Monday Morning MD: Tannehill ACL tear preventable?

The Dolphins were victorious staying in playoff contention, yet they lost big when their starting quarterback suffered a serious knee injury. Ryan Tannehill routinely stepped into a throw when Calais Campbell, who may have been pushed from behind, hit the QB’s lead leg.
Miami fears an ACL tear for their star signal caller. By video, it was a classic lead leg hyperextension injury, the kind that has ended many quarterbacks’ seasons. Opposing QB Carson Palmer, back in 2006 when he was a Bengal, tore his ACL the same way on a long completion. Tom Brady had a near identical mechanism with his 2008 ACL. I was on the opposing team sideline in 1999 when Trent Green tore his knee ligament in similar fashion, after which Kurt Warner led the “greatest show on turf” to Super Bowl victory.
All of these examples were routine completions where the QB steps into the throw and transfers weight to the front leg on follow through. None of them were broken plays or excessively violent hits, although intentional contact to a quarterback’s legs in the pocket is now illegal for just this reason.
Would a knee brace have prevented these injuries? No one can be sure, but in college prophylactic bracing is largely mandatory on offensive lineman and often the lead leg for the quarterback. Some NFL players use it routinely as well, including Brady after he learned his lesson after his ACL tear.
Studies have shown some ability to prevent ACL tears with knee bracing. However, due to small sample size, there are no definitive statistics on how effective lead leg bracing is on NFL quarterbacks.
I am not definitively saying Tannehill would still be playing had he wore a prophylactic brace. The point is with known injury risk on such a routine play, wouldn’t it make sense to take the precaution? It might even give a QB more confidence to step into throws and keep his eyes up the field. Many quarterbacks, like Joe Flacco, routinely use a lead leg brace after their reconstructive knee surgery, but why not before to prevent the first injury?
The team knows before the MRI. The Dolphins will get the results of imaging to assess associated damage and confirm the tear before the formal announcement is made today. Obviously, Tannehill’s season is over, but there is a likelihood to be ready for Week 1 of 2017. The question is would a brace on the lead leg have saved the rest of this season for the Dolphins QB.
MMMD 1: Lions fans should not panic with QB finger injury
Finger dislocations are common. In my experience, on average, there is one or more a game. However, when it happens on the throwing hand of the star QB, everyone is understandably worried.
By video and reports, Matthew Stafford dislocated his middle finger PIP (proximal interphalangeal) joint. There should be no fracture or tendon injury. With every finger dislocation ligaments are torn, but once reduced, heal well with tape/support and do not need surgery.
This injury should not have a big effect on Stafford. In fact, he stoically never missed a play, but did don a glove afterward to improve grip. Derek Carr recently dislocated his pinky finger and has continued to play effectively (outside of a poor team performance in the cold this past Thursday). Even if a description of mallet finger with tendon injury is true (which does not fit the video), expect him to play through effectively.
Stafford played thru a 2011 broken index finger. If he can play through a fracture, which can be unstable on the 2nd finger, surely he can play effectively on a stable reduced dislocation on a less important for throwing 3rd finger.
MMMD 2: Aaron Rodgers déjà vu?
In December 2014, the Packers QB suffered what seemed at the time an innocuous left calf strain. The injury lingered and bothered Rodgers running ability throughout the playoffs.
Sunday on the third play, Rodgers suffered a right calf injury and although he noticeably limped, led his team to a dominant win. The injury likely was due to compensation for the left hamstring.
Calf injuries tend to linger so this one bears watching. Expect to see Rodgers throw well with his arm strength. He should be able to move in the pocket, but don’t expect Rodgers to take off and run anytime soon, including potentially during the playoffs if the Packers get there. This may be a repeat of the 2014 injury.
MMMD 3: Melvin Gordon hip
A star running back being carted off is always a scary sight. When the injury is to the hip of a young talented recent first-round pick, fears of a Bo Jackson career altering injury flash to mind.
By video, Gordon’s injury has no similarity to Jackson’s other than both were hip injuries. The Chargers RB was injured with extreme flexion, adduction and internal rotational twisting. The end of Jackson’s career was a result of significant axial load trauma instead.
With playoffs out of reach, the Chargers were smart to hold Gordon out pending a confirmatory MRI. I expect a posterior capsular sprain and it will be good to rule out any small avulsion fracture or labral tear.
My guess is that Gordon will return without surgery to get his 1000 yards rushing (he is 3 yards shy), but also expect the team to stop making him the work horse to save him for next year.
MMMD 4: JPP groin surgery
Jason Pierre-Paul was having a resurgent season after his 2015 fireworks injury. Now he is out for an extended period of time. Nowadays, traveling to Philadelphia is a harbinger of core muscle surgery and indeed JPP has a sports hernia fixed.
It would be optimistic to think JPP could come back and be effective unless the Giants made a deep playoff run. The recovery takes 6-8 weeks to return to play but several months to get to 100%. Don’t expect JPP back unless the Giants make a Conference Championship appearance.
MMMD 5: Jamaal Charles return?
Despite the disappointing ACL comeback earlier this season and now two knee surgeries, the Chiefs could get their star RB back for the playoffs. Charles is eligible to return off IR in Week 17.
This is not far-fetched. Both knee procedures were arthroscopic clean ups and the eight week short term IR timeline would fit nicely. Look for Kansas City to have a playoff boost from Charles.
MMMD 6: Injury rundown
Matt Forte left the Jets game early with lateral popping/crunching. His ligaments are OK but a MRI is pending. Don’t be surprised if this veteran has a knee scope when his season ends.
Jared Cook left with a chest injury after a hard fall to the ground. Hopefully there is no pneumothorax and he can return soon.
Chris Harris Jr was chop blocked on his right knee and suffered a MCL sprain. Thankfully his foot was not trapped and the injury appears minor as he returned to play.
Marcus Gilchrist collapsed onto his right knee. Unfortunately, he tore his patella tendon which is harder recovery than even ACL tear.
Su’a Cravens was reported to have a biceps partial tear. If the distal tendon is torn, that could mean season-ending surgery.
By video, Jack Mewhort left the Colts game with a MCL injury and I hope his ACL was spared.
Joey Bosa was evaluated for concussion and later neck injury. I hope this to be a temporary setback for the potential rookie of the year.
Derrick Johnson had Achilles surgery. Medically, this should not end his long and illustrious career.
Brian Cushing is reported to be playing through two spine fractures, which are likely to the transverse process.
MMMD 2: ProFootballDoc scorecard
Cecil Shorts unfortunately did tear multiple ligaments in his knee. Braxton Miller did injure his AC joint. Julio Jones did miss with his turf toe. Trevor Siemian did play with his foot injury. Sammy Watkins and Robert Woods were far from themselves. Derrick Johnson did rupture his Achilles. Charles Johnson did miss time with a hamstring injury.
Melvin Gordon hurt his left hip but it did not appear to serious. Joey Bosa appears to avoid serious injury. Randall Cobb has a mild high ankle sprain and returned. Ty Montgomery appeared to have a stinger. Chirs Harris Jr left temporarily with a mild MCL sprain.
I am documenting an error on Marcus Gilchrist. His season is over but with patella tendon rupture, not ACL tear. I probably should not have opined off only one replay angle.
The previous 161-9 (94.75) record for 2016 is now 174-10 (94.6%).

Monday Morning MD: Earl Thomas season over

Three weeks ago two stars collided when Earl Thomas tackled Rob Gronkowski in one of the most talked about hits of the year. Now both headline players are done for the year.
Gronk was placed on IR on Friday (details in Item #1 below). Thomas, a leader of the Seahawks “legion of boom”, will soon follow suit after his lower leg injury last night.
This time the collision was between star teammates, when Kam Chancellor’s leg inadvertently “karate chopped” Thomas’ tibia bone. He tried to stand on it momentarily but couldn’t, yet refused to be carted off the playing field.
Pete Carroll indicated a “cracked tibia” and mentioned six weeks in his timeline, but Chancellor said it was a fibula but season ending. By video, the truth is somewhere in between: a season ending nightstick tibia fracture (with fibula intact).
The tibia is the much larger weight bearing bone in the lower leg. The fibula is the smaller bone. The recovery for an isolated fibula fracture is non-surgical and approximately six weeks (see Thomas Rawls). The healing for an isolated tibia fracture is about six months and usually means rodding surgery. Because the fibula was intact, the lower leg did not need an immediate fracture splint, yet it is still a serious injury.
Unfortunately, I don’t see a scenario where Thomas could return this season, even if the Seahawks make it to the Super Bowl two months away. Fortunately, he has an excellent chance at full recovery for the 2017 season. Famously, UFC fighter Anderson Silva and NBA star Paul George fractured both tibia and fibula and both made full returns. Other recent NFL players to come back after tibia fracture include Khiry Robinson and James Develin.
Thomas tweeted about possible retirement immediately after the injury. I would never blame a player who makes the decision to hang up his cleats, but the best safety in the league will be back next year, if he chooses to do so.
MMMD 1: Gronk career not over
With his eighth surgery consisting of a low back procedure, some are saying Rob Gronkowski may be done or on serious decline. No question a third disc surgery is concerning, but all were not at the same level (one L4-5 and now a second at L5-S1). Three at one level would beg the need for lumbar fusion, which would end an NFL player’s career. This does not seem to be the case.
The Patriots and Gronk/family are rightfully taking the cautious course. Gronk could return to play at 6-8 weeks post discectomy in time for the conference championship game or Super Bowl, but would not be at 100% until at least 3-4 months. Just like J.J. Watt could come back now after his second surgery on his same disc; however, the Texans are being cautious and looking at the long-term picture.
One can argue any player starts to decline as he approaches the age of 30, but I do not see this as a career ending deal for the 27 year-old superstar. Yes, Gronk will need to be careful and perform lifelong back stabilization exercises and he does risk back pain and degenerative changes long term; however, it would be premature to say his career is over or in decline.
MMMD 2: Hockey injury descriptions?
Julio Jones was described by his head coach as having a “lower body injury”. Normally such descriptions are reserved for the NHL, where a team indication of upper or lower body injury are all that is routinely given.
Although the NFL reports are far from complete, at least it requires a body part and is far superior to the NHL. With the NFL getting rid of “probable” designations, I hope this is not a sign of moving towards even less information.
MMMD 3: Sideline tent
During last week’s Monday night game, there was much intrigue over the Packers structure behind the bench. Cameras followed Aaron Rodgers entering the mysterious canopy causing fans to wonder.
This is simply a medical tent for potential evaluation and treatment. Rodgers entered for privacy to drop his pants to get a hamstring pressure pad wrap.
Several colleges have even bigger versions. I personally wanted to have one when I was a NFL team doctor. Ironically now, I would rather teams not have them as I would rather see what is going on.
Often it saves a trip to the locker room or provides a place to quickly relieve one’s self without running inside.
MMMD 4: Vikings get head coach back
Mike Zimmer had emergency eye surgery and missed his team’s game. This third procedure for a detached retina was likely more than a simple laser and may be his last chance to regain all of his vision. Opthomologists have quoted to me a 25% chance of permanent visual impairment if this surgery doesn’t go well.
Position, stress, airplane restrictions and temporary visual impairment are common. It has been reported that if Zimmer can now fly to Jacksonville for the next game and has resumed coaching duties. Even with the good news, there is no question he will be limited this week in terms of watching film and installing the game plan.
Zimmer and the Vikings should be smart and do whatever it takes to restore his vision as a priority.
MMMD 5: Medical marijuana in NFL?
Seantrel Henderson was suspended for marijuana use that he claimed was used to treat his known Crohn’s disease. The 10 game suspension was confirmed despite the medical reason for usage.
Although recreational and medical marijuana are becoming increasingly legal in various states, it is still strictly prohibited in the NFL. Currently there are no medical use exemptions. If players want this to change, it needs to be a topic for the next collective bargaining agreement (CBA). Don’t be surprised if that happens.
MMMD 6: Injury rundown
Let’s start with positive medical news. Eric Berry beat cancer just over a year ago and now his pick-6 and pick-2 literally won the game for his Chiefs.
Aaron Rodgers was limited but survived without re-aggravating his hamstring, which is tough given the cold weather and poor footing with the snow. If the Packers can continue a playoff push, this injury should be behind Rodgers if they make it to the post-season.
Derek Carr didn’t have any issues with his finger dislocation. He did not use a glove or buddy tape the pinky and lead the Raiders to a decisive comeback win.
Dennis Pitta had a career threatening injury when he dislocated his hip the second time. It took surgery and two years but he is finally back, as he had nine catches for 90 yards and two TDs, his first since the injury.
Clay Matthews and Justin Houston both played through AC joint sprains on Sunday.
Michael Bennett returned to play four and half weeks after his knee scope.
The worst injury of the day belongs to WR Cecil Shorts. By video, he suffered a multi-ligament knee injury which likely involves his ACL and MCL.
The Patriots likely will loose Danny Amendola for some time with a right high ankle sprain, but the hope is to be 100% for the playoffs.
Jason Pierre-Paul by video has a groin strain, which was confirmed.
Sammy Watkins played through his Jones fracture, which has still not completely healed. The Bills targeted him nine times but he only had three catches for 28 yards. At some point, one has to shut him down and have surgery again to get right for next season.
A.J. Green seems to be improving and on course for a late season return from a grade 2 hamstring injury.
Doug Martin limped off with an injury to the left side where the injury was obscured by a pile of bodies, but hoping/expecting that it is minor.
Trevor Siemian did not practice with his left foot injury and missed the start but I think he has a good chance for this week.
Charles Johnson injured his left hamstring and may miss some time.
An abdominal injury is trouble for any kicker and the Steelers replaced Chris Boswell with Randy Bullock temporarily.
MMMD 7: ProFootballDoc scorecard
There were three mistakes this week. They were not bad ones and I could argue that I was at least partially correct but I will take my lumps. There may have been more to Gronk’s injury than the innocuous Jets fall but he is done for the year with a disc injury. Despite the fact the Jordan Reed should return soon from his grade 3 AC sprain, he did miss this week. The Danny Trevathan injury turned out to be an ACL tear.
Jay Cutler’s season is over with labral tear surgery. Ryan Kalil is suffering the same fate. A.J. Green has a multi-week proximal hamstring strain. Daryl Williams has a left high ankle sprain. Steeler’s kicker Chris Boswell abdomen did keep him out. Derek Carr played well despite last week’s finger dislocation. Sammy Watkins does still have a fracture in his foot.
Dont’a Hightower avoided serious injury from a chop block as his feet were not planted. Andrew Whitworth suffered a mild MCL sprain and later returned. Luke Stocker appears to have a left high ankle sprain. Bucs WR Adam Humphries left due to a concussion. JPP had a groin strain confirmed. Michael Crabtree avoided serious injury. Charles Johnson exited with a left hamstring injury. Justin Houston played through his apparent mild AC joint sprain. Michael Bennett took longer than the original 2-3 week return as expected. Danny Amendola was confirmed with a high ankle sprain.
These new additions to the scorecard lower the previous 145-6 (96.0%) record to 161-9 (94.7%).

Monday Morning MD: Solution for Thursday Night Games

Coming off the biggest Thursday with three Thanksgiving games there seems to be a renewed call to get rid of some midweek contests. Even John Madden is critical saying “it just doesn’t work”. The league is reportedly revisiting the subject to consider ending or limiting Thursday Night Football.
My suggestion that I first wrote about in 2014 is simple. Add a second bye week and pair all teams playing on a Thursday with a bye. This way, there would be 11 days before and still 10 days after.
Playing on four days rest and all of its problems would be eliminated. There would be no more health and safety concerns. Players like Andrew Luck who missed the Thanksgiving game with concussion could then play and improve the competitiveness of the game. There would be no need to schedule only regional matchups to avoid long flights and thus provide more compelling matchups. Teams would be able to install normal game plans and the quality of the product would improve.
Teams look forward to the bye week and there are often complaints that the singular break comes too early or too late. Byes are universally acknowledged to be good for player health and recovery so why not have one in the first half of the season and another in the second?
To alleviate the CBA and scheduling concerns of adding a week to the season, the league could get rid of one preseason game. The money lost doing that would be more than made up for by the TV revenue of an extra Sunday, Monday and Thursday game as well as an extra slate of games in the regular Sunday slots. Currently, it is impossible to follow all the nine or ten early games or the three to four later games and spreading 16 weeks of football over 18 weeks would barely be noticed.
A second bye week was tried in 1993 but that was over two decades ago and the league only had 28 teams at the time instead of 32, so it was like four teams were on a perpetual bye already in terms of scheduling.
Heck, if this happened, the league could even add a Wednesday night game and there would be no short week issues.
The bottom line is, I believe players would be in favor of adding a second bye and pairing Thursday games as long as it didn’t lengthen the season. Owners will be for it as there would be more dollars to be had. Fans would get one more week of meaningful football. In the end, this is a rare opportunity for the NFL to improve safety and increase revenue at the same time.
MMMD 1: Derek Carr finger dislocation
Finger dislocations are commonplace in the NFL. Often players will put their own fingers back into place without even running to the sidelines to seek medical help. Most linemen tape their fingers to help prevent dislocation. Most of us have seen the gnarled finger joints of ex-players.
Derek Carr’s right fifth finger dislocation brought lots of attention as it was publicly visible, resulted in a turnover, he ran off the field with pain, everyone always notices the quarterback and it was on his throwing hand.
By video, it was a pinky finger dislocation without associated fracture. The PIP joint is the most common one dislocated and once reduced is stable. Carr did go to the locker room for likely X-rays, tape/splint support, medication/treatment and returned with a glove to lead the Raiders to victory.
Although he will be more sore and swollen after the game, Carr will play next week against the Bills. There may be some practice time and game modification but he should still perform well. Note that Carr lined up in victory formation from the pistol, likely to avoid the pain from a direct under center snap on his top dominant hand.
MMMD 2: Brady and Gronk
Both Tom Brady and Rob Gronkowski started the game as expected and the Patriots were lucky to escape the Jets with a win.
Gronk chest issue and presumed pneumothorax was not a problem but he did leave the game early due to a back issue after a diving attempt at a pass. He did not return and was seen after the game walking stiffly and needing to use handrails on steps. By video, this is not a recurrence of disc herniation that has necessitated previous surgery. Back spasms can be tricky and this hopefully remains a short-term setback.
Brady seemed to be off his normal game throwing high several times. He was clearly bothered as the Patriots QB even supported and favored his right knee as he sat down on the bench. I don’t think this is related to the Kam Chancellor hit to the thigh from two weeks ago. In any case, I expect this to be a relatively minor issue going forward.
MMMD 3: Jordan Reed plays through severe AC injury
The Redskins TE returned from a grade 3 acromial clavicular joint sprain to accumulate 10 catches and two touchdowns. After going down hard on his left shoulder, Reed was seen with a sling on. However, with some treatment and medication, he returned for a big second half.
The bad news is that multiple ligaments around the end of the collarbone are torn causing significant pain, presence of an obvious deformity with a visible bump and he will miss significant practice time. The good news is Reed is unlikely to miss games, although he will have to play through pain despite the help of medication. The next game is the hardest as swelling sets in post-game. Ironically once the swelling subsides, a more severe grade 3 injury looks worse but is less painful than a less severe grade 2 sprain as the end of the clavicle is riding so high it no longer rubs against the acromion to cause pain.
MMMD 4: Both Justin Houston and Von Miller dominate after ACL
The Sunday Night Game featured two great pass rushers recovered from ACL surgery. Von Miller had a 2014 ACL surgery and Justin Houston is only 10 months out from reconstruction. Miller had 10 tackles (9 solo) with three sacks and four tackles for loss. Houston matched those numbers with 10 tackles (10 solo) with three sacks and five tackles for loss. Miller is the NFL season sack leader and Houston might be challenging for the lead if surgery on his November knee injury wasn’t delayed until February.
MMMD 5: Harvard player health study
The NFLPA has funded a Harvard study on NFL player health. The report was released last week including the top 10 recommendations.
The best recommendation is for the NFL and NFLPA to stop using health issues as bargaining chips in the CBA negotiations. The most obvious are that all involved should follow a code of ethics and continue to collect/study injury data. The least game-changing is the suggestion that players be supported in their right to a second opinion as that is already the case and second opinions are very routine.
The most controversial recommendation is the use of “player’s medical staff” not hired or reporting to the team. I see the potential ethical concerns but in reality they are not there. Just like this study has potential bias because it was funded by the NFLPA, doesn’t mean it is biased. If Dr. James Andrews can serve as a Redskins team physician and yet be considered ethical and above reproach, so can other team doctors. Besides a system of independent doctors would be very cumbersome and result in many delays. For example, I don’t see how Derek Carr or Jordan Reed return to play with their injuries this week under such a system. Of course you can make the argument they shouldn’t have, but I think both Reed and Carr would object to that.
MMMD 6: Injury rundown
LeSean McCoy played well as expected despite having surgery to relocate his thumb six days ago and rushed for 103 yards with 2 touchdowns and two catches for 31 yards. https://twitter.com/ProFootballDoc/status/802987411143725056
Justin Houston, by video, suffered a mild left AC sprain when he caused the safety, but returned quickly to the game.
Odell Beckham Jr. had a thumb injury that did not seem to slow him down much.
Luke Willson was said to have a mild knee sprain, which was not the same side as earlier this year.
18 months ago, some feared Jason Pierre-Paul’s career was over due to the fireworks injury. Instead, on Sunday he had 3 sacks and fumble return over 40 yards for a touchdown, a first in the NFL in over four decades.
By video, Jordan Richards, Patriots safety, had a mild MCL. Luckily his knee was flexed and he avoided more severe injury and returned to play.
The mechanism for Danny Trevathan’s knee injury is likely to result in a right ACL tear.
Martellus Bennett seemed to re-aggravated right high ankle sprain that has bothered him since Week 5 but continued to play.
Derek Wolfe returned in three weeks with a brace and avoided elbow surgery for a fractured coronoid process.
MMMD 7: ProFootballDoc scorecard
LeSean McCoy played well despite his thumb. He performed better than Sammy Watkins who was also active. Tom Brady and Rob Gronkowski played as expected. Jordan Reed’s injury was more than just a mild AC and was announced as Grade 3 sprain. Jamison Crowder was OK with low ankle sprain and continued to play.
Josh Forrest was confirmed to tear a ligament in his knee. Robert Woods does have a significant MCL and missed the game. Andrew Luck was not cleared for the Thursday game. Marshall Newhouse did have a MCL sprain. Halapoulivaati Vaitai does have a MCL sprain. Demetri Goodson unfortunately is confirmed with a multi-ligament injury with ACL tear. Derek Wolfe did avoid surgery and returned in just under a month with an elbow brace. Blake Martinez missed with a confirmed MCL strain. Kelvin Benjamin returned to the game and caught a touchdown.
This slightly improves the 130-6 (95.6%) record to 145-6 (96.0%).

Monday Morning MD: NFL players show incredible toughness every week

Few doubt how tough you have to be to play in the NFL. This week has many examples of how players react and play through injury.
LeSean McCoy got up and casually walked to the Bills sideline as if almost nothing happened. He missed the second half with a dislocated thumb, which could not be reduced and now needs surgery. Yet, he is likely to play next week. The crazy part is this actually makes sense as by video, he dislocated his small (IP) joint without fracture. Once reduced with surgery today (as the flexor tendon blocks reduction). The thumb should be stable and relatively pain free.
No one even knew Giovani Bernard was injured but he reportedly tore his ACL on his final catch. Since the Bengals were down by four with under a minute to go and no timeouts, he hopped up to avoid a 10 second runoff then went right back to line up for the next play and even attempted to throw a block before the play was called dead. With the stoppage, Bernard then subbed himself out. Now he will need major surgery and will have to race to return for Week 1 of 2017.
A.J. Green’s season is likely over with a significant hamstring tear, yet his body language indicated a routine play with a minor issue. The injury appears to be high up and proximal hamstring tears take longer to recover.
Safety Eric Reid acted like nothing happened when by video, he tore his distal biceps tendon. He almost continued to play until stopped by a delayed timeout. Typically, this injury ends one’s season and requires surgery.
Terrell Suggs is delaying surgery and playing with just such a distal biceps rupture. Sunday he had a sure sack, but due to weakness to flexion/supination on his injured left arm, Dak Prescott stepped through the tackle.
Even long snappers got in the tough guy act. Clark Harris limped badly with a foot/ankle injury and was about to be driven off. He hopped off the injury cart to play, even though he could no longer even jog to cover punts.
In a bad injury week, there were plenty of examples of how the NFL is a real man’s game.
MMMD 1: Emotional Luke Kuechly
The former defensive player of the year was not showing weakness when he appeared to reveal vulnerability. Certainly he was red-faced and sweating from the game; however, Kuechly’s body was heaving to try and catch his breath, not blubbering in tears.
By video, he took a blow to the chest/sternum and was gasping for air from having the wind knocked out of him. He also hit his head and it is a known medical fact that a concussion can cause mood alterations. Combine the fear of not being able to breathe and the loss of emotional control from head injury and you get Kuechly’s reaction to injury.
MMMD 2: Seahawks RB carousel
Seattle leads the NFC West but will start its third running back in three weeks. Christine Michael was released after a mild hamstring issue. Now C. J. Prosise is injured.
By video, the worry was a scapula fracture for Prosise who did not return in the second half. Typically, a scapula body fracture does not need surgery but is very painful and leads to a 4-6 week recovery. A report surfaced that Prosise will not return until the playoffs.
Fortunately for the Seahawks, Thomas Rawls is finally healthy after an early season fibula fracture. This truly has been “next man up” after Marshawn Lynch retired.
MMMD 3 Accuracy of team reports
Two weeks ago, I documented the differences in teams’ use of the “questionable” designation. “Questionable” also seems to be the tag whenever a player initially exits for injury, but is it accurate?
Demetri Goodson suffered a horrific multi-ligament knee injury. (Video here but warning: graphic) The Packers officially classified him initially as questionable to return to the game. In reality, what is questionable is whether Goodson can return to a productive career as a cornerback. Best wishes to him.
MMMD 4: Who is ready to return?
Three quarters of teams have yet to use the single “designated for return” spot to bring a player off injured reserve. With six weeks left in the regular season, watch for more teams to start bringing players back.
Ameer Abdullah is seeking a second opinion and may be the Lions player to return off IR.
Sammy Watkins is slated to have a CT scan to assess fifth metatarsal bone healing and might be able to come off IR to help with Robert Woods’ absence.
Everyone has forgotten about J.J. Watt after his second back surgery. I know the club wants to be cautious but he is eligible to come off IR after today. I expect Watt to be medically healthy now and lobbying to help his team to the playoffs. The Texans lead the AFC South and if they beat the Raiders tonight, they would be in position for a possible playoff bye.
Branden Albert missed this week after surgery on a dislocated wrist and could be back next week.
Rob Gronkowski was not allowed to fly to California this week with a pneumothorax, but I fully expect him to travel and play against the Jets next week.
Mo Claiborne having torn “some bone off the pelvis” sounds ominous but it simply is a groin avulsion, which usually heals without surgery. A 6-8 week timeline from injury puts him back at Week 14-16. Hope his follow up MRI confirms this expected healing.
Look for lots of late season roster moves.
MMMD 5: Harvard health study
A comprehensive report with medical recommendations for the NFL and NFLPA was released this week. I promised to analyze the top ten recommendations but there were just too many injury issues this week to find the space in this column.
I will agree with one finding. Stop using player health as a bargaining chip in the collective bargaining agreement. My full thoughts are to follow in the coming weeks.
MMMD 6: Injury rundown
Zach Miller has a broken left foot and needs surgery.
By video, Robert Woods has a MCL sprain and is on crutches. He is likely will miss several weeks.
Cody Kessler is out with his second concussion of this season. Don’t be surprised if an extended absence is coming.
Fortunately, Leonard Floyd seems to have escaped significant neck injury. He took a head down hit and was sent off on a spine board.
Seattle FS Earl Thomas and CB DeShawn Shead both have hamstring injuries.
Dee Ford has a hamstring issue as well. Justin Houston has returned from February ACL surgery to help the Chiefs linebackers.
Ryan Matthews is reported to have a MCL sprain and Darren Sproles has a rib injury.
Laremy Tunsil left with a shoulder injury and did not return for the second half.
Rams LB Josh Forrest by video has a major knee ligament tear, which is likely the ACL.
Matthew Slater was knocked out with a left foot injury and seen post-game in a walking boot.
By video, Halapoulivaati Vaitai suffered a MCL sprain. Hopefully he can return in a week or two with a brace.
MMMD 7: ProFootballDoc scorecard
Even though Branden Albert finished last week’s game, he did have wrist surgery and missing this week but has a chance for next week. Tom Brady had no issues despite a scare. Rob Gronkowski was not allowed to travel with his pneumothorax. Jordan Howard avoided Achilles tear or other significant injury to play well. Kyle Long does have a high ankle injury requiring surgery. Kelvin Benjamin overcame mild AC sprain and returned in the same game.
Cody Kessler does have a concussion. The Leonard Floyd news is encouraging. Jake Ryan and T.J. Lang missed this week after being rolled up on last week. C.J. Prosise has a presumed scapula fracture. Eric Reid does have a left distal biceps tear. Nick Perry’s mild ankle sprain is OK and he returned to play.
This improves last week’s 117-6 (95.1%) scorecard to 130-6 (95.6%) through Week 11.

Monday Morning MD: Offensive line injures aplenty

Fans may think of this week as a relatively healthy one. In reality there were plenty of injuries. A plethora of offensive players were hurt, just not the ones most fantasy owners and fans are interested in.
Offensive line injuries lead the way in Week 10. The trend began on Thursday when the Ravens left guard was carted off and their center limped off. Alex Lewis’ right leg was placed in a vacuum splint after being rolled up on. Though early reports indicated no fracture, by video, Lewis has a significant high ankle injury that will result in an extended absence and may still need surgery. Teammate Jeremy Zuttah was much luckier with a standard basketball type low ankle sprain.
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The trend continued Sunday when two linemen with the last name Long (no relation) suffered apparent season ending injuries. Kyle Long of the Bears was carted off in an air splint. By video, he suffered a significant high ankle injury with possible fibula fracture and likely needs surgery. Jake Long’s twice torn left ACL was spared but video evidence of a left Achilles rupture was later confirmed by his head coach. The Vikings have now lost their third offensive tackle and their fourth consecutive game after five victories to open the season.
Dolphins left tackle Brandon Albert was reported to have dislocated his wrist but finished the game in a cast. A wrist (lunate) dislocation means ligaments are torn, thus surgery is likely. Miami is on an 11-day west coast trip (played Chargers on Sunday and Rams up next) creating logistical difficulties but I hope the injury is not truly a medical dislocation.
Knee injuries knocked out the Packers David Bakhtiari and Buccaneers Evan Smith. Also Packers guard T.J. Lang, by video, left with a high ankle sprain. Meanwhile, Bears Bobby Massie left with a concussion.
This may seem like a good week of injures as the offensive stars stayed healthy. However, their protectors took their share of injuries.
MMMD 1: Injuries to stars narrowly avoided
Near miss was the theme of the day. Tom Brady avoided a hit to the knee, instead took a blow to the thigh just above. He avoided serious injury but instead will deal with a quad muscle contusion. Teammate Rob Gronkowski took one of his hardest hits ever but since Earl Thomas stayed away from the head delivering the blow, Gronk avoided concussion.
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Larry Fitzgerald and Lamar Miller returned for the second half after brief absences. Jordan Howard’s coach said he hurt his ankle or Achilles. By video, Howard does not have a tendon tear. I am always happy to be reporting good news.
MMMD 2: Running back news
Christine Michael was active but limited with his late week hamstring issue. Doug Martin finally returned from his Week 2 hamstring injury and re-aggravation.
Dion Lewis was activated off PUP with his post-ACL patella stress fracture but was not dressed this week. DeAngelo Williams had midweek knee scope and is likely out longer than the initial three-week estimate.
MMMD 3: Tony Romo not active
The Cowboys QB is almost three months out from his L1 back compression fracture. He has been medically cleared.
No one is arguing that Dak Prescott should relinquish the starting job as the Cowboys now have the best record in the NFL. However, it was interesting that Romo was not even dressed as the back up. Even if Romo has not practiced with the first team, isn’t a rusty Romo better than Mark Sanchez who has yet to take a live snap as a Cowboy?
After the game, Jerry Jones said indeed Romo would be the backup next week. After all, every 2nd stringer is one play away from being the starter..
MMMD 4: Maurkice Pouncey heroic
The Steelers center tried to return last week after dislocating his thumb but lasted only one series. After thumb surgery, he is to be congratulated for not missing more time.
A snapping hand injury is like a throwing hand injury for a QB. With a cast and likely pins/screws to stabilize the thumb, Pouncey played with what could have been a 4-6 week injury. There were a couple of low snaps, but that could be forgiven. Kudos to the Steelers medical staff.
MMMD 5: NFL can go further for safety
As the league has begun its public relations campaign, I hope it continues to go further for safety. Commercials with Dean Blandino touting 42 rules changes including the elimination of the three-man wedge ran last week. This week featured a second ad pointing out sideline video, radio communication, hand held tablets with medical records and X-ray access.
These are all good advances. I remember getting multiple memos from the league saying cell phones are illegal on the sidelines. I argued they were necessary for communication to other medical personnel that may be in the locker room or with a hospital. The league now supplies all medical personnel with earpiece and radio.
A simple additional change is to not have mandatory charged timeouts when checking on player health. This would have prevented the Case Keenum situation from last year. It also would have helped with the Bills at Seahawks debacle Monday night at the end of the half. When medical came onto the field to check on the down kicker, the Bills were out of timeouts, meaning he had to leave for one play. Allowing medical checks without penalty of timeout would improve safety by removing the inhibition to check a player. Of course, the league would have to police for injury faking but if medical is a priority, this change should be done.
MMMD 6: Injury rundown
DeSean Jackson’s rotator cuff injury kept him out even with the bye week to recover. The hope is that there is no tear. Remember, a partial tear led to surgery and injured reserve for Eric Decker earlier this season.
Last week, people took note that Jimmy Graham was finally healthy after patella tendon repair. Now it seems his QB is fully healthy. Russell Wilson looks like his same old self while leading the Seahawks to a big win over the Patriots. His high ankle, knee MCL and pectoral muscle injuries seem to have finally improved.
The Steelers big free agent tight end signing finally played. Ladarius Green is off PUP and had three catches. It is unusual for a free agent to end up on PUP like he did since teams perform full physicals before inking deals, but that is all behind the team now.
MMMD 7: ProFootballDoc scorecard
Ryan Fitzpatrick did have a mild MCL sprain. Mike Evans did return from concussion in one week as expected. Eric Wood did suffer a high ankle fracture and need surgery. Justin Pugh did have a MCL sprain. Derek Wolfe will return soon from a hairline elbow fracture. Doug Martin did beat Jacquizz Rodgers back. Jake Long does have an Achilles rupture. Kyle Long does have a high ankle injury/fracture. Alex Lewis has a significant high ankle injury. Jeremy Zuttah’s low ankle sprain is not severe.
Credit Maurkice Pouncey and the Steelers medical staff for having him ready to play against the odds. Although the point of my tweets were correct about a snapping side injury for a center, he beat the odds and returned early so it will count as a mistake.
This makes the previous 107-5 (95.5%) record update to 117-6 (95.1%).

Monday Morning MD: Teams take different approaches to injury reporting

This season, the “probable” category for pregame injury reporting was removed. Now players need to be either eliminated entirely from the report and deemed ready to play, or placed in the “questionable” category.
With the help of followers, I have gathered new injury reporting statistics. This season, approximately three out of every four (~75%) players listed as “questionable” are active league-wide, compared to just over half (~55%) in the previous year.
At the halfway mark, it has become clear that teams take different approaches to injury reporting. I am not accusing any teams of manipulation or cheating; however, the numbers lead to stark contrasts. Over 90% of the “questionables” suit up for the Bengals, Panthers and Redskins. In contrast, under 50% of the same category are active for teams like the Titans, Jaguars and Seahawks.
Here is a full list of teams and the percentage of “questionable” players that are ultimately activated each week through the first half of this season.
RANK   TEAM   PERCENTAGE

  1. Bengals         100%
  2. Panthers         95%
  3. Redskins         91%
  4. Chargers         90%
  5. Bears               86%
  6. Buccaneers    84%
  7. Colts                84%
  8. Dolphins        80%
  9. Lions               79%
  10. Texans            79%
  11. Rams               77%
  12. Cardinals       76%
  13. Bills                 76%
  14. Jets                  75%
  15. Steelers           75%
  16. Raiders           72%
  17. Giants              71%
  18. Patriots           70%
  19. Cowboys         69%
  20. Ravens            66%
  21. Saints              65%
  22. Packers           64%
  23. Chiefs              64%
  24. Eagles              64%
  25. Falcons            60%
  26. Browns            59%
  27. 49ers                58%
  28. Broncos           54%
  29. Vikings            50%
  30. Seahawks        47%
  31. Jaguars            41%
  32. Titans               38%

Microanalysis will show many reasons for the differences. For example, the Bengals average only one player listed as “questionable” weekly but every player (a league low total of eight thru eight weeks) has been active. Some teams use the “doubtful” and “out” categories more liberally and thus have a higher percentage of “questionable” suit up.
I am an injury expert, not a fantasy expert. Thus I will leave it to the fantasy gurus to interpret the significance of the mid-season findings. However, there is clearly a big difference between how the Bengals who have activated 100% of their “questionable” players and the Titans who have only suited up 38% of theirs.
MMMD 1: Veteran leaders play through injury
Ben Roethlisberger, Terrell Suggs and Steve Smith, Sr. all played Sunday for the AFC North lead in the Steelers at Ravens clash. None of the three were at 100%, but most players are not at this juncture of the season.
All three have a history of toughness and early return from injury. Big Ben coming off knee scope and Smith dealing with a high ankle sprain will improve each week. Suggs who is putting off biceps tendon repair surgery will have to deal with elbow weakness for the rest of the year. Players will tell you that as the season marches on, 80% healthy is considered a good week.
MMMD 2: Joe Flacco breaks knee brace not knee
The Ravens QB scared fans when he came up hopping on one leg after an awkward slide. Fears of re-injury to his ACL or visual of a bone sticking out flashed through minds, but Flacco was fine. As he slid, his knee brace caught the turf and was mangled.
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Teams have spare knee braces, although they may not be the exact custom model for each player. The Ravens were at home but even on the road, athletic trainers pride themselves as “boy scouts” who are ready for anything.
MMMD 3: More knee braces and Patriots health
Even on their bye week, the Patriots made health news. Bill Belichick explained why he has the offensive line wear knee braces. Essentially every major college mandates it but it is rarely required at the professional level. A few teams like the Patriots and Cowboys insist, but players resist due to the perception restricting knee fluidity. A brace cannot prevent all injuries, but could lessen the degree of injury.
Belichick also noted how his staff tries to prevent the avoidable non-contact injuries. Part of New England’s success this season may be having only three players on injured reserve versus the 19 from last season. The league average is approximately 10 IR players per season.
MMMD 4: Marijuana use in NFL
An ESPN survey of 226 players indicates 71% support legalization and 61% say fewer painkillers would be used if pot could be used. 22% claim they know a teammate who smoked before a game. 67% indicate the NFL testing for recreational drugs is not hard to beat.
Overall, players feel marijuana is better for recovery and pain control than pills. If players are committed to this, look for the next CBA to change the rules on marijuana usage.
MMMD 5: Medical sideline reporting improved
With the change in the Thursday night broadcast from CBS to NBC, the medical updates are much more precise. The difference from one week to the next was noticeable.
This is not a slight at the CBS sideline reporter, rather it is a compliment to the NBC sideline team that has a secret weapon. Longtime former Jaguars head athletic trainer, Mike Ryan, is on site behind the scenes providing his expertise. This is why reports now talk about specific tests and the anatomic references are all on point. Kudos to the NBC team for improving medical accuracy and the broadcast experience. The future is medical experts on broadcasts, like every network has a referee to help explain calls.
MMMD 6: Injury rundown
Maurkice Pouncey dislocated his right thumb and valiantly returned for one series. Look for surgery to be announced as dislocation is often associated with fracture. Unless he can move to guard or snap with his off hand, expect a 4-6 week absence.
Darrius Heyward-Bey suffered a midfoot sprain. His absence will be determined by severity but will likely be weeks.
By video, Allen Hurns had a left high ankle sprain but returned. His availability will depend on swelling.
Victor Cruz had a low ankle sprain that should not keep him out for long if at all.
Ryan Fitzpatrick injured his left knee and will get an MRI. By video, I am hoping for a minimal injury that could show a mild MCL sprain.
Cody Kessler had X-rays on his right leg that were negative and should not miss time.
Derek Wolfe hyperextended his right elbow and had a non-displaced coronoid process fracture. If the piece is small, he can avoid surgery and return in 4-6 weeks and possibly sooner with a brace.
Justin Pugh, by video, exited with a MCL sprain. His return with a brace will depend on severity and swelling.
Derrick Henry injured his calf in warm ups. Careful here, as medially, gastrocnemius muscle strains tend to linger.
Sammy Watkins is out of his boot but that doesn’t meant he is ready. Being placed on IR means he is out for at least another month anyways.
Mike Evans was initially cleared for concussion and later removed from the game. Hope he can return next week.
Jameis Winston’s knee injury is not expected to be significant.
Jamaal Charles’ menisectomy lends to a quicker recovery than the meniscus repair for C.J. Anderson. Charles has to now overcome swelling of the other knee, his IR status, age approaching 30 and a high salary cap number.
Doug Martin (hamstring) should be able to beat Jacquizz Rodgers (Lisfranc midfoot sprain) back for the Buccaneers.
Carlos Hyde missed another week with, by video, what seems to be an AC joint sprain.
MMMD 7: ProFootballDoc scorecard
Big Ben played in three weeks as expected. Terrell Suggs and Steve Smith, Sr also played. Sean Smith missed the game with left shoulder subluxation. It was time to worry on Jamaal Charles who had surgery and was placed on IR. Jameis Winston’s knee seems OK. Kwon Alexander had a stinger. Ty Montgomery sickle cell issue was only a one-week ordeal. Tyrann Mathieu did dislocate his shoulder. Barry Church is out 4-6 weeks with a forearm fracture. Corey Coleman missed six weeks with a broken hand. Referee Ed Walker tore his quad and Wade Phillips is OK but neither of these will count as this scorecard is for player predictions.
The previous 96-5 (95.0%) record improves to 107-5 (95.5%).

Monday Morning MD: Time for transparency

Transparency is long overdue. Why not let the doctors speak or provide rationale for return to play decisions?
Once again we have another concussion controversy involving a quarterback. Last season we had Case Keenum. In the NFL opener, Cam Newton became the national focus. Now we have the Alex Smith situation.
The Chiefs QB’s head hit the turf, lacerating his ear, and had to be helped up by Spencer Ware (who ironically later suffered his own concussion) and a referee. Smith passed a concussion test and was returned to the game. The QB later suffered a second blow to the head on the turf and was then deemed to have a concussion.
I am not suggesting that the Chiefs or any doctor did anything wrong here. I am saying the optics of the situation are not good when a wobbly QB is allowed to stay in the game.
The latest concussion controversy deserves explanation. Credit head coach Andy Reid for trying to address it post game (even though he erroneously said Smith passed both concussion tests). However, when pressed, coaches always use the “I am not a doctor” line and say I just followed the doctor recommendations.
Why not let the medical staff speak or at least release a statement? Of course the player would have to grant permission, but perhaps that would clear up the misperceptions. Maybe the physician, knowing he would have to publicly defend his decision, causes a further pause before a player is cleared.
I don’t believe in conspiracy theories. Certainly the unaffiliated neurotrauma consultant (UNC) who lives in Indianapolis was not incentivized to keep Smith in the game to help the Chiefs beat his hometown Colts. I believe the doctors are doing their best with an inexact science of diagnosing concussions. I have been there and know what a difficult job it is. It is impossible to get every “play/no play” decision correct, like it is impossible to expect a referee to get every call right. My point is why not let the public know about the process and what the doctor’s thinking was? Even the referee has to answer a pool reporter’s questions post game.
I am curious as to what the referees were thinking on this first hit. The umpire was one of two people there to help hold Smith up and referees are also charged with player health. I would also love to hear the UNC’s side of the story. Did the UNC see a wobbly Smith? Was he provided with the video replays? What lead him to clear the player? Even if a player passes concussion tests, visual evidence of a balance issue is enough to rule a player out.
The NFL has been accused of conspiracy and denial in the concussion crisis. Why not shed that image and allow some transparency in the current head injury decisions? Not allowing for comment just makes the situation look worse.
MMMD 1: Good injury week
Overall Week 8 seemed to be the least injuries for 2016, yet there were still plenty. The year to date has seen a slightly higher rate than average with 40 ACL tears and 32 Achilles ruptures.
Lets hope we don’t get Monday morning bad news. Or as seems to be the pattern this year, Wednesday bad news like we did for Adrian Peterson, Dez Bryant, C.J. Anderson and others.
MMMD 2: Two stars trying to return
Ben Roethlisberger and Terrell Suggs are both coming off injury and a bye week to face off in a big divisional game. Big Ben will be three weeks after a knee scope. Suggs suffered a biceps tendon tear.
There are varying reports of stitches and whether Roethlisberger will be ready. Medically, expect him to play. The sutures are in the skin, not the meniscus; therefore, will be removed and is a non-issue. Suggs is forgoing surgical repair to play through what may be his final season in the NFL.
MMMD 3: All meniscus tears not the same
Earlier this season we covered the difference between the Adrian Peterson and Big Ben meniscus tears. Now we have additional examples.
C.J. Anderson had his meniscus repaired, which means six weeks of rest and minimum three months of recovery. Michael Bennett’s return timeline after his cartilage trim procedure is set at 2-3 weeks. Trimming meniscus is like mowing the lawn where you can play football immediately after, while repairing is like laying down new sod where you need to keep of the grass to let the roots grow in.
MMMD 4: Time to worry for Jamaal Charles
Swelling when increasing activity after an ACL surgery is not unusual. When it does not go away for several weeks, the effusion becomes a concern.
Charles is now seeking a second opinion. Hopefully, rest, time, compression, medication and draining the knee will be enough. I hope there is no need for a post-ACL knee scope.
MMMD 5: Worst injury of the season
Texans right tackle Derek Newton ruptured both of his patella tendons last Monday. Even though there was a report of successful surgery to repair both tendons, he has a long path to return to the NFL. Three players have torn both patella tendons at the same time: Wendell Davis, Gary Baxter and Greg Childs. None of the three returned to their pre-injury levels of play. Hopefully, Newton can be the first.
The road game presented several difficulties. First, Newton did not have access to pain medicine immediately as the visiting team is not allowed to bring narcotic medication per federal laws and the home team medication supply is limited. Second, the 300+ pound lineman was essentially wheelchair bound and could not fly home with the team but instead needed special medical transport.
MMMD 6: Injury rundown
Broncos defensive coordinator Wade Phillips was knocked over on the sidelines and rushed to the hospital. Fortunately rumors of a broken leg were inaccurate and he passed all tests and was released.
Four players were concussed during the Chiefs at Colts game: Alex Smith, Spencer Ware, Joe Reitz and Vontae Davis. Statistically expect at least two of the four to miss next week’s game.
Jacquizz Rodgers injured his left foot but video was not clear as he was in a pile and the mechanism or severity could not be seen.
Ty Montgomery has a kidney-related ailment. It is unclear what type or how long he might miss.
Martellus Bennett continues to deal with a high ankle sprain. He injured it in Week 5 and still caught three touchdown catches. Here is hoping the bye week gives him a chance to fully heal.
Barry Church fractured his right forearm, the same side that he broke causing him to miss the last game of 2015. He likely will undergo plating surgery and return in 4-6 weeks.
Morris Claiborne has a significant groin injury. Sometimes one can play through or the Cowboys could make the decision to fix it now to be back by the end of season/playoffs.
By video, Charles Clay suffered a left shoulder AC joint sprain but returned to the game.
Sean Smith appeared to subluxation/dislocate his left shoulder. If he torn his labrum, that could mean surgery or trying to play with a brace as Charles Woodson did last year for the Raiders.
Duke Ihenacho suffered a scary hit in London. After a substantial time on the ground, was able to walk off under his own power.
Vontaze Burfict’s knee injury does not appear to be serious. By video, he suffered a contusion to the muscles in back of his left knee and he did return to the game. Meanwhile, Burfict inadvertently hit Rey Maualuga’s left arm but there was no fracture and he ultimately continued as well.
Russell Wilson was able to play through his pec, knee and ankle injury but not well enough to come away with victory.
Tyran Mathieu left the game with an unspecified shoulder injury. Hopefully the follow up news will be good.
Sammy Watkins is out of his boot. That certainly is a good sign but only a first step to return and there is no medical certainty that he can come off IR when eligible in a month.
MMMD 7: ProFootballDoc scorecard
By video, I did not expect Geno Smith to tear his ACL. Demarcus Ware did return after ulna plating surgery and even had a strip sack fumble with his right arm that was reversed. Lamar Miller played with what has been confirmed as a deltoid contusion. Antonio Brown’s hip contusion is confirmed to be progressing well for this Sunday and will not miss time. Duke Ihenacho, Vontaze Burfict and Rey Maualuga injuries are all less significant than originally feared. Derek Newton was confirmed with bilateral patella tendon ruptures.
Counting the missed ACL tear lowers the previous 89-4 (94.7%) record to 96-5 (95.0%).
Happy Halloween to everyone!
 

Monday Morning MD: Easy to just blame the coach

When a player returns early and is re-injured, it is too simplistic to blame the coach for pushing a player to hurt. Bills head coach Rex Ryan faced that criticism when LeSean McCoy played through and aggravated a hamstring strain in a Dolphins loss on Sunday.
Mid-week, McCoy was originally declared with only muscle tightness that turned out to be “coach speak” for a mild to moderate strain per media reports. It would be easy for me to say “I told you so” after the Bills star RB left the game in the second half feeling pain after 8 carries for 11 yards. I did warn of ineffectiveness and aggravation but that is nothing the Bills medical staff would not be aware of and had considered. The offensive coordinator even said earlier this week, “I don’t want to do what we did last year. I don’t want him playing 85% re-injuring the hamstring and this thing lingering all year.”
Return-to-play decisions are not solely made by the team doctor or the head coach. Typically it needs to be a unanimous group decision between three parties: the medical staff, the team and the player. Any of the three has “veto power” and must share in the responsibility of all return-to-play scenarios.
The medical staff input is a combination of the doctors and athletic trainers. The team decision requires varying input from coaching (head coach, coordinators and position coaches) and management (general manager and sometimes owner). The player component includes the athlete, agent and often family. (Certainly agents have stepped up and prevented their guys from playing before.) All three combined parties must agree, otherwise a player doesn’t step on the field. Decisions like these are always joint discussions and are never made in a vacuum.
Ryan acknowledged, “We never play a guy our doctor and trainers don’t clear”. I am sure the medical staff was aware of and discussed risks of re-injury and ineffectiveness. McCoy accepted his role in the decision to play as well, saying “I felt good…I wouldn’t play, if I wasn’t 100%”.
Given this situation plus the Sammy Watkins, Aaron Williams and Shaq Lawson decisions to play through injury, it is inevitable critics will blame the Bills for allowing these players to push the envelope and get back to action prematurely, causing a bigger risk for re-injury down the line; however, that would not be telling the whole story. At least in this case McCoy himself acknowledges his role in pushing to play and admitted it might have been better to hold off.
MMMD 1: Geno Smith injury “not too significant”
The Jets Sunday starter exited with a left knee injury. By video, there was no major ligament injury but there is some worry for a meniscus tear (similar to Roethlisberger’s injury last week) that will be cleared up by a MRI. Smith himself indicated it wouldn’t be “anything too significant”; however, he spent the second half in street clothes on the sidelines. Unlike Big Ben who was cleared to play the 2nd half, doctors didn’t clear Smith to return as a precaution. The thought is Smith will avoid a knee scope and it doesn’t appear to be serious, even though he may not be the starter anymore.
MMMD 2: Steelers hope to get healthy with bye week
Antonio Brown took a knee to the quad and was hampered the rest of the game. Fortunately muscle contusions heal quickly and the week off comes at a perfect time for the Steelers star WR. With rehab, expect Brown to be 100% for the next game.
It would also help if Ben Roethlisberger would be throwing him the ball. Despite some doom and gloom reports of missing up to six weeks, I have never waivered (and a new CBS report agrees) http://www.cbssports.com/nfl/news/big-ben-unlikely-to-miss-more-than-two-games-could-return-after-bye/ from my feeling that Big Ben is most likely to return for the post-bye divisional games versus the Ravens.
MMMD 3: Giants injury designation faux pas
Odell Beckham Jr. and five other players were listed as “probable”, a designation that doesn’t exist anymore on the Friday injury report. Perhaps, the Giants share in the thoughts of fantasy players in wanting that category reinstated.
All six players were subsequently removed completely from the injury report, as downgrading to “questionable” would have proven the fallacy of the new system. Beckham did play as expected with a hip pointer, but he was seen working with trainers pregame and perhaps was not 100%. With the post overseas game bye, OBJ should not be hobbled for his next game.
MMMD 4: No Reggie Bush touchdown
It didn’t matter in the outcome of the game but it could matter for future safety. A play is dead when the ball carrier’s helmet comes off. Reggie Bush’s helmet was completely off just before he crossed the goal line yet he was still awarded the score.
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Officiating guru Mike Pereira agreed. The NFL and NCAA rule are similar here except that the professional player is not required to leave the field for a play after his helmet comes off like the collegiate players. I would lobby that non ball carriers deserve the same protection. If the helmet comes off, any player should be deemed a non-participant meaning he can’t tackle, be hit, block or be blocked.
MMMD 5: 2016 Health and Safety Report
The annual medical update was released this week. The NFL has been far from perfect in dealing with head injury over the years but before anyone criticizes the league’s current action, they should read this comprehensive 39 page report of all of the health initiatives.
One piece of unfinished business is the NFL has yet to announce it’s new Chief Medical Officer.  The often maligned previous medical adviser was forced to retire in July but the new full-time position has yet to be filled.
MMMD 6: Injury rundown
Jay Ajayi was cramping and not injured. Who can blame him after two consecutive 200+ yard performances in Miami.
Russell Wilson still seems to be hampered by the knee and ankle injury, which I expected to be behind him after the bye.
Jamaal Charles was limited by knee swelling and only had 1 carry for 0 yards. Knee effusion is common after ACL surgery but the swelling usually goes away quickly. Only if it persists, is it time to worry.
Tevin Coleman left with a hamstring strain but it is difficult to discern severity off video so his absence is yet to be determined.
Brian Hoyer’s doctors were working Sunday despite the Thursday game this week. The Bears QB underwent surgery with plate and screws into his radius (forearm) bone. Contrary to popular belief, team doctor’s have “day jobs” outside of the NFL and likely the regular weekly workload made the off day schedule more convenient.
Ron Brooks of the Eagles ruptured his quad tendon and will need surgery. This injury is similar to patellar tendon tear and will require a minimum of 6-9 months recovery.
Aaron Williams left the Dolphins game in an ambulance for a precautionary MRI that was negative and flew home to Buffalo with his team. Jarvis Landry apologized for the penalized hit that may still draw a fine.
Jeremy Hill seemed to aggravate again what by video seems to be a left AC joint sprain.
Jerick McKinnon by video suffered a high ankle sprain but had a limited return for the Bears.
Josh Norman and Cody Kessler suffered concussions.
Jordan Reed was out again and admitted to hiding his concussion.
John Brown missed the game as his sickle cell trait work up continued. Expect a full return as most teams have at least one player with the trait that play without issue.
Saints special teams ace, Jake Lampman is hoping to avoid major knee ACL and/or MCL injury.
Josh Doctson was placed IR for recalcitrant Achilles tendonitis.
Dez Bryant cut his fingers making soup, but his knee and digits should be fine after the Cowboys bye this past week.
MMMD 7: ProFootballDoc scorecard
Please be clear that I take the time to chronicle the correct/incorrect video and injury analysis to publicly vet my stats. This allows readers and twitter followers the chance for a public audit of my numbers.
This week, Russell Wilson does not seem to be over the knee and ankle injury as I expected, thus will count as a mistake. Unfortunately LeSean McCoy did aggravate his hamstring. Carson Palmer played with his as expected. Jerick McKinnon had a mild high ankle sprain confirmed. Brian Hoyer did have an isolated radius and needed surgery, Dwayne Allen missed the Colts game with a high ankle sprain. Michael Bennett did avoid serious knee injury and played.
Add these into last week’s 83-3 (96.5%) drops the numbers to 89-4 (95.7%).

Monday Morning MD: All meniscus tears are not the same

Ben Roethlisberger will need surgery but his season will not be over. Big Ben has a meniscus tear like Adrian Peterson; however, the Steelers quarterback will return in short order.
Not all meniscus tears are the same. A locked bucket-handle displaced meniscus tear like the Vikings running back had requires repair to prevent long-term problems. Sutures require healing time measured in months. By video, Roethlisberger has a simple smaller meniscus tear that likely will be trimmed without the option for repair and his return will be measured in weeks. When laying down new sod, one must “keep off the grass”; however, after mowing the lawn, one can play football on the grass immediately.
The worst fears of injury were avoided. Roethlisberger described what he thought was a hyperextension injury but fortunately there was no serious ligament tear.
Big Ben will have had knee arthroscopy surgery by the time this article posts. Expect confirmation of a trimming procedure and a definite return this season.
With menisectomy (trimming) surgery, there is no wait for healing, thus, return is measured in weeks. Typically recovery is 2-4 weeks but given that Roethlisberger is not a position player and his recovery prowess is legendary, it is not impossible to return next week to play the Patriots. After all, Philip Rivers played New England in the 2008 AFC Championship game six days after a knee scope (and with a torn ACL).
However, the most likely return is after the Steelers bye the following week. I fully expect to see Roethlisberger play the division rival Ravens in Week 9.
There are many reasons to have immediate surgery. First, the tear can get worse. Second, playing on a meniscus tear can accelerate arthritis. Third, a cartilage injury limits playing effectiveness. Finally, with the quick recovery and the bye coming, there is no time like the present and Steelers doctors are acting quickly to make it happen.
Big Ben returned to play in the second half but there is no way he should continue to chance further injury without surgery first. I am sure if Roethlisberger had clinical signs of meniscus tear or mechanical symptoms, he would not have been allowed to return to play. Now that the meniscus tear is diagnosed, there can be no thought of playing through the injury.
Roethlisberger will return to 100% in terms of football. He will have some increased chance of long-term arthritis as a result of loosing some of the meniscus as cushioning, but less than without surgery.
An operation is never good news, but this type of meniscus procedure is really a positive scenario for Roethlisberger and Steelers fans. With a trim, Big Ben will have a chance to return very quickly.
MMMD 1: LeSean McCoy avoids serious injury
Like Big Ben, McCoy had a scare and clutched his right knee. By video, the Bills RB averted disaster and only had a mild MCL sprain. The key is that his foot was not fully planted or trapped. Indeed, McCoy returned for the second half and I don’t expect issues going forward.
MMMD 2: Odell Beckham, Jr. injures hip
The Giants star WR was injured within minutes of Roethlisberger and McCoy. Fortunately he too avoided major injury and returned for a big game.
By video, Beckham suffered a left hip pointer. The key is how swollen and sore he is this AM. Just because Beckham came back to play is no guarantee for next week. I expect the Giants to be aggressive treating this injury and thus a good chance to see Beckham in action next week in London. I do not expect the long flight to be a factor as teams fly on a chartered 747 and it’s like spending six hours in your living room. In fact, the Giants medical staff can set up a mini-training room on the plane as well.
MMMD 3: Terrell Suggs injured again
The 34 year-old pass rusher recovered from his second Achilles rupture, now he will have to deal with his second biceps injury. By video, Suggs ruptured his left distal biceps tendon at the elbow and Jay Glazer has confirmed the injury.
In 2012, he played through the month of December and into the Super Bowl with a right biceps tear. I suspect he will want to try to delay surgery and do the same now. Most players end up with surgery to re-attach the tendon to restore full flexion and supination (palm up rotation) strength.
Suggs has proven to be a quick healer and still can be an effective pass rusher. His ability to wrap and tackle may be hindered by this injury, but given his experience compensating and playing hurt on the other elbow gives him hope that he can do the same now.
MMMD 4: DeMeco Ryans sues over Achilles tear
The former Eagles linebacker ruptured his Achilles tendon in 2014 at NRG stadium and is now suing the Texans, NFL and stadium operators.
Originally the field was made up of natural grass pallets that were rotated into the sun for growth but the seams generated complaints. Subsequently the surface has now been switched to artificial grass.
Reggie Bush sued the St. Louis Rams stadium over his knee injury slipping on concrete and the case is still pending. Ryans returned to play during a subpar 2015 campaign but is no longer playing and seeks over $10 million in damages.
MMMD 5: Active does not always mean playing time
A big pregame topic is who will and won’t be on the inactive list. This week there was much discussion of to play or not to play for Arian Foster and Will Fuller.
Foster was called a game-time decision. The Dolphins RB was active but had minimal contribution with only 3 rushes for 3 yards.
Fuller was reported by Adam Schefter to be out. The Texans instead activated the wide receiver but he essentially did not play. Seems the Texans had no healthy scratches so Fuller was activated even though his effectiveness from hamstring injury was limited. In the end, the ESPN report was not wrong even though Fuller was technically active.
These are prime examples of where active does not equal effective.
MMMD 6: Injury rundown
Browns S Jordan Poyer was taken to the hospital with a concussion and diagnosed with a lacerated kidney. Expect a minimum one-month absence that could extend to season long.
Seahawks DL Michael Bennett suffered a scary looking knee hyperextension injury.
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The hope is his ligaments were spared despite the gruesome appearance and only minor anterior bone bruise or posterior capsular stretch injuries.
By video, Colts TE Dwayne Allen left with a right high ankle sprain. His status for next week is in doubt.
Redskins TE Jordan Reed did not play as expected after his recent head injury. With his sixth reported concussion, it will be smart to take great care and consideration before return. The bigger concern is not when he will return but potentially if he will return. There is no absolute number of concussions when one has to retire but I hope Reed makes the right decision.
Today, Chiefs LB Justin Houston can come off PUP from his ACL. He has been cleared for football activities. If he is activated, he has two weeks to practice before potentially playing in Week 9.
Packers RB James Starks underwent an unusual Sunday AM knee scope surgery. The timing may have been necessitated by a family emergency last week. Usually in season arthroscopy are done early week to maximize return, as is the case for Roethlisberger (detailed above).
MMMD 7: ProFootballDoc scorecard
I am glad that this section generated some interest this week. A follower thought I should count Dez Bryant as a mistake as initially I only said MCL. His bone bruise is indeed related to the MCL but I will follow his advice and call that a mistake. It was correct that Big Ben did not have a major injury and returned to play; however, I will not count it as correct as he now has what I consider to be a minor meniscus tear.
Despite three touchdowns last week, Martellus Bennett did show up on injury report with an ankle as expected. Eddie Lacy did play through his high ankle injury while Steve Smith was inactive as no player listed as doubtful has been activated in 2016. Trevor Siemian and Terrance Williams played with AC injuries. Jordan Reed was out with concussion and although limited, Sammie Coates was active with index finger fracture and laceration.
There were three correct pure video impressions. Odell Beckham, Jr. was confirmed with a hip pointer. LeSean McCoy did avoid major knee injury. Terrell Suggs does have a biceps tear.
This takes last week’s 73-2 (97.3%) mark to 83-3 (96.5%).

Monday Morning MD: High ankle is not always dreaded injury

The average fan knows and fears the high ankle sprain. We have come to know this injury can knock players out for extended periods of time. However, does every high ankle sprain lead to a player missing multiple weeks?
Like any injury, there is wide variety in high ankle severity. Yes, players can perform thru mild sprains while severe sprains can even lead to surgery.
Early in the game by video, TE Martellus Bennett suffered a high ankle sprain and was in obvious pain. He channeled his inner superhero and returned to play, catching three touchdown passes for the Patriots. How sore and how much swelling he has this am, will determine if he can also play next week.
Steve Smith Sr. also appeared to suffer a high ankle sprain.
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He continued to play for awhile but ultimately limped off the field.
By video, Eddie Lacy also suffered a high ankle sprain. The Packers RB left the game but hopefully that has as much to do with the score at the time as the severity of the injury.
Meanwhile, high ankle injury can be very severe. Last week, Kevin White limped off under his own power but has been reported with a severe high ankle sprain with an associated fibula fracture. The injury to the Bears receiver has nothing to do with his tibia stress fracture from last year but he has been placed on injured reserve and likely needs surgery.
By video the worry is Trumaine Johnson may have suffered the same fate as White. The best case scenario is a severe high ankle sprain with a prolonged absence. The worst case for the Rams cornerback is season ending surgery if an associated fibula fracture is found. Neither possibility is good for someone playing on a franchise tag without a long-term deal.
We have chronicled both ends of the high ankle injury spectrum. Of course there are plenty of scenarios in the middle as well. Bottom line is the high ankle sprain is not always the dreaded injury it is made out to be in the media.
MMMD 1: Early stats for new injury categories
With PROBABLE being removed, what does QUESTIONABLE now mean? It used to mean a 55% chance of playing in 2015. Now with the two combined, the early returns show about a 75% chance to be active. It makes sense that when combining a 50/50 and 95% category that the results are somewhere in between. The challenge now is to figure out which players are truly questionable to play and which ones were always very likely to make it.
Of note, zero DOUBTFUL players have been active in 2016. Jay Cutler, Stefon Diggs, Dwayne Washington and others continued the no-go trend here. Seems like this should have been the better category to remove for the league.
MMMD 2: Browns can’t get started
Every offensive play starts with the snap. Cleveland can’t keep their centers or quarterbacks on the field. With the Cody Kessler injury to his chest/ribs, the Browns have now used eight players at these two positions. Kessler’s X-rays were negative so he has a chance to return next week.
Meanwhile, recently acquired backup QB Charlie Whitehurst was the fourth Browns QB injured when he hyperextended his left knee but hopefully escaped serious injury. Both Robert Griffin and Josh McCown suffered shoulder fractures previously.
MMMD 3: Trevor Siemian could return for Thursday
The Broncos starter was reported by Jay Glazer to have a grade 3 AC sprain and was inactive Sunday but that doesn’t rule him out for the midweek division clash versus the Chargers. The injury is to his non-throwing shoulder and contrary to some speculation, will not need surgery. With aggressive treatment and medication, I think Siemian has a good chance to play despite the high grade AC injury. Jimmy Garoppolo had a reported grade 2 injury to his throwing shoulder and missed 2 weeks but was healthy enough to back up Tom Brady and play in mop up duty this week.
MMMD 4: Gary Kubiak hospitalized after game.
I hope it is just illness and nothing more as flu-like symptoms sent the Broncos head coach off in an ambulance post game. In 2013, he collapsed at halftime as the Texans head coach and suffered a mini stroke. Hopefully this is all precautionary and Kubiak will be fine.
MMMD 5: Injuries no excuse
All teams have injuries and need to make adjustments. The Vikings head into their bye as the only undefeated team at 5-0. They lost their franchise QB, star RB, starting left tackle and others, yet still remain undefeated. Kudos to the GM, coaches and players for their success.
Versatility often helps a team as well. There is no better example than Texans LB Brian Peters. He had kick off duties Sunday and has even stepped in as long snapper. As they say in the NFL: the more you can do.
MMMD 6: Injury rundown.
Tevin Coleman had no issues with sickle cell in Denver. He tied the Falcons record for most receiving yards (132) for a running back as he helped hand the Super Bowl Champions their first loss.
A.J. Green was rolled up on late in the game but returned after six plays.
Jeremy Hill left with a shoulder injury after his previous chest injury but should not miss significant time.
Josh Norman injured his right hand/wrist and finished the game with a splint and tape.
By video, Terrance Williams had a mild left AC sprain, which he confirmed. He should not miss any games.
Cam Heyward will have a MRI on his hamstring to determine severity.
Letroy Guion said he had a complete tear of MCL from week 2 but returned this Sunday with a brace and will not need surgery.
WRs Randall Cobb and Chris Hogan had ugly looking hits but neither suffered significant injury, but likely both will be sore.
Tony Romo will have a repeat MRI Monday. Expect good news as compression fracture heals reliably. Despite a long list of injuries there is no medical reason for Romo to retire. With his replacement playing well, expect Romo back after the week 7 bye.
Dez Bryant was inactive Sunday but will beat Romo back as he does not have a true fracture.
Latavious Murray was out with a turf toe and his return is undetermined.
Senquez Golson was placed on IR as Lisfranc injuries are hard for defensive backs to play through.
Zach Ertz was active after his early season first rib dislocation. No surgery was needed and he should do well going forward.
Tyler Eifert has yet to play after a Pro Bowl ankle injury and surgery. His return is now delayed by a back issue.
Jacoby Brissett needed thumb surgery. Likely his ulnar collateral ligament injury kept the Patriots from having a full offense last week. Kudos for toughing it out and delaying surgery until Brady returned.
Josh Doctson’s Achilles tendonitis continues to linger. I am sure the Redskins are doing what they can but this is just one of those frustrating issues.
Eric Decker is still out. Optimists will say it is good news the team has not put him on IR for his partial rotator cuff tear. Pessimists will say he is done and needs surgery. The truth will depend on the extent of the tear, where greater than 50% thickness spells trouble.
MMMD 7: ProFootballDoc scorecard
Lee Smith was confirmed with an ankle fracture. Kevin White had a severe high ankle sprain with fracture. Randall Telfer did miss the game with a high ankle injury. Zach Ertz returned to play without surgery on his dislocated first rib. Sickle cell indeed was a non-issue for Tevin Coleman. Senquez Golson was placed on IR for long standing Lisfranc injury. Randall Cobb and Chris Hogan were ok despite nasty looking hits. Charlie Whitehurst knee hyperextension seems mild as expected. Martellus Bennett had a mild high ankle sprain. Josh Doctson Achilles tendonitis is lingering. Cody Kessler seems ok with no fracture.
This makes the previous 61-2 mark, now 73-2 (97.3%), but one or two misses will bring it right back to the 95% target.