Normally that person would jointly conduct the investigation with the NFLPA physician. With only one physician involved, penalties become more likely as the NFLPA physician has no counter. It is like only one side having an attorney in court or only one side having an expert witness in trial. The outcomes potentially get skewed.
Protocols are guidelines not rules. The NFL and NFLPA should stop practicing medicine and allow the UNC and team physicians to operate. They should allow them to speak to clear up misperceptions. If the independent physician is complaining, that should be fully and aggressively investigated with full representation from both sides.
MMMD 1: “Witch hunt” part 2
There has been lots of conjecture on fines/penalties for the Seahawks not disclosing Richard Sherman’s MCL injury. I have explained why I feel Seattle will escape punishment. Sherman has now confirmed my thought that the MCL injury was minor. Thus, there was no requirement to list it on the report.
Now the Steelers are undergoing scrutiny for not listing Le’Veon Bell’s groin injury. Last year, the Colts were investigated for not listing Andrew Luck’s rib injuries, but no penalties resulted.
The reality is there are many more injuries on every NFL team than listed in the injury report. The speed limit is 55mph but everyone on the highway is going 65mph. Only the ones going 75mph will be ticketed. Or as Mike Garafalo tweeted at me, the “Ferarri’s” (star players) get all the attention from the cops but the “Kia’s” (average players) are ignored when it comes to getting pulled over.
MMMD 2: Everyone will play in SB51, but how well?
Everyone gets healthy in the two weeks before Super Bowl. Fortunately, both the Falcons and Patriots are relatively injury free.
The Falcons have no one listed on the game status injury report. Julio Jones is still dealing with his turf toe and is said to have two ligament injuries and a mid foot issue. This is the same foot that has had two previous 5th metatarsal fracture surgeries. I do not think the extra week will allow Jones a full recovery. Despite a monster Conference Championship game, don’t expect a repeat performance. Center Alex Mack, by video, suffered a high ankle sprain and finished the NFC title game but has now missed considerable practice. No doubt he will strap it up for the big game.
Of course the Patriots will miss Gronk (on IR for back surgery) but everyone else should play. Nate Ebner is on pace to be cleared from concussion and may accomplish an unprecedented feat. In the last six months he will have played in the Rio Olympics (for USA rugby) and now a Super Bowl. All of his many teammates listed as “questionable” should be available as well.
It is the Super Bowl. Everyone will be available.
MMMD 3: Teddy Bridgewater not back for 2017?
A small uproar was created when it was reported that the Vikings QB would miss next season. This is a case of don’t shoot the messenger. Jason Cole correctly quotes the typical recovery time from a knee dislocation, where multiple ligaments are torn, to be a year and a half. When NaVorro Bowman torn his ACL and MCL, he missed the following season and still struggled after that. There is optimism for Jaylon Smith after his multi-ligament knee injury but he is still wearing an AFO indicating a nerve problem. The point is that all knee dislocation/subluxation injuries are far harder to return from than the average ACL tear.
There is no guarantee for 2017 for Bridgewater. Typically there is always offseason injury optimism but head coach Mike Zimmer has said he does not have a timeline for return. After all, did the Vikings trade for Sam Bradford just for one season, or were they also buying insurance for the next year and beyond?
MMMD 4: League injury data
The annual NFL injury data was released early instead of at Super Bowl week. The league data showed concussions remained essentially the same over a five-year span with 244 total this past season. ACL tears remained constant over the last five years with just under two per team as the average. MCL tears also were similar, averaging just under five per club. With the new touchback rule, there was not a big statistical change on kick-off related injuries. If anything, knee injuries increased. Thursday games continue to have fewer injuries than Sunday games.
MMMD 5: Three unusual situations
Cyrus Kuoandjio had hip surgery after a fall at home. Details were not released but the implication is a potential hip fracture. That is not unusual for grandma, but extremely unusual for a young healthy NFL player. We will need to wait to hear more details on whether there is some underlying pathology or if this truly was a fluke. Dexter McCluster was signed by the Chargers and had a previous forearm fracture and re-broke it with an at home luggage incident.
Josh Doctson is still dealing with his Achilles tendonitis. I am sure the Redskins medical staff has tried all sorts of conservative care, modalities and likely PRP/stem cells. If he doesn’t turn the corner soon, surgery to debride the Achilles may become an option.
Ryan Tannenhill finally had surgery ruled out this week. He injured his ACL and MCL but only recently determined that no ACL reconstruction was needed. There are reports of him flying to Germany for treatment despite PRP and stem cells being legal and routinely used in the US. Players will literally go to the ends of the earth if there is a chance for something better.
MMMD 6: Hardest part of retirement
Steve Smith, Sr. on the “Know Them From Adam” podcast talked about one of the hardest adjustments to post-NFL life. He singled out medical care. Indeed now he will need a new set of doctors. All player’s (and sometimes family) needs are met by the team doctors. Most times, the physicians make “house calls” and come to the facility. There are even preferential appointment times for the dentist. Indeed, life after football involves getting to know what a doctor’s waiting room is for.
MMMD 7: ProFootballDoc
I did not watch the Pro Bowl and thankfully there are rarely injuries in that all-star game. Having covered two of these exhibitions, anyone with the slightest of medical conditions is pulled for safety. No injury analysis this week and thus the 95.1% accuracy rate stands.
I am in Houston this week for Super Bowl and the media activities. I hope there will not be a need, but will be at the big game to provide live injury analysis from NRG stadium.

Monday Morning MD: History repeats itself

Another AFC Championship game in Foxboro. Another opposing star running back is injured early and sits dejected on the sidelines with an oversized jacket to stay warm. The Patriots advance to another Super Bowl.
When Le’Veon Bell left just after the start of the game with a groin injury, it reminded me of LaDainian Tomlinson’s early exit with MCL injury. Both came into the game with their injuries but could not continue. Both sat helplessly trying just to stay warm as their teams lost to the host Patriots. Both incidents just had the same look and feel.
Injuries are always a big part of the game. Would the Steelers been able to hang tight with the Patriots if Bell stayed healthy? Would the Chargers have prevailed in 2008 if LT would have been healthy?
A groin injury is debilitating for a running back. Not only does it make it hard to cut, it robs a player of his burst. The cold didn’t make it any easier. Bell could have limped through his game like LT could have hobbled through his, but clearly it was the better move in both circumstances to play their capable back-ups.
Is it just luck for the Patriots that their path to the Super Bowl was made easier by the opposing team’s key injury? Certainly, to some extent New England makes it’s own luck by having the best record in the NFL.
The only thing these Patriots have in common with the 2008 team is QB Tom Brady and K Stephen Gostkowski, plus of course the head coach. In fact, there are 30 new players out of the 53 since the last Super Bowl victory just two years ago. We shall see if it will yield the same results as the Falcons seem to be a formidable opponent.
I provided medical coverage for two Super Bowls but my team never made it to the big game in my almost two decades. The Patriots had a new team doctor when they won it all in 2015. Again they have a first time team doctor this year. Will history repeat itself?
MMMD 1: Everyone plays
When it comes to the Conference Championship games, no one wants to miss the chance to help their team get to the Super Bowl. After all, next comes an extra week of rest before the big game or an offseason of rest. This is what drove Philip Rivers to play fresh off a knee scope and with a torn ACL in 2008.
All three injured Packers wide receivers (Jordy Nelson, Davante Adams and Geronimo Allison) played. Also Morgan Burnett (quad) and Christine Michael (back) suited up as well.
It was obvious that James Harrison would play and so did his flu-ridden teammates. I doubt a 3am wake up had much effect for an evening kickoff. Besides, in my experience, players don’t get up to leave their rooms with a fire alarm without team security personally performing the evacuation.
MMMD 2: Everyone will be ready for SB51
Barring any surprises, it should be a healthy game in Houston. The additional week before the big game should allow all players to be near top form.
Julio Jones with his turf toe/foot issues will be a player to watch but I anticipate he will be fine. Alex Mack finished the game with his ankle spatted and should be in good shape in two weeks.
Martellus Bennett will need ankle surgery with his bone chips/fracture but that should be a minimal issue. Chris Hogan had a big game despite coming in with quad injury and then having hamstring issues where the two weeks will help here.
Here is hoping both squads remain at full strength and the better team wins.
MMMD 3: How did Jordy Nelson play with multiple broken ribs?
When it was reported that the Packers WR was on the second bus on Sunday, that confirmed to me he would play. Players that are game-time decisions, arrive early on the first bus to test the injury out. Ones that know they won’t play take the 3rd bus.
The much talked about Kevlar vest is not the main reason Nelson could play. Any protection doesn’t eliminate the pain of twisting, reaching, blocking or even deep breaths. Often rib blocks are utilized where the intercostal nerves are numbed with injections. This allows a player to move without pain and is an entirely legal form of medication in the NFL. Pain pills are used less frequently than people think, as a player’s mind needs to be clear to play this complex game.
MMMD 4: Seahawks won’t be penalized
Pete Carroll said Richard Sherman had a “significant” MCL but he was never on an injury report. This led many to expect a Seahawk penalty to come.
I don’t think it will happen. Teams are not required to report all injuries. Trust me that every team’s injury list is longer than the one that is published.
Only significant injuries are required to be reported. This is where the semantics come into play and Pete Carroll is obviously not a physician.
Medically, it is impossible for any CB to play with a significant MCL injury. Of course you can argue that any mild MCL is a significant issue for a defensive back. However, if the MCL was medically graded as mild (even though the coach described it as significant), that will be the loophole that allows the Seahawks to escape league penalties.
MMMD 5: Zach Orr gets lucky
Unfortunately the Ravens budding star linebacker was forced to medically retire from football. In reality, Orr is quite lucky. He has a dangerous congenital C1 condition that was discovered after a routine work up for a stinger.
He had unknowingly played his entire career with the potentially deadly problem. One wrong hit and a C1 problem could easily be fatal and there is no reason to take chances.
In the end, Orr is lucky to have discovered the issue and that he didn’t play one play too many. That is the bright side of this unfortunate situation.
MMMD 6: Pro Bowl replacement season
This is the annual ritual where players tap out due to injury. The Pro Bowl game is always a game of musical chairs to the point that it is hard to keep up.
Alex Smith and Dustin Colquitt are now in. Jadeveon Clowney, among others, is out. With the game now the week before the Super Bowl, Conference Championship winners will all be out, while many of the losers will choose not to attend.
Also this week, many offseason surgeries were announced. Andrew Luck had a clean up throwing shoulder procedure. Meanwhile, Sammy Watkins finally had his much anticipated second foot surgery.
MMMD 7: ProFootballDoc scorecard
Sammy Watkins finally had the second predicted foot surgery. Ladarius Green missed as expected. James Harrison, Jordy Nelson, Davante Adams, Morgan Burnett, Julio Jones, Chris Hogan and Martellus Bennett all played as expected. Le’Veon Bell did not return. Alex Mack did injury his left ankle.
I was wrong in too hastily opining on T.J. Lang’s injury with only one view.
This slightly lowers the 203-10 (95.3%) record to 214-11 (95.1%).

Monday Morning MD: Who is healthy for the Championship Games?

Not all ACL surgeries go smoothly. Even ones done by renowned orthopedic surgeons can go wrong.
After tearing up his knee last year, Dion Lewis flew to seek out who he thought was the best to perform the procedure but still had a serious complication. After his initial surgery, his kneecap developed a fracture from where the ACL graft was taken. He needed a second surgery with screws in his patella and missed a majority of this season.
The Divisional Round was his come back party. Lewis triumphantly scored three touchdowns in three different ways: receiving, rushing and special teams. He was a passing TD away from a historic cycle.
At the start of the season with Lewis missing, there were many questions why the Patriots could not get their star RB on the field. As I have always said, the truth comes out eventually. In fact, given the surgical complication, Lewis has made a tremendously quick recovery.
Medical staffs and especially team physicians are quick to get the blame. Their names are rarely mentioned when credit is due. When a second opinion doctor performs the surgery, their name is often announced with the obligatory proclamation that “surgery was successful”. When the team doctor does it, it is usually done in anonymity. In many ways the medical team is like offensive lineman or long snappers. Their names are often mentioned with blame but rarely with kudos.
I am glad this story has a happy ending but it serves a reminder that there is always risk in surgery and despite everyone thinking that return from ACL surgery is routine, there are definite pitfalls along the way.
Here are how the teams look from a health perspective headed into the Championship Games as well as the medical rundown.
MMMD 1: Packers injury outlook
The Jordy Nelson good news is that he has no organ damage, did travel to the game, and was on the sidelines. The bad news is he was moving very gingerly and I saw him clutching his ribs as he congratulated players on the first touchdown. Reports also said his current goal was to breathe normally again. With a week to go there is a chance, but far from a guarantee, that Nelson would play. If Green Bay gets to the Super Bowl, he would have an excellent chance of playing.
Morgan Burnett appeared to have a quad contusion. If the Packers can control swelling and maintain flexibility, he has a chance to play next week.
By video, David Bakhtiari suffered a mild right knee MCL sprain. He returned after being taped/braced. He should be fine moving straight ahead but likely will have some limitations side to side.
Slow motion showed DeVante Adams with a mild left high ankle sprain. He was taped and returned. Careful here with the swelling. I would expect a post-game boot and some missed practice but that he would try to go next week.
LaDarius Gunter appeared to have the wind knocked out of him and finished the game. I don’t seen any issues with him being 100%,
MMMD 2: Falcons injury outlook
Julio Jones left with a foot injury late in the game. The presumption is a re-aggravation of his turf toe. His coach said he could have continued but was pulled for the score. Jones will likely be limited in practice this week. This bears watching but the hope is Jones will be just fine.
Adrian Clayborn was reported to tear his biceps tendon at he elbow. Normally that is a season-ending injury that requires surgery. If Clayborn and the Falcons want to pull out all stops, he could try to play and have surgery after the season. It would be hard due to pain/swelling to play in the Championship game but he could play with some flexion and supination weakness in his elbow for the Super Bowl. Before you say this is far-fetched, ask Terrell Suggs. He played thru the second half of this season with a biceps tear.
MMMD 3: Patriots injury outlook
Chris Hogan appeared to have a thigh bruise and with good medical care should be good to go for the Championship Game.
Martellus Bennett survived a hyper-extension injury scare to finish the game and should be healthy.
Danny Ammendola continues his recovery from a high ankle sprain and another week should improve that.
MMMD 4: Steelers healthy
Big Ben is fine. The ankle scare when he was seen with a boot post-game last week is long behind us. As expected it was purely precautionary and he played and moved well.
Hope no injury news pops up as sometimes happens, but right now the big news in Pittsburgh is all about Antonio Brown’s social medial locker room post.
MMMD 5: Head coach younger than player
The Rams have a very young team but new head coach Sean McVay (age 30) is still younger than one player on his roster and the same age as two others. I am not sure what the NFL precedent is for this.
I don’t think this will be an issue. In my first eight years as a NFL team physician, there was at least one player on the team younger than me. That was an oddity but never an issue other than perhaps locker room banter.
MMMD 6: Will medical staff move with the Chargers?
Typically, the athletic training staff moves with the club. The doctors usually do not. NFL physicians all have full-time practices outside of the team that account for the majority of their income. With the move to Los Angeles, the UCSD medical sponsorship and the local team physicians will certainly change.
MMMD 7: Injury rundown
Chief WR Chris Conley took a vicious penalized hit to the head, yet returned to the game. Another example of how concussions cannot be judged by video. By the eye test, he certainly should have been removed from the game but the independent doctor allowed his return after examination.
Seattle CB DeShawn Shead likely tore his ACL. Unfortunately, that means surgery and starting next season on PUP.
Seahawk Germain Ifedi by video suffered a left high ankle sprain but will have plenty of time to recover for the offseason program
Jimmy Graham has made everyone forget about his patella tendon rupture playing very well at season end.
Mike Zimmer is just being honest on Bridgewater when he says “We don’t know when Teddy will be back”. Video posts show progress in rehab but he is a long way from a full return. A knee dislocation is among the severest of injuries.
MMMD extra: ProFootballDoc scorecard
I was on vacation with the family so I did not have my usual video capabilities in the hotel but thanks to the extra cameras and playoff coverage, many great replays were shown allowing me to still provide some input.
Davonte Adams returned from left high ankle sprain. David Bakhtiari returned from a mild MCL sprain. LaDarius Gunter avoided injury from a bad looking hit. DeShawn Shead appears to have torn his ACL.
C.J. Prosise did not play as expected and neither did Jordy Nelson. Big Ben’s foot/ankle was a non-issue. Blake Martinez was limited with his MCL.
This improves the 203-10 (95.3%) record to 211-10 (95.5%)

Monday Morning MD: Who is healthy for the Divisional Round?

Will Big Ben or Jordy Nelson play this week? How will injuries play a role in who moves on to the Conference Championships?
Ben Roethlisberger made the collective hearts of Steelers Nation stop when he showed up at a post-game press conference in a boot. He injured his right ankle/foot on the final interception with 4:34 left to go in the fourth quarter up 18 points trying to extend a play. Big Ben was rolled up on with a plantar flexion sprain to his right ankle/foot. This is not a dreaded high ankle or Lisfranc sprain. Walking boots are commonly used as a precaution to help control swelling and will likely come off shortly. The Steelers QB may even skip a practice or two, adding to the drama. Recently, Roethlisberger has played through a meniscus tear, Lisfranc sprain and separated shoulder. I am expecting he is more hurt than injured here, thus Big Ben will undoubtedly be healthy and mobile when they face the Chiefs, but whether he has Ladarius Green as a target is up in the air due to concussion symptoms.
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Jordy Nelson took a helmet to the left lower postero-lateral ribs and did not return. Not only is there worry for rib fracture, there is some concern for internal organ injury. He left the field on a cart with a primary care physician (not orthopedist). If there is a fracture (and there may be more than one), it will be difficult to play in Dallas this week for not only the pain, but the risk of injury to his spleen/lung/kidney. Without a fracture, Nelson might have a chance to play with medication/rib block and a flak jacket.
In other Packer news, Ty Montgomery who had recent ankle issues and was twisted up awkwardly and limped off the field. He returned to finish the game. By video, LB Blake Martinez injured his MCL. He had a similar injury in November. He could play and run well but would have trouble cutting.
Tom Savage has a good chance to get cleared from his Week 17 concussion but would still be the back up as Brock Osweiler has already been named the Texans starter.
Danny Ammendola returned to practice for the first time since the Week 13 apparent high ankle sprain. I expect him to be near 100% given he has had six weeks to recover by the time the Patriots kickoff.
The Cowboys should be at full strength with Tyron Smith coming off a mild MCL sprain and Morris Claiborne finally returning to action after a groin avulsion injury in Week 8.
I expect both Justin Houston (knee) and Spencer Ware (ribs) to both give it a go this week for the Chiefs.
Russell Wilson shed his knee brace and looks to finally be himself after knee and ankle issues for most of the season.
Let’s hope we see all players at full strength and may the better team win.
MMMD 1: Should Matt Moore have been pulled?
The Dolphins QB took a ferocious and penalized hit to the jaw. The internet was abuzz with outrage that he was returned to the game after missing just one play and thought that he could not have been properly checked for concussion.
I took a stopwatch to the sequence of events. With the prolonged time tending to Moore on the field and the adjudication of the multiple penalties, there was exactly five minutes of elapsed time between the hit and his next snap. If play had resumed immediately, Moore would have missed a handful of plays or more. He only missed one play due to the protracted stoppage.
Typically a sideline concussion screen only takes about two minutes. If positive, a full locker room evaluation takes approximately 10 minutes. The league appointed Unaffiliated Neurotrauma Consultant (UNC) was seen taking an active role. Remember, this is a local Pittsburgh area physician (who is likely a Steelers fan) and I would find it hard to believe he was influenced by the Dolphins’ desires to keep Moore in the game.
A hit to the jaw can cause a concussion. After all, that is why mouthpieces can decrease head injury risk. However, Moore was hit with more of a rotational force to the jaw torquing his neck and thus may have escaped concussion symptoms.
I don’t know the details of how the medical decisions were made but here is another reason for transparency. Referees are questioned by a pool reporter after the game. Why not let the UNC speak as to what he saw and what the medical thinking was? This would not be a patient privacy violation as the UNC is the league observer and is not there to treat the player and thus HIPAA would not apply.
MMMD 2: Changing of the guard?
Some are proclaiming Jadeveon Clowney as the new Texans defensive leader. Certainly he played well and with a skinny J.J. Watt in street clothes on the sideline, that was an easy narrative as we are prisoners of the moment.
Don’t count Watt out yet. First, the team is just being cautious after the second disc surgery. Second, I expect a full recovery, as disc surgery does not typically end careers. Third, it is easy for a workout warrior to lose muscle mass quickly but it is also relatively easy to regain weight with the start of lifting, if you have been that big before.
Expect a double-headed monster for the Texans defense next year, not a passing of the torch.
MMMD 3: Tyrod Taylor contractual controversy?
The Buffalo QB underwent sports hernia surgery as expected. The Bills announced Taylor “elected” to have the procedure. Is that wording posturing for the looming $27.5 million March contract guarantee?
Typically core muscle surgery takes 6-8 weeks to return to play but three months to be 100%. The March date comes in between this timeline.
By contract, the team physician will be the one to determine if Taylor is healthy. This does present a potential conflict. When I was a team doctor, I avoided these situations by asking the team to never inform me about the business side. It was my job to get all players healthy as soon as possible. The best player needed to be healthy to get on the field and the worst player on the team needed to be healthy to get released to make room for roster improvement. I did not want to be influenced by factors other than my medical judgment.
I hope the Bills ownership and Taylor can get on the same page
MMMD 4: Injury rundown
Dominique Rodgers-Cromartie suffered a thigh bruise early against the Packers. With a quad contusion and stiffness, it is hard to run and play cornerback. The challenge to get and stay loose was made harder in the cold and he was thus ineffective.
Jason Pierre-Paul will return to be 100% from his sports hernia surgery but there is no rush anymore as the Giants were eliminated.
Donald Penn reportedly has a small fracture in his knee but will not need surgery.
Ryan Tannenhill did not return from his ACL/MCL sprains. The MCL heals with conservative care but do not be surprised if surgery is announced for his ACL.
Jay Cutler’s shoulder labral surgery is recovering well. Whether the Bears will keep, cut or trade their QB, they need him healthy as soon as possible for all three potential reasons.
Trevor Siemian had left shoulder surgery. He finished the season but it is not unusual to have clean up procedures. This is why the end of the season is the busiest medical time of the year.
Terrelle Pryor had finger ligament surgery and is expected to have a full recovery.
Sammy Watkins finally is having his much anticipated second Jones fracture surgery. This time, likely bone graft and a larger screw will be used. Dez Bryant and Julian Edelman had similar second surgeries last offseason and recovered well.
Matthew Stafford will not need surgery on his mallet finger. The extensor tendon heals well with immobilization.
MMMD 5: Coaches union?
Brandon Marshall said, “It’s time for our coaches to unionize. We’ve had four coaches in the hospital this year. If people understood how many hours, and what it takes to be a head coach, how many hours they put in, it would be an issue.”
Perhaps instead of a union, it could be a competition committee issue. Even if hours were limited, coaches would take work home. However, that is still better for their health than long hours at the office.
MMMD 6: Jaylon Smith back in the news
The Cowboys high second round pick says he is still recovering and wearing his ankle foot orthosis (AFO) but can run a 4.5 40-yard dash.
I appreciate Smith’s optimism but I have never seen anyone in the NFL play with an AFO. Mike Ryan, a long-time NFL athletic trainer and now sports medical analyst for NBC, concurred.
A tendon transfer is not the answer either as those procedures are done to help everyday people to walk, not get around the corner to rush a QB.
I wish Smith the best and hope he can make history.
MMMD 7: ProFootballDoc scorecard
Matt McGloin was available but the Raiders played Connor Cook. Tom Savage was not cleared. Ryan Tannenhill was not ready to go. There was no way for Derek Carr to even travel to the game. Matt Forte did have a knee scope. C.J. Mosely had a calf strain and no surgery needed. JPP did not return. Tyrod Taylor and Sammy Watkins did have surgery as predicted. Jordy Nelson injured his ribs. Ty Montgomery is OK and returned. DRC had a quad contusion.
The previous 191-10 (95.0%) record is now 203-10 (95.3%).

Monday Morning MD: Smart to sit?

To play or not to play was the theme of the week for both college football and the NFL. Leonard Fournette and Christian McCaffrey ignited debate when they decided to skip their college bowl games to prepare for the draft. Meanwhile the Cowboys and Steelers rested their stars in meaningless games as other teams played their starters.
Medically speaking, it is certainly smart to sit as it is the only way to avoid injury. McCaffrey’s teammate, Stanford QB Keller Chryst appeared to tear his ACL. Michigan’s high draft prospect TE Jake Butt tore his ACL which will affect his draft stock as there is no guarantee he will be ready for the start of the next season.
The key is what do the 32 NFL general managers think of the decision to miss bowl games. The natural question is: are they “me” guys more than “team” guys?
Sometimes the decision to miss the bowl game is clearly smart. Michigan’s Jabril Peppers was better off not playing for risk of making his hamstring injury worse and effecting his Combine as well as potentially being downgraded for not playing up to par.
On the other hand, not playing sometimes hurts. Florida State’s Dalvin Cook had a spectacular bowl game performance, which may have catapulted him to the top of the RB draft board. Meanwhile, Fournette could not respond to reclaim his top status as he had elected to sit.
NFL decisions to sit are made by the team not the individual player like in college. Weighing the potential of injury versus momentum/continuity is the playoff team’s dilemma. The Raiders clearly needed Matt McGloin to play to get more snaps but unfortunately he was injured.
If the argument is to always sit for meaningless games then the majority of the NFL would not play as most Week 17 contests had no postseason implications. In retrospect, the Cardinals probably wish they had sat David Johnson (details below).
There is precedent for NFL players to choose to skip meaningless “bowl” games. It is common for professionals to pull the injury card to skip out of the Pro Bowl. Tyler Eifert injured his ankle during the all-star game last year and needed surgery. He now says even if selected, he is never going back.
The bottom line is many things factor into a “play or sit” decision for the individual and teams. I certainly can’t argue with a player’s right to decide or a team’s necessity to strategize.
MMMD 1: Another QB concussion controversy?
Questions arose after Tom Savage was returned to play and then pulled due to concussion. It certainly looks fishy when the Texans QB is cleared and the head coach says at halftime he will play but he is re-evaluated and pulled from the game.
In reality, it is common to be fine and develop later concussion symptoms. It is routine for doctors to perform serial exams. Likely Savage had a routine re-check at halftime and doctors decided to pull him.
This is another reason that I have lobbied for more transparency. Why not let the doctors speak or at least issue a statement? Even referees are interviewed by a reporter post game. Understanding what happened would help clarify these situations and help dispel the distrust the public and media have for the NFL when it comes to concussions.
MMMD 2: Playoff QB injuries
With Savage in the concussion protocol, Brock Osweiler will be the likely Texans starter for the Wild Card round. The majority of head injuries are not cleared in one week. This will be a short week with the game on Saturday. Even if Savage was cleared late in the week, he would still miss practice snaps important for a first time starter.
Matt McGloin left the Raiders game with an apparent left AC joint sprain and later reports of trap muscle issues. It appeared that McGloin was not happy he was replaced and he was in uniform on the sidelines for the second half. It will be interesting to see if Connor Cook gets the playoff start and how much of this is coaching decision versus purely injury.
Matthew Stafford’s injury appears to be a mallet finger. I have suspected this by the type of splint but media had only reported dislocation with torn ligaments. A mallet finger is a tear to the extensor tendon at the tip of the finger and requires full-time immobilization in extension for six weeks or there is risk for surgery. Stafford can play through without long-term implications but a mallet finger injury is significantly harder to deal with than a finger dislocation as it affects his grip since he is not allowed to bend the tip of his middle finger. This could explain his declined performance post injury.
David Carr reports that brother Derek’s ankle ligament was not torn and the fracture was already healing. That may be a lay person’s interpretation but no way a bone starts to heal in three days. Also when your knee points “north” and your toes point “east”, the syndesmotic ligament is torn even before the fracture happens. Derek Carr will be back at 100%, but no way it will be in time for a potential Super Bowl appearance.
Ryan Tannenhill seems to be getting closer to playing but I think it will be beating the odds for him to be the Dolphins Wild Card round starting QB. Even if it is just a grade 2 MCL, it is a stretch to go from a cast and a crutch to playing NFL football in three weeks.
Aaron Rodgers seems to have put any worries about his calf strain and hamstring injury behind him. He moved and ran well during the Packers win to seize the NFC North crown.
Tony Romo played in a real game for the first time in over a year. He is completely healed and at no further risk for injury. What a luxury for the Cowboys to have an experienced back up like Romo.
MMMD 3: David Johnson escapes horrific injury
By video, many feared the worst for the Cardinals star RB. Fortunately, it seems to be the best-case scenario for Johnson with only a significant MCL injury with his ACL spared. He is unlikely to need surgery and should be healthy for the offseason program.
MMMD 4: Jets medical staff blamed
Muhammad Wilkerson appeared to criticize his team’s training staff for not having a plan as he returned from ankle surgery. He did acknowledge his responsibility in the process as well.
There is no question that hindsight is 20/20 and that medical staffs can look back and wish they had approached an injury differently. However, it is unusual to call out a teammate and indeed the athletic trainers are looked upon as teammates.
Undoubtedly the medical staff was consulted before Wilkerson was offered an $86 million contract while he was injured this offseason. If anything, he should thank the trainers and doctors for vouching for his ability to recover.
MMMD 5: Decreased injuries with more touchbacks?
The rule change to place the ball on the 25-yard line has decreased kick-off returns but has it reduced injuries? Bill Belichick cited the Broncos Kayvon Webster’s concussion as an example of how the new rule has not worked. Sometimes injuries can happen when covering teams ease up as they see the runner kneeling down, but blockers don’t know the play is over. Full speed versus half speed will result in injury.
I am eager to see the season long statistics on this rule change. The NFL usually releases this type of injury data during the Super Bowl week health and safety press conference..
MMMD 6: Non QB Injury rundown
Vic Beasley left shoulder “popped out” but he returned to finish the game with a brace. Don’t be surprised if he needs offseason surgery similar to what he had on the right side last year.
Zaire Anderson was placed on a spine board after a head down hit. Fortunately he was released from the hospital.
Donald Penn left the game with a knee injury but returned. He will likely play against the Texans on Saturday.
C.J. Mosely was carted to the locker room but I do not expect a serious left leg injury.
Sammy Watkins injured his hip that he had surgery on in 2015. The hip does not appear to be severe but he will need to address his 5th metatarsal lingering fracture which may need a second surgery to heal properly.
Quinten Rollins was placed on a spine board for head/neck injury but early reports indicate that he will be OK.
DeMarco Murray played with a plantar plate injury this season to become the leading AFC rusher. This is essentially a turf toe injury. He will avoid surgery unless the plantar plate is retracted.
Ryan Kerrigan exited with left hand/finger injury
Ty Montgomery left the game briefly with and ankle issue but returned to be effective.
Tyrod Taylor has a groin injury and don’t be surprised if he elects to have a sports hernia surgery.
Tyler Eifert had back surgery. It has been a rough year after his ankle surgery from the Pro Bowl injury.
Tyron Smith sat out with a mild MCL from last week where the knee brace may have saved him form more severe injury.
MMMD 7: ProFootballDoc scorecard
Only a few injury first takes this week as I was on vacation with the family in the mountains and did not have my usual set up and access to all videos. David Johnson fortunately with only MCL sprain. McGloin has an AC joint sprain and trap spasm. Quinten Rollins neck was OK. Tyron Smith did have a mild MCL.
Last week’s 187-10 (94.9%) is now 191-10 (95.0%).

Monday Morning MD: Derek Carr and Marcus Mariota with similar season-ending injuries

The leader of the Raiders and Titans both were announced to have suffered broken fibulas. Unfortunately by video, the injury is more than just to the bone. Both were felled by the severest form of high ankle sprain where the syndesmotic ligament (holds the fibula and tibia together) is torn before the fracture even happens.
Essentially both injuries are considered ankle fracture-dislocations where the talus (ankle bone) shifts out of place. The need for surgery is not for the fibula fracture as much as to reposition the bones due to the ligament tear.
Derek Carr was reported to be having surgery on Christmas Day, but was delayed due to holiday staffing issues and he is now reported to travel to Los Angeles for the procedure. Marcus Mariota was set to have surgery in the next few days after injury. The procedure is not an emergency and can be done in the first week or two.
The initial urgency for Carr’s surgery may have been born out of a desire to keep any slim hopes of a Super Bowl 51 return alive. Assuming the Raiders make it to the big game six weeks away, it would still be a considerable stretch to think that Carr would perform anywhere near his MVP candidate level. This is not just an issue of bone healing but one of the ligament and associated structures as well. Typically, this injury carries a six-month recovery, thus reports of earlier return seem optimistic to me. To cite the Charles Woodson or Terrell Owens early Super Bowl return from ankle fracture would be unfair comparisons as there is a dislocation component here for Carr.
The good news is that this is not a career-ending injury and both should return to essentially 100%. A good example is Darren Sproles who had a similar injury/surgery 10 years ago and continues to perform at a high level and is still known for his quick cuts as a running back. Both quarterbacks should be ready for the start of the 2017 season.
MMMD 1: Another broken leg
Tyler Lockett suffered a gruesome tibia and fibula fracture (graphic video here). Teammate Earl Thomas broke only his tibia and did not need surgery. Lockett broke both bones and likely has an open fracture with the description of blood immediately on the field.
This fracture is very unstable and requires early surgery. Fortunately the Seahawks were in Seattle, otherwise Lockett would have needed surgery before flying home.
Despite how horrific the injury seems, this is not a career-ending injury. Many others, including Patriots fullback James Develin last season, have made full recoveries. This is a similar injury to NBA’s Paul George and UFC’s Anderson Silva who both have returned to their sport. Lockett may not be ready for the start of the season as there is typically a 6-9 month recovery.
MMMD 2: Earl Thomas returning
Thomas likely suffered a non-displaced isolated tibia fracture and thus did not need surgery. He contemplated retirement at the time.
Medically, this was not an injury that ends careers. I would not begrudge any athlete who chooses to retire as I agree one needs to be “all in” to play effectively.
Fortunately for us as fans, Thomas has decided to return next season. Since he tweeted retirement thoughts on his twitter account immediately after the injury, it was appropriate that he used twitter to announce his return.
MMMD 3: Play or sit?
Christian McCaffrey and Leonard Fournette started much discussion with their decision to skip bowl games to prepare for the draft. Skipping games is a precedent that already exists in the NFL. Many players choose to miss the Pro Bowl. Tyler Eifert hurt his ankle there last year and needed surgery, which affected his season. He would not go back if asked.
Now the discussion of play or sit turns to the teams that have clinched post-season spots. For example, should the Cowboys sit their stars for rest and/or injury protection or keep momentum going? Does the season-ending injuries to Carr and Mariota make it more likely we see Tony Romo over Dak Prescott to finish the regular season?
MMMD 4: Return to play decisions
A.J. Green is unhappy he was not allowed to play. He made the trip to Houston for the Christmas Eve game with the expectation to suit up, while other injured players stayed behind.
Green was pulled from a team meeting and informed of the ownerships decision to not risk further injury and he subsequently flew home. The decision was based on fear that the tendon portion of the hamstring injury had not fully healed and further damage might mean surgery.
Return to play is always decided by a unanimous vote between the player, medical staff and the team. It is clearly within the ownerships rights to withhold the player, but perhaps communication of that intent prior to travelling to the game would prevent any hard feelings.
MMMD 5: Team doctors care for more than players
Todd Bowles was treated for kidney stones and gall bladder issues. With Gary Kubiak (complex migraine) and Mike Zimmer (retinal detachment), that marks the third head coach to be hospitalized this season which is a higher rate than for players.
Line Judge Sarah Thomas was knocked down and taken to the locker room. She did return to finish the Vikings at Packers game.
Head coaches and all team staff are cared for by team physicians. In fact, coaches’ physicals is a big part of a team doctor’s job. On game days, the home team medical staff is responsible for providing care to the game officials.
MMMD 6: Injury rundown
Aaron Rodgers left the game briefly with a stinger. This should not be a major deal if the Packers protection holds up. The calf injury seems to have progressed nicely.
Ryan Tannehill came out of his cast which is certainly good news. Still with the partial ACL/MCL injury, he may not be ready to go for the wildcard round.
Jay Ajayi fell on his left shoulder in overtime suffering a likely AC joint sprain that is hopefully mild and won’t have him missing time.
Carlos Hyde injured his knee and will be done for the season. MCL sprains do not typically need surgery and he will be healthy for the off-season program.
Justin Houston sat out, proving again that even though players return well from ACL surgery, the second season back is the fully healthy one.
Robert Griffin III left with a concussion but the Browns notched their first victory.
Jordan Reed did not play with his grade 3 AC separation which is usually a six week injury.
Ryan Matthews is reported to have a herniated disc in his neck. Even if he needs surgery, return from single level cervical discectomy/fusion is reliable in the NFL.
Derek Wolfe left with a neck injury that has plagued him in second half of this season.
Kayvon Webster was blind-sided, but riding off in the passenger seat of the cart is a great sign that his spine was OK. Of course his head injury will need evaluation.
MMMD 7: ProFootballDoc scorecard
Unfortunately the significant injuries to Derek Carr, Marcus Mariota and Tyler Lockett were easily seen on video. Will Gholston did dislocate his elbow missing this week. Kayvon Webster suffered a concussion but was spared neck or back injury. Earl Thomas will play in 2017 as expected.
The previous 181-10 (94.8%) record now improves slightly to 187-10, a 94.9% accuracy rate.