Monday Morning MD: Ultimately things make sense

Dez Bryant’s injury was called a “hairline fracture” by his head coach. With his team saying their star wide receiver was day to day, that just didn’t make medical sense.
Were the Cowboys that desperate that they would jeopardize a playmaker’s health? Was Dallas just sending out false information to make the opposition do extra homework in game planning?
The truth seems to be neither, but rather that Bryant seems to have a bone bruise rather than a fracture. This new diagnosis indeed jives with how the team has been handling the injury.
The first thing that seemed weird is that the team didn’t release Bryant’s MRI results. Fans feared that they were hiding something. Then it came out that there was no Monday MRI. This led me and others to think the injury wasn’t significant enough to warrant an MRI. The truth was the Cowboys were initially just protecting their star player, as Dez missed his MRI appointment while going temporarily AWOL.
The next unusual thing was that Jason Garrett broke the news of a “hairline fracture” to the 49ers media rather than his hometown beat reporters. Now it seems clear that it wasn’t an intentional slight but simply being forthcoming with the next media opportunity after the Wednesday MRI results.
When the injury was confirmed to be in the lateral tibial plateau, medically that meant a minimum 4-6 week absence. However, the Cowboys continued to insist it was a day-to-day injury. A hairline fracture implies injury to the cortex (hard outer surface) and indicates damage to the structural integrity of the bone. Playing on it would risk displacing the fracture and needing surgery.
Now it all makes sense. A bone bruise can be described as microscopic fracture of the trabecular (soft inner) bone. This is not structural and one can see how Garrett could have unintentionally mistermed it a “hairline fracture”. Indeed the team is not putting Bryant at risk with its “pain tolerance only” stance expecting return in 1-3 weeks. A bone bruise was always a worry and made sense combined with the MCL sprain based on video.
I have always said that teams aren’t stupid. If a decision made on the inside looks silly to the outside, that just means we don’t have all the facts. The Bryant/Cowboys situation is another example of how there is usually a logical explanation for everything.
MMMD 1: Another major NaVorro Bowman injury
By video, the star 49ers linebacker unfortunately suffered a left Achilles rupture.cty9ysrumaax_wc
The team ruled him out immediately with a lower leg injury. Media has confirmed worry of Achilles tear. I hope my film analysis to be wrong but this was a classic change of direction, non-contact, eccentric load type mechanism.
Bowman missed the entire next season after his 2014 combined ACL and MCL tear needed surgery. Now he will miss all of this season with surgery again. The only good news is he medically should be on track for Week 1 2017 and chances are good to be 100%. The injury is on the same side but there is no definite linkage of the two.
MMMD 2: Concussions for Cam and Carson
Cam Newton needed to keep his head on a swivel but a momentary relaxation lead to a goal line concussion. Carson Palmer’s head slammed to the turf before entering the concussion protocol.
The Panthers play next Monday, while the Cardinals are scheduled for this Thursday night. Newton has twice as long to recover before the next game. Although concussions are unpredictable, Palmer seems very unlikely to play while recent data would have Newton 50/50 on getting cleared.
Safety of Thursday games comes into play again. Adding a bye week and pairing up midweek games with the bye would eliminate this problem. With the Packers and Eagles having their bye this past week they likely would welcome a second bye in the late season.
MMMDS 3: Broncos win with another rookie QB
Trevor Siemian has now been confirmed with an AC joint sprain (separated shoulder). By video, it was never a clavicle fracture as some feared.
Siemian could have returned to play but instead was confirmed as the emergency QB. Likely the Broncos decided a healthy rookie Paxton Lynch was a better option than an injured QB. Siemian’s injury is very similar to that of Jimmy Garoppolo except it is on the non-throwing shoulder and thus should be available next week. If Siemian doesn’t start/play next week, it will mean a coaching decision regarding limited practice and a QB not being 100% rather than an inability to play through the injury.
MMMD 4: Rookie quarterbacks fairing well
This year seems like a Seinfeld episode with a “George Costanza opposite” season for signal callers. The Broncos, Eagles, Patriots & Cowboys all have first time starters at QB and are a combined 13-2 so far. Meanwhile, established Pro Bowl QBs Drew Brees, Cam Newton, Philip Rivers and Carson Palmer are a combined 4-12.
In a quarterback league, it is certainly a “bizzaro world” to see rookies with all this success and star players struggling.
MMMD 5: Harbinger of a London based team
The Jaguars played overseas for the fourth straight year but that is not what signals to me the growing likelihood of a British team. To me the significance is that both clubs voluntarily choose to fly to London on Thursday. The days of the early travel and week-long stays in England seem to be over. This signals the growing feasibility of travel.
In fact, the Colts do not even follow London with a bye, which had been the league norm. These subtle but important changes are paving the way for a global NFL.
MMMD 6: Injury rundown
As feared, Sammy Watkins does seem to have a bone issue with surgery with a larger screw and bone graft coming. He was placed on injured reserve and will not return. This is not uncommon for Jones fractures, but when healed, he will be 100% again for 2017.
J.J. Watt had a second discectomy surgery on the same L5-S1 level. There was no fusion and thus no fear of career implications.
Eric Decker has a partial rotator cuff tear. The extent of the tear and his response to rehab will determine whether he needs surgery.
Russell Wilson lead his team to victory and the good news is with the bye, he should be 95% healthy by his next game with the MCL and high ankle essentially behind him.
Tony Romo is likely to practice fully and is getting close to a return. With Dak Prescott performing well, it gives the Cowboys luxury to wait until after the Week 7 bye.
Lee Smith suffered a gruesome ankle fracture yet still limped off the field under his own power.ctygyiousaafwzw
The Raiders TE will likely need surgery and is done for the year.
Kevin White appeared to have an third quarter mild high ankle sprain but there was only one limited view.
Darelle Revis left with a hamstring strain and his return is uncertain.
Chris Johnson was announced on TV as his left knee giving out, but by video to me he had a groin strain, which was confirmed.
Dewayne Washington was announced as an ankle, which may be good news as there was initial worry for turf toe or Lisfranc injury.
Eric Ebron, Brandon Bolden and DeForest Buckner were rolled up upon in similar fashion. All three may have the combo MCL and/or high-ankle sprain with recovery based on severity.
Dont’a Hightower played with partially torn meniscus. He seems to be trying to finish the season but a scope may be in his future.
Gerald McCoy left with a calf injury. This may be something that lingers for the Buccaneers.
Tyler Lockett is reported to be playing through a PCL sprain. Kudos for toughness but the worst is likely behind him and he is unlikely to need surgery for what seems to be a mild sprain.
Tyron Smith of the Cowboys has a bulging disc, which usually does not need surgery but return to play depends on symptoms.
Randall Telfer had a Browns friendly fire high ankle sprain.
The Steelers suffered a host of injuries including Marcus Gilbert with a likely mild high ankle sprain.
MMMD 7: ProFootballDoc Scorecard
Russell Wilson played through injury. Sammy Watkins did indeed have a bigger issue. Brian Cushing played at three weeks, sooner than the six week projection as expected. Josh Doctson’s Achilles tendonitis is lingering. Charles Tapper is now on IR with pars defect. Dez Bryant does have a MCL with bone bruise. Jay Cutler missed while Jacoby Brissett played.
NaVorro Bowman does seem to have an Achilles rupture. Trevor Siemian has an AC sprain and was available to play. Chris Johnson has a groin strain, not knee. Martellus Bennett’s injury was mild. Dez/Scandrick/Tyron Smith all were inactive as expected.
The previous 48-2 record is now 61-2 (96.8%).

Monday Morning MD: MCL and high ankle combo

What do the injuries to Russell Wilson, Dez Bryant & Brandon Marshall have in common? They all have a similar mechanism of being pulled to the ground in a “horse collar” type fashion.
Wilson’s tackle was flagged as a penalty. Bryant was pulled to the ground legally by the jersey. Marshall was illegally yanked down by his facemask last week. All three tackles are dangerous and have the same injury patterns. They all are at high risk for knee MCL injury and same side high ankle sprains as the tackler’s body pins the ankle while the knee is rolled up upon.
Fortunately all three only had mild MCL sprains. Wilson continued to play before being removed for a coaching decision based on the lopsided score. Bryant was injured the second play of the game and returned to catch a touchdown pass. Marshall surprised people when he finished the game last week and proved doubters wrong by starting this week.
When the defender’s body traps the leg as the ball carrier is pulled to the ground, either the medial collateral ligament (MCL) and/or the syndesmotic ligaments (high ankle sprain) are injured. Sometimes it is both. In these cases, there may have been some ankle symptoms but all three were primarily knee injuries.
The good news of all three are that by video, they appear to be mild. Marshall’s injury is known. Wilson and Bryant will have the prerequisite MRI that will confirm the mild MCL sprain. Contrary to some internet fears, I am sure there is no additional ACL tear or bigger injury looming for either player.
Pulling a player to the ground by the collar, facemask or jersey is dangerous as the tackler’s body often pins the leg. Fortunately, Wilson, Bryant and Marshall escaped with minor injuries; however, this can cause ankle fractures or more rarely tibial plateau fractures as well. Players need to take care of each other. Football is dangerous enough and no one should suffer a preventable injury.
MMMD 1: The dreaded non-contact injuries beginning with “A”
Everyone knows anterior cruciate ligament (ACL) tears end seasons. Achilles tendon tears are second only to that in landing players on injured reserve. As players get bigger, faster & stronger, the ACL and Achilles do not get larger, thicker or stronger, thus a weak point exists.
By video, DeAngelo Hall tore his right knee ACL. The Redskins officially called it a “knee sprain” during the game, which is technically not inaccurate; however, an ACL tear is a severe form of a knee sprain. Ironically, Hall tore his Achilles in 2014.
Manti Te’o was announced to be out with an Achilles. There was no official mention of tear yet but the bad news is expected with the formal announcement of tendon rupture, surgery and IR. This marks the 3rd Achilles tear for the Chargers (RB Brandon Oliver & TE Jeff Cumberland). This is also the 3rd week in a row that San Diego has lost a key player for the year. Keenan Allen and Danny Woodhead tore their ACLs in Week 1 and Week 2.
MMMD 2: Walk-through injuries
Injuries in games, practice and preseason are bound to happen, but injuries during walk-through practices? The Browns kicker injured his knee during the lightest of practices and was later placed on injured reserve.
Sammy Watkins had his foot stepped on in walk-through and missed Sunday’s game. His pain predated the stomping injury and my hope is that he won’t need a second Jones fracture surgery as happens up to 20% of the time with this problem fracture.
MMMD 3: Weather delay in Tampa
A thunderstorm delayed the end of the Rams at Buccaneers game by just over an hour. The delay was not just about player safety but fan safety too. Lightning is dangerous for both fans and players.
Reports of danger in football are usually in high school fields without large structures like stadiums; however it pays to be smart when the chance of a potentially deadly injury is preventable.
MMMD 4: Several medical timeouts
It seems that referees have gotten the message after the season opening Cam Newton potential head injury incident. A medical timeout was not called and the league underwent criticism.
This week, several medical timeouts were called by referees. Cardinals WR Michael Floyd was sent off for a play. So was Browns QB Cody Kessler. Both were not diagnosed with concussion.
This is a good step forward. Now let’s hope the system works this well the next time a big star QB in the final two minutes takes a significant head blow.
MMMD 5: UNC needs to watch the action
I feel bad for the elderly gentleman on the Cowboys sideline that got run over. He was clearly mesmerized by the video boards and not watching the action as it came towards him. I hope he wasn’t hurt.
This does bring up a different question. The gentleman was on the sidelines working as the official unaffiliated neurotrauma consultant (UNC). His job is to watch the action and protect players. It is the spotter’s job to watch video and sideline personnel’s job to watch the field. Certainly it would be appropriate for the UNC to watch the video boards after the whistle for replays but not to miss the live action.
Lesson number one on the sidelines is to watch the action. With this incident, I wonder about the experience of UNC doctors. Last week, I was told by a NFL doctor that the assigned UNC had never worked a football game in his/her life and had no specific football training. Recently, Jenny Vrentas was allowed access to observe a sideline neuro doc in action and he admitted to only having 10 games experience in 3 years. In contrast, up to half of team doctors have 10 plus years of experience.
Since the UNC plays an important role, perhaps there should be some formal training mandated before stepping onto the sidelines to help give players more protection.
MMMD 6: Injury rundown
The Steelers had multiple players leave the game. LB Lawrence Timmons (shin – hospitalized and quickly released), G Ramon Foster (chest), S Rob Golden (hamstring), WR Eli Rogers (toe) and LB Ryan Shazier (leg) were all nicked. Their status will be determined this week.
Redskins WR Josh Doctson was a surprise late scratch with Achilles tendonitis. This injury has lingered from preseason and hopefully will not hamper him all year. Teammate CB Bashaud Breeland suffered a high ankle sprain.
Bears RB Jeremy Langford left with an ankle injury. Contrary to some reports of Achilles injury, by video, his tendon is not torn. His return to play is yet to be determined but fears of his season being over are premature.
Packer TE Jared Cook left with an ankle injury. Video was not clear as to diagnosis or when he might return.
Giants CB Eli Apple left with a hamstring injury and his return is to be determined.
49ers CB Jimmie Ward strained his quad/thigh muscle and left the game.
DeSean Jackson and Morris Claiborne both suffered different contusions and were able to return to play.
Tony Romo helped warm up Cowboys with throws during pregame. At five weeks after L1 compression fracture, I expect to see him at practice at any time now in a red jersey. Romo is not ready to take a hit but he is ready to practice with a red jersey.
Jay Cutler did not play with his UCL thumb injury as expected. Even though he doesn’t need surgery, expect his absence to continue as his ability to grip and spin the ball is affected.
Patriots QB Jacoby Brissett’s thumb sprain has not been confirmed as an UCL and thus still has a chance to play next week. Either he or Jimmy Garoppolo (AC) is likely to be available for Week 4 before Tom Brady returns.
Browns QB Josh McCown was announced with a hairline clavicle fracture in addition to AC sprain. His estimate to return is pegged at 2-4 weeks. WR Corey Coleman broke his hand in practice and will not need surgery but will miss 4-6 weeks.
Jimmy Graham appears to be rounding into form after his patellar tendon tear last year.
Titans G Chance Warmack’s season is over after finger tendon surgery. The reason for IR is the post-op recovery protocol is extensive, thus making it impossible to play through, even thought it is just a finger.
MMMD 7: ProFootballDoc scorecard
Josh Mcown does have an AC sprain but he also has an unanticipated hairline clavicle fracture, so even though video was right, it was also wrong, so it will be counted as a mistake.
Adrian Peterson did have a locked knee with bucket handle meniscus tear. He did end up with repair, which is better long term but longer recovery. There was much misleading info but scope and repair were always the likely outcome.
DeMarcus Ware did have surgery for an ulna fracture and returns in a month. DeAngelo Hall confirmed ACL tear. Manti Teo will have Achilles tear announced soon. Jay Cutler did miss due to his thumb. Mo Claiborne and DeSean Jackson continued through contusions. Eddie Goldman was confirmed with high ankle sprain. Chance Warmack will miss the season with flexor tendon finger injury.
The 39-1 record moves to 48-2 for a 96% average.

Monday Morning MD: Running back carnage

After a relatively healthy Week One, the law of averages has unfortunately caught up with the NFL. Among the many injuries this week, seven prominent running backs were injured. Fans and fantasy owners of Adrian Peterson, Arian Foster, Jonathan Stewart, Doug Martin, Thomas Rawls, Ameer Abdullah and Danny Woodhead are holding their collective breaths.
Adrian Peterson is the headline injury as he could not put weight on his right leg when he was helped off the field and into the locker room. There were initial fears of ankle injury but further examination of video focused on his knee. His right knee appeared to be locked, a condition that could be caused by a bucket handle meniscus tear when knee cartilage flips and catches in an awkward position preventing full motion. I hope the early optimism is correct, but crutches and a locked knee brace is not the look of a player ready for next week. cstdebtvyaawkr0
The big concern is the high association with ACL tear, although it is possible to not tear your ligament and suffer a locked knee. I wish I had a different angle on video as my worry is the step before the ankle is pinned. I hope his season and ACL are spared but even when a locked knee “calms down” and can straighten, that doesn’t mean the problem is solved. It would not surprise me to hear Peterson needs arthroscopic surgery at a minimum. Lets hope for a small meniscus tear and a quick return.
Arian Foster was immediately ruled out with a groin injury. It is unclear if the injury is related to his hamstring issue, which he entered the game with. At the start of last season, Foster did suffer a groin injury that needed core muscle surgery. I hope his current injury is a pure groin muscle issue and not a sports hernia type injury like 2015.
Jonathan Stewart and Doug Martin exited with hamstring injuries. There is no way to tell severity or if respective teams were being cautious by removing the two players. Their returns will be likely week to week.
Thomas Rawls was coming off a high ankle type fracture and left with another lower leg injury. Coach Pete Carroll related Rawls got kicked and suffered a contusion which hopefully means he is back for next week.
Ameeer Abdullah left with a foot injury after a nifty run with several hard cuts. The good news is, by video, there was no obvious injury mechanism on that final play. The bad news is one has to worry about potential fifth metatarsal stress fracture with all those hard cuts and no definitive misstep leading to his exit. X-rays were negative but that doesn’t preclude a stress fracture. Here is hoping it is not.
Danny Woodhead injured his knee and did not return. As I indicated on twitter, I am purposefully refraining from comment or analysis here for professional reasons. I try to provide insider knowledge but can never give insider information.
I hope this unlucky group of seven running backs can dodge serious injury and all be back to top form soon.
MMMD 1: Quarterback AC joint injuries
Jimmy Garoppolo and Josh McCown both appeared to suffer AC joint sprains. The Patriots QB did not return, but the Browns QB did. The difference is severity as well as injury to throwing versus non-throwing shoulder.
The acromioclavicular (AC) joint sprain is also called a separated shoulder, but has nothing to do with the ball and socket joint. Still it can interfere with throwing mechanics and there are different grades of injury.
It will be difficult but not impossible for Garoppolo to play on a short week here but the race is on to beat Tom Brady back to action in Week 4.
McCown will undergo further evaluation on his left shoulder but the hope is he can continue to lead the Browns in RG3’s absence. After all, he did finish the game with the non-throwing shoulder injury.
MMMD 2: DeMarcus Ware breaks forearm
“Meet me at the quarterback” took on new meaning as Ware’s forearm met Von Miller’s knee. cssneptuiaetdyt Ware is reported to have an ulna fracture. I expect surgery to be announced to allow for a quicker return measured in weeks without going on injured reserve. This appears to be a similar injury to the one Thomas Davis suffered in the NFC Championship Game where he had surgery and returned for the Super Bowl. My hope is to see Ware playing in a cast as early as in 3-5 weeks.
MMDM 3: Buffalo injury worries continue
The Bills have had bad injury luck already with Shaq Lawson and Reggie Ragland. They don’t need Sammy Watkins to miss time.
Watkins had offseason foot surgery for a 5th metatarsal fracture and is reportedly dealing with foot pain. If the pain is from the bone, that is a bad sign. Jones fractures have a high rate of second surgery as happened with Dez Bryant, Julian Edelman and others recently. X-rays were reportedly negative but if symptoms continue, a bone scan or CT scan will likely be next.
Here is hoping the pain is from the soft tissue and not related to the original bone injury.
MMMD 4: Stiffer penalty for face masking
I am not talking about an incidental tug or even instinctive grab; however, when a player is literally pulled to the ground by his face mask, that calls for a fine, ejection or even suspension.
Brandon Marshall was brought down by his face mask to prevent him from scoring and injured his knee as a result. Fortunately it was a mild MCL, but it could have been much worse. In many ways, tackling by the face mask is just as or more dangerous than a horse collar tackle.
MMMD 5: injury rundown
There were the typical early season muscle injuries. Stewart, Martin and Braxton Miller were examples of hamstring strains. No matter how in shape players are, football shape is different and we usually see these injuries more frequently early on.
Saints CB P.J. Williams was carted off on a spine board but appears to being doing better. He does not appear to have a cervical injury but rather concussion issues.
Jaguars guard Kelvin Beachum also appears to have avoided serious neck injury after he too was carted off on a spine board. He was kept in San Diego overnight for observation after a concussion.
Browns center Cam Erving was hospitalized for a bruised lung after being hit in the chest/ribs. He will likely miss at least a month. If he is placed on IR, then a choice would have to be made between him an RG3 as only one player per team can return from IR.
Lions DE Ziggy Ansah ultimately left the game after an early leg whip from friendly fire. He was seen without a boot or crutches after the game so here is hoping for a quick return.
Chargers safety Jaleel Addae was reported to have a clavicle fracture. Expect surgery and a 4-8 week return.
Seahawks WR Doug Baldwin got the wind knocked out of him and injured his knee. He will have a MRI this morning.
Vikings QB Sam Bradford’s hand was noticeably swollen but that doesn’t mean injury. The back of the hand swells easily and indeed Bradford finished the game without issue. No, the medical staff did not cut and drain his hematoma as some opined.
MMMD 6: Concussion co-chair exoneration
The co-chair of NFL Head, Neck and Spine Committee was cleared by a University of Washington panel of improperly influencing grants. A congressional subcommittee made headlines with accusations of impropriety singling out this doctor. I hope the exoneration makes similar headlines, but I doubt it will. Unfortunately, the original accusations will live forever at the top of any Google search but the clearing of his name will end up buried in the depths of the internet. Such is the world we live in today.
MMMD 7: ProFootballDoc scorecard
It was a busy week. Matt Jones did play with his AC joint injury as expected. Unfortunately, Keenan Allen did tear his ACL. Brian Cushing was confirmed with a MCL injury as was Brandon Marshall and T.J. Green. Russell Wilson was confirmed and played with a high ankle sprain. Demaryius Thomas played with his hip injury. Jimmy Garoppolo indeed has an AC sprain, not clavicle fracture. P.J. Williams and Kevin Beechum had concussions, not neck injury. Sam Bradford’s hand was not a big deal. Other analysis including Adrian Peterson is pending cross checking with MRI results.
For the time being, the 28-1 record jumps to 39-1 at 97.5% .

Monday Morning MD: Second opinions routine

Week one of the 2016 season was relatively healthy but there still were the inevitable injuries. Despite an opening night victory, Broncos fans fretted about star WR Demaryius Thomas’ left hip and his reported second opinion.
Does a second opinion mean trouble? Not really. Getting someone other than the team doctor to evaluate a player is a mantra the NFLPA tells every agent to always do. In almost two decades in the NFL, I witnessed the second opinion rates skyrocket, even for routine injuries. It is not something that I discouraged as a team physician as transparency was important.
In this case, there are several additional reasons that Broncos fans can relax. First, Thomas injured the hip in the first quarter and finished the game. Next, he is not technically seeking another examination of his hip, rather just sending his MRI out for review.
A true second opinion would involve Thomas visiting with another doctor. That does not seem to be the case here. If the player/agent were worried, Thomas himself would have headed somewhere, especially with the extra time having played on Thursday.
The MRI is always read by an independent radiologist anyways and that doctor has usually never met or examined the player. Technically, any further impressions would constitute a third opinion.
Some still worry that the MRI would not be sent unless there was an issue. In my experience, over 50% of the time, agents would routinely request sending the MRI to a “players” doctor regardless of findings.
By video, the early game internal rotation injury did not seem significant. Thomas finished the game with four catches for 48 yards.
In any case, no surgeon operates solely based reviewing a MRI. If there was worry about a hip labral tear, the second opinion doctor would have wanted to see the player. Media and twitter speculation of surgery are very premature.
This seems to be a case of over worry. Second opinions are routine. Sending the MRI for an additional set of eyes is extremely common. In this information era, sometimes too much information creates what I think is unnecessary worry.
MMMD 1: Chargers lose game and star receiver
The Chargers were the week one surprise when they jumped out to a 21-3 lead while dominating the home team Chiefs. Then Keenan Allen went down without contact, was carted off and everything changed.
Allen was visibly distraught, but I go off injury mechanism not player reaction. We all hope his ACL was spared but several reports indicate the worst case scenario.
Head Coach Mike McCoy said ACL tear was suspected but saying further test with a MRI upon return to San Diego was needed. We can all hope for the best but physical exam is very accurate on the field and I always knew a ligament tear by feel. The MRI was done more to determine associated injury. Last year it was a kidney injury and it looks like this year a knee injury will end Allen’s season prematurely.
MMMD 2: How bad is Russell Wilson’s injury?
Seahawks fans continue to worry about their star quarterback’s ankle injury. By video, it was a high ankle sprain type mechanism, but appeared to be mild. Wilson was able to finish the game.
High ankle sprains are the dreaded type that can have a player out for multiple weeks; however, like all injuries, there are different levels of severity. Wilson was seen in a boot after the game and that is commonly used to control swelling overnight. The fact that he was putting weight on it and out at a restaurant were good signs as well. A more severe high ankle sprain would have necessitated crutches and at home ice/elevation/compression.
The worry is how much swelling there will be the next day and this will be the key. Expect Wilson to be limited in practice but I also expect/hope he will be ready for Week Two despite early reports to the contrary.
MMMD 3: Cam Newton concussion controversy
It didn’t take long for the NFL to have this years “Case Keenum” type head injury controversy. As expected, threats of fines and loss of draft picks have not changed anything. Adding a second ATC spotter makes an impossible role a little easier, yet the process is far from foolproof.
The concussion protocol continues to be confusing and the optics of the Newton situation are not good. There was an unsubstantiated report of an on field medical check, but no mention of it by Newton, no video proof, no media eyewitness accounts nor league statement confirming the on field check was done. The NFL should allow the spotters, referees & unaffiliated neurotrauma consultants to speak or release a statement on their mindset. Short of that, it just looks like the league is hiding something.
Now the NFL and NFLPA will conduct separate investigations. Lets see if the up to $150,000 fines for a first time event happen. I doubt that it will.
MMMD 4: Injury rundown
Texans LB Brian Cushing left the game with a knee injury later reported to be a MCL where he is said to miss six weeks. By video, this injury actually occurred on the very first defensive play with friendly fire and Cushing played nine more plays to finish the opening defensive series before leaving the game. This is the other knee from his previous ligament damage. I don’t believe the injury to be severe and fully expect Cushing to return well before six weeks.
Patriots TE Rob Gronkowski missed the opener with a four-week old hamstring issue. He has been at limited practice so I expect him to be close to playing, although severe strains could have a player out 8-12 weeks. Playing a road game without Gronk, Brady, Lewis, Vollmer, Solder, Ninkovich and with Chandler Jones trading sides, the minus-2 turnover ratio still didn’t keep the Patriots from winning.
Falcons WR Julio Jones re-sprained his same left ankle. Fortunately it is a low (not high) injury and he should be healthy enough to play next week.
Browns QB Robert Griffin III injured his left shoulder but finished the game. By video, he likely has a mild AC joint sprain and should not miss time.
Viking QB Teddy Bridgewater was confirmed to have a multi-ligament knee injury.
Saints CB Delvin Breaux fractured his fibula. No announcement yet but expect surgery and IR as real possibilities.
Giants WR Victor Cruz and Ravens TE Dennis Pitta overcame long odds of missing two NFL seasons and returned to play for their respective teams.
Packers WR Jordy Nelson and Panthers WR Kelvin Benjamin took advantage of their extra recovery time with their preseason 2015 ACL tears making successful returns. Running backs Dion Lewis and Jamaal Charles who were injured mid-season did not make the opening week bell.
Texans DE J.J. Watt kept his streak of never missing a NFL game alive. As expected, he was only minimally effective and not the usual dominant player.
Seahawks TE Jimmy Graham overcame odds to suit up after patellar tendon rupture. In limited action, he produced one catch for 11 yards.
Cardinals G Evan Mathis injured his left foot, tried to continue playing but couldn’t. This may be a big blow to the offensive line.
Seahawks RB C.J. Prosise was in a cast for a wrist sprain despite no broken bones. He will have limited availability.
Jaguars RB Chris Ivory was hospitalized for a general medical issue before the game. Here is hoping he is OK and there is nothing related to his calf injury like a blood clot.
MMMD 5: Injury reporting confusion
Week one saw a big change with the new rules eliminating “probable”. With the help of medical followers, we documented that league-wide “questionable” lists more than doubled for the first week 2016 vs 2015 (82 vs 39).
With a player 99% likely to play lumped with someone who is 50-50, this surely will cause confusion. For example, Andrew Luck was described by his head coach as “absolutely” playing yet he was listed as “questionable”. I don’t see the advantage of this new reporting system where less information is given.
MMMD 6: Future expansion to London
Many speak of the travel being unfeasible for an overseas team. This weekend, the Dolphins travelled to play the Seahawks. A flight from Miami to Seattle is longer than if the Patriots were to fly to London.
With some scheduling accommodations, a London based team seems inevitable.
MMMD 7: ProFootballDoc scorecard
Thankfully, this was a relatively good injury week. Carson Wentz rib injury was not an issue. Kyle Long was reported to play through labral tear issues that likely will require surgery at season end. Teddy Bridgewater was confirmed to have a multi-ligament knee injury.
This takes the 25-1 record to 28-1 at 96.6%.

Monday Morning MD: Doctors overlooking injuries?

Media outlets reported Fred Taylor was unhappy with his NFL doctors for withholding information about his injuries. Who is he unhappy with and what really is going on here?
After analyzing the articles and Taylor’s twitter tirade, this is primarily about NFL appointed neutral doctors determining his disability benefits. “I never complain as a player or now.” The focus is not about team doctors lying about diagnoses to get the running back to play through injuries. He has not directly implicated his long-time Jaguars team doctors or Patriots medical staff. He directly criticize NFL “neutral” docs.
First off, let me be clear. It is WRONG to ever overlook injuries or withhold information from a player or patient at any time. To do so is illegal and considered malpractice which carries civil liability and is actionable by state medical boards.
Contrary to sensational media reports, Taylor makes no direct accusations against team doctors that treated him during his 13 year NFL career. His complains against league appointed “neutral” doctors in determining his post-NFL disability.
After Taylor was unhappy with being denied his “line of duty” benefits three times, he sought out his own doctor who performed 11 MRIs and a dozen X-rays. Taylor says he unknowingly played through a fractured clavicle and bilateral partial labral tears.
As much as one might suspect a player’s current team doctors might minimize injuries, when the player changes teams, the new team doctors provide quite a bit of scrutiny. Just this week, two players passing physicals for current teams failed physicals for the new team (see MMMD 5 below). If Taylor had active clavicle or shoulder issues, the Patriots doctors certainly would be incentivized to call that out on their post-Jaguars physical.
If the NFL neutral doctors are underreporting injuries to deny disability, that is certainly inappropriate and justifies Taylor’s indignation. However, lets not turn this into something along the lines of the concussion or painkiller lawsuits.
NFL neutral doctors are typically jointly appointed by the NFL and NFLPA. If there are “shady practices”, I hope the players union steps forward to help advance these claims rather than take the position that they only represent current players.
I can see why Taylor holds a medical grudge about being called “Fragile Freddy”. That certainly is not a fair nickname. Anyone who plays 13 years in this day and age has to be tough and endure to play through plenty of injuries. Retiring as the 15th all-time rusher, he deserves consideration for the Hall of Fame and a fair shot at disability benefits.
MMMD 1: Teddy Bridgewater dislocated knee and subsequent trade
The worst injury to date for 2016 is the Vikings QB’s knee dislocation. Details of how a non-contact injury can be so severe and my medical analysis have already been explained at Real Football Network.
What does giving up a first round pick (and more) imply for health of Bridgewater’s knee going forward? Would a team pay that price to get Sam Bradford to start for just one year? Certainly this move confirms that Bridgewater is out for 2016. It may indicate the Vikings know that the start of 2017 is not a guarantee. As Vikings GM Rick Spielman said, “no one knows how long it’s going to take Teddy to recovery”.
I knew it was bad when I saw paramedics were called and not just an ambulance. In my 17 years as a head team physician, I never called an ambulance much less 911 for a player injury. I hope Bridgewater can recover to be 100%, but that would be against the odds.
MMMD 2: Carson Wentz will be game one starter
With the Eagles trading Bradford, there was news that Carson Wentz would start when healthy. Medically you can book that Wentz will take the first Philadelphia offensive snap of 2016.
Wentz’s rib fractures may not be healed 100% but they will be healed enough to play. It would be very unusual for a rib injury to prevent play five weeks after occurrence. Teams rarely wait for full healing with players routinely playing with added protection and rib blocks.
If Wentz were an established starter, I would be 100% certain he would start. The only reasons he would not is if Eagles want to protect the rookie or feel that he missed too many practice reps with the injury.
MMMD 3: Cramp not knee dislocation
On the heels of the horrific Bridgewater injury, a video purported to “pop leg back into place” received over 100k combined retweets and likes. Instead it was just a cramp, as I indicated based on video during the college game.
Sometimes video makes injuries look bad, but they are not. Other times replay makes it look mild, but injury is severe. A trained medical eye is needed. In this case, a cramp can be very painful and it is essentially a “seizure” of the muscles. Anyone who has had a cramp knows it can be very painful, but it is far from a knee dislocation.
MMMD 4: Why is Nick Chubb playing but Jaylon Smith is not?
Visually, the two players suffered very similar injuries. Congratulations to Chubb who made a terrific collegiate return gaining 222 yards. Meanwhile, Smith was placed on the non-football injury list and has not practiced or passed his physical for the Cowboys. The big difference is the peroneal nerve injury for Smith where he still is using the AFO. Structurally, Smith’s knee should be sound. The question is when and if the nerve will return to normal.
MMMD 5: Bizarre saga of Browns cornerback continues
K’Wuan Williams was waived by Cleveland while serving a two-week suspension for not playing in a preseason game. Two independent doctors are said to have recommended surgery and now the Bears have failed him on a physical. His agent is now asking the Browns to pay for his ankle surgery. There is no doubt in my mind that the Browns will need to pay for his surgery. This is the “old maid” principle of NFL injuries. The last team to pass a player on a physical owns all of the injuries. Unless there are facts not disclosed yet, the only question here is the argument over the ensuing missed pay. How many weeks will the Browns owe the player in injury settlement? There likely will be a grievance coming unless there is agreement.
It is not uncommon for one team to pass a player and another to fail him. This week, Patriot Bryan Stork failed a Redskins physical. I wrote in detail about the famous 2014 Rodger Saffold failed Raiders free agent physical after there was agreement to terms. http://footballpost.wpengine.com/what-happened-in-oakland/ This case is unusual as the Browns have not acknowledged the injury at all.
MMMD 6: Injury rundown
Tony Romo’s status is still in limbo, but that is good news. After a CT scan this weekend, the Cowboys QB was not placed on injured reserve yet. An IR stint would mean missing eight games. Medically, he will miss a minimum of six weeks but that could mean only four games. Hopefully staying off IR means his recovery may be closer to the six week estimate than the 10 week one.
J.J. Watt is off PUP and likely for Week 1. This would keep his playing streak of never missing a NFL game alive. Watt may play but is unlikely to be 100% until mid season as was the case with Dontari Poe of the Chiefs last season.
Josh Doctson is off PUP and on the 53 man Redskins roster. Hopefully the rest has put the Achilles tendonitis behind him, but be careful as this injury can linger.
Kyle Long gets Bears new deal despite a reported labral tear. This likely means he will play in a shoulder harness this season and have offseason surgery.
Neither Andrew Luck nor Keenan Allen are at significant risk for kidney re-injury. Both are hoping for a healthy 2016 after several injuries in 2015.
Is Ladarius Green’s ankle hurting or is he suffering from headaches? He is now on reserve/PUP and will miss minimum six games. Either way it is unusual for a free agent signing to be on PUP as that indicates residual medical problem from the previous season.
Dion Lewis is on reserve/PUP after ACL surgery and will have at least an additional six weeks to recover.
Will Jamaal Charles be ready week 1? The Chiefs have hinted he may not be, but clearly he is not far away or he would have been placed on PUP.
Darren McFadden was placed on NFI for his elbow fracture.
Dennis Pitta is back after finger fracture but the bigger news is his comeback from his second hip dislocation that had him out two seasons.
Tyrann Mathieu is expected to play every single play during Week 1 after ACL surgery.
Justin Houston coming off February ACL is on PUP and may be out for longer than the minimum six weeks. He would have until Week 12 to be activated.
Dion Jordan will not come back from suspension yet as he was placed on the NFI list for his knee.
Jimmy Graham’s status is up in the air after patella tendon rupture. As expected, this is a harder injury than an ACL to bounce back from.
MMMD 7: ProFootballDoc scorecard
Unfortunately, Mike Jenkins of the Cardinals did indeed tear his ACL as it seemed by video. Fortunately, A.J. Green does not have a significant injury corresponding the impressions on game tape even though he was pulled from the final preseason game.
This takes the 2016 tally sheet from 23-1 to 25-1 at 96.2%.

Monday Morning MD: No medical reason for Tony Romo to retire

Tony Romo is not too old or too fragile. The Cowboys quarterback is not injury prone. Medically, when his compression fracture heals, he will be cleared to play and will not have increased risk for long-term problems or further injury.
Sure, Romo is 36 years old, but Tom Brady is 39. Yes, the Dallas signal caller has now had his fourth fracture since 2014. However, it would be unfair to say his body is too ancient to play football. 36 may be the tail end of a football career, but medically, weak bones or osteoporosis are decades away.
The L1 vetebral body compression fracture suffered Thursday is unlikely related to his previous back issues. Disc surgery is typically performed at a much lower level (L4-5 or L5-S1). Transverse process fractures are located to the back and side (posterolateral) of the spine, while this break is located in front (anterior). Details on his previous cyst surgery are sketchy but I still don’t see the relationship to the current injury. When healed, Romo’s back will not be physiologically weaker or prone to injury.
There is not an underlying weakness in Romo’s body. Anyone who has a 300 lb defender jump forcibly on a flexed spine would suffer these same injuries. In 2014, the same year Romo suffered, transverse process spine fractures, 23 year-old Baylor QB Bryce Petty had the same injury. Certainly, the then collegiate QB’s bones were not weak. Both returned after one missed game.
Likely the two clavicle fractures and now second spine fracture does not happen out of his fragility, but there may be another reason. Romo has always been among the best at creating a big gain out of a broken play. Now, his continued desire to extend plays versus his decreased ability to avoid big hits is catching up to him.
I wrote last year that Romo has to learn to protect his left collarbone and not take similar hits. At this point, it may be time to resist his natural temptations to create something out of nothing and throw the ball away. The Cowboys clearly need him, going 1-11 last season without their star player.
With his 2014 spine fracture, he recovered quickly and missed only one game. No way a fracture heals in two weeks but a transverse process fracture doesn’t have to heal, as it is not structural. The compression fracture is structural and there is no way to rush back from this injury. No surgery or kyphoplasty will be needed. No brace or special therapy either, just time.
Romo will definitely miss the season opener and should take a minimum of six weeks to return. If hit in a similar fashion, a compression fracture can progress to a burst fracture with potential injury to the spinal cord or nerves. No one can be allowed to take that risk. Once healed, the risk of paralysis or permanent injury is no greater than normal.
Romo could resume throwing in a few weeks, but the earliest I see him playing and being exposed to a hit is six weeks. In 2007 with the Panthers, David Carr only missed a couple of weeks with his compression fracture but admitted he wasn’t at full strength until much later.
Of course Romo could decide to retire, but if he does, it won’t be because he couldn’t pass a physical or was risking further damage. No one can question his toughness. How many other people can say that they walked off the field on two separate occasions with spine fractures?
MMMD 1: Paucity or plethora of injuries?
Some journalists have gotten the erroneous impression of 2016 being a good injury year a few days ago. The reality is that injuries are near the average.
Up until this weekend, we just didn’t have as many big name stars injured. Now with Romo injured and the parade of Achilles and ACLs continuing, within a day, the chorus has now come that this may be a bad injury year including calls to modify the preseason.
MMMD 2: John Harbaugh calls to change preseason
The Ravens head coach’s preference is for no preseason games at all to avoid injury. Harbaugh states that coaches can evaluate and ready players through practice and scrimmages. He also wants to add meaningful games.
While noble to try to find a way to decrease injuries, this would not do it. Injuries happen in practice and scrimmages as well. Adding regular season games certainly would also increase injury.
My long-standing proposal has been to eliminate one preseason game and add a second bye week, keeping the total length of players time the same. Having a week’s rest early and later in the season would be positive for player health. Paring Thursday games with a bye week would eliminate playing on four days rest. An added week of televised opportunities Sunday, Sunday night, Monday night and Thursday night games would boost revenue as well.
MMMD 3: Unusual in-game injury report
Last week we discussed how pre-game injury reporting was going to become more confusing this year. Sunday night, the Bengals broke form and went out of their way to give more than the typical cursory information.
All teams are required in-game is to give a body part and a status. When A.J. Green injured his knee, the team released more than that. Instead of the usual “knee – questionable (or out)”, the Bengals tweeted Green’s right knee as “reported as not serious”.
This helped calm fans worry. After the game, Green said he “banged knees”. I bet fans wish all teams would be this forthcoming with injury information.
MMMD 4: Achilles tears continue
Ben Watson TE Ravens tore his Achilles tendon. Brandon Oliver RB Chargers had a classic eccentric load Achilles rupture as well that was well documented with HD video. This is another example of how obvious some diagnoses are off publicly available images.
Achilles tears continue to be the second most common season ending injury to ACL tears. As players get bigger/faster/stronger, the size of the Achilles remains essentially the same. It is the strong muscle that overcomes the tendon to cause a tear.
MMMD 5: Preseason injury rundown
Bengals RB Cedric Peerman has a forearm fracture that will need surgery and is likely to be 6-12 weeks for return, making him an IR candidate and possible return.
The fear by video is Cardinals DB Mike Jenkins has an ACL tear. I hope my eyes deceive me here.
Ravens RB Kenneth Dixon has a mild MCL sprain. While media have said 4-6 weeks for return, I am hoping for 2-4 weeks.
Colts G Jack Mewhort does not have an ACL tear despite initial reports to that effect but will still miss some time.
Bears backup QB Connor Shaw has a tibia and fibula fracture and likely had immediate rodding surgery.
Steelers OT Marcus Gilbert hyperextended his elbow and is seeking a second opinion. As a lineman he should be ok for the season to play with a brace. By video, Steelers DE Cam Heyward had a mild high ankle sprain. Being seen in a boot but putting full weight on it is a good sign for Week 1 appearance.
Redskins RB Keith Marshall has a strained elbow and I fear ligament damage, but won’t need surgery and will return in weeks. LB Ryan Kerrigan has a groin strain. RB Matt Jones has a previous mild AC sprain and I expect a Week 1 return.
Tyler Eifert just started jogging and is targeting a Week 4-6 return and may be a PUP candidate.
Falcons S Keanu Neal will miss 3-4 with a “clean up” knee scope.
Rams WR Pharoh Cooper is said to be out several weeks. By video, he suffered a left AC joint sprain on a spectacular catch Saturday vs Broncos.
Texans LT Duane Brown with a torn quad is not expected to he ready for season and likely will be on PUP. Meanwhile C Nick Martin had ankle surgery and his season is over.
Patriots TE Rob Gronkowski is back practicing.
Bears OT Kyle Long has a torn labrum. Offensive lineman can play with a shoulder harness, unless the labral tear is in the more unusual posterior location.
Ravens WR Breshad Perriman is finally practicing.
Chiefs LB Tamba Hali is off PUP now.
Packers WR Jordy Nelson has been off PUP but is only doing individual drills and not full go yet.
MMMD 6: Eddie Lacy cutting his hair?
Hair is considered part of the body. Although tacking a player from behind by grabbing his hair is just as dangerous as a horse collar tackle, it is not illegal.
After just such a tackle, Lacy is considering cutting his hair. The Packers running back is not worried about the pain of losing some hair but rather the safety of his legs.
In this era of health and safety, I am surprised the competition committee has not outlawed pulling a player down from behind by any means, including hair.
MMMD 7: ProFootballDoc scorecard
One can never be perfect and I will definitely call my initial Tony Romo assessment a mistake. I didn’t see the injury when it happened as I was at the 15th annual Taste at the Cove fundraiser. Although when I saw the injury video the next morning, it had me worried about compression fracture. However; by then it was reported that Romo did not have X-rays at the stadium. I read too much into the fact that team doctors did not get films at the game. Dallas has a spine surgeon as one of it’s regular team doctors. I am right about it not being related to previous injuries, but the bottom line is this is an error in video diagnosis.
Brandon Oliver’s Achilles rupture was fairly easy and a classic example for the eccentric load injury.
Connor Shaw does indeed have a tibia and fibula fracture and had immediate surgery with a rod.
Ravens RB Kenneth Dixon did indeed have a MCL sprain.
These take the previous 20-0 record to 23-1 or 95.8%.

Monday Morning MD: New injury reporting rules will cause confusion

The intent of new injury reporting rules is to provide clarity. Instead, the changes are likely to provoke more confusion. If the NFL wanted to make injury reporting more transparent, the new system is likely to have the opposite effect and cloud the issue.
Previously, injury reporting was broken up into “Probable”, “Questionable” and “Doubtful”. These words essentially corresponded with “75%”, “50%” and “25%”. Now the “Probable” category has been removed and “Questionable” and “Doubtful” has been redefined. It is like changing a traditional “A, B and C” grading system to “pass and low pass”. There is less delineation of injury grades.
Instead of 50-50, “Questionable” will now mean “uncertain whether the player will play”. “Doubtful” now means it is “unlikely the player will participate”. “Out” still means the player will not play as that designation does not change.
For practice designations, “Out” will no longer be used. The practice categories of the new policy make sense. “Full”, “Limited” and “Did not participate” are easy to understand practice designations.
Certainly the new definitions make injury designations more vague. As it is, only the body part and status is listed. No side or specific diagnosis is required. Now the status becomes murkier with the removal of a category.
Essentially, the old probable and questionable categories are now combined into one. It seems to me the new system will have teams listing anyone in doubt to be questionable. The new rule explicitly states “if there is any question concerning a players availability for the game, he should be listed as ‘Questionable’”. Now anyone with a 50-50 chance of playing is lumped with someone who is 99% certain to play.
Teams will be incentivized to liberally use “Questionable” as anyone not listed who doesn’t play puts a club at risk for possible discipline. The move to list more players as “Questionable” was already happening. Now the rules justify it even more often.
A new cottage industry will be created. Information on the “questionable” players will be at even more of a premium. The 90-minute inactive list release will take on higher importance. Perhaps the real motivation of this is to create ratings for the pregame shows.
As a fan, I am not in love with the new changes, which provide less specific information. On the other hand, as an injury analyst, I think this is going to be good for my twitter handle as fans, fantasy players and gamblers seek more specific information on their own.
MMMD 1: ACL tears continue at high rate
There are 17 ACL ruptures to date this league season. Torn ACLs through all of preseason 2015, 2014 and 2013 were 25, 22 and 31. With week 2 preseason games just concluded, the league is on track to hit the average in the mid 20s.
The new CBA limited contact has not lowered ACL tears since it is primarily a non-contact injury. With the high tempo of practices, one can argue that introduces more high-speed cutting activity, which puts ACLs at risk.
MMMD 2: Dion Lewis 2nd surgery
The Patriots running back recovering from a torn ACL was rumored to be coming of PUP soon. Instead, he had additional surgery.
The only good news is that the procedure is not directly related to the ACL, but instead is a “cleanup”. Having follow up surgery after an ACL is not uncommon and is usually related to associated scar tissue, meniscus tears or articular cartilage damage.
Lewis is eligible for Reserve/PUP come the regular season since the team placed him on Active/PUP at the start of training camp despite practicing in June. At least the early news is the set back does not involve an ACL re-tear and there is a good chance to return later this season.
MMMD 3: Alex Okafor decides to play without surgery
The Cardinals linebacker had previously torn his distal biceps tendon and had surgery which cost him the season. Now in a contract year, Okafor will try and avoid surgery and play through the injury.
Typically, proximal biceps tendon tears near the shoulder do not need to be fixed, but ruptures distally near the elbow do. Okafor has experienced the surgical route before, I hope the non-surgical option goes well for him.
MMMD 3: What headaches?
Ladarius Green denied headaches have been keeping him from practice and insisted it was his ankle injury. Last week, we discussed the Steelers only big free agent signing and the controversy.
Despite being reported to be in the concussion protocol, Green now denies the headaches. Medical personnel cannot come out and clarify the truth due to HIPAA privacy laws so we will just have to wait and see what happens.
MMMD 4: J.J. Watt uncertain for first two games
Texans head coach Bill O’Brien acknowledged that Watt may miss the first two games of the season. This would break his perfect streak of never missing a game in his NFL career.
When he first had back surgery, I indicated the procedure was relatively simple, but the rehab was difficult. The disc is about five inches deep in the back and that means a deep dissection through core muscles making for a long recovery. I hope the defensive player of the year can come back to form quickly.
MMMD 5: Preseason injury rundown
Jamaal Charles is off PUP and practicing. I am expecting a productive year as he ran for a career high 1506 yards coming off his previous ACL surgery.
Jordy Nelson is back practicing after a stint on PUP for the presumed patellar tendonitis in the other non-ACL knee. Packers may have been smart to get this better to avoid a nagging injury.
Steve Smith, Sr. is off PUP and soon starting practice for his 16th NFL season. Normally, Achilles ruptures can end careers for a wide receiver in his thirties, but not for this 37 year-old.
Larry Fitzgerald is already back practicing after a mild MCL sprain. Seems his missing time was truly a preseason precaution.
Tyrann Matthieu is off PUP and practicing. He overcame a previous multi-ligament knee injury, so this isolated ACL should be easy for him to overcome.
Matt Jones was said to have a “slight” AC joint sprain. Normally this is a 0-2 week injury if mild. Caution, he did leave the stadium with a sling which is not always needed for low grade shoulder separations.
Breshad Perriman feels like déjà vu. Last season a PCL injury teased fans for a return that never happened. This year a “partial” ACL is the culprit and as of yet no timetable for return.
MMMD 6: Texans permanently switch to artificial grass
There have been many complaints about the seams in the natural grass due to pallets in Houston. Now it has been decided to permanently switch to artificial surface and this presumably includes for Super Bowl LI.
Interesting that the switch was made for safety. Typically, grass fields are safer than field turf. Although, the new sport grass is clearly better than the old astroturf for injury. In this case, it wasn’t the surface of the natural grass that was the problem, it was the connections of the patchwork field that caused issues.
MMMD 7: ProFootballDoc scorecard
We haven’t tallied right or wrong in awhile. Soon we will have plenty of access to video with the regular season. In the meantime, previous predictions about Jordy Nelson and Julio Jones minor injuries were correct. Add in Watt likely missing time and Lewis’ knee scope not related to ACL. This takes the previous record from 16-0 to 20-0.

Monday Morning MD: Common for medical staff to get the blame

Whenever something goes wrong, the blame game is started. We look for whom to blame with the league concussion issues. When injuries pop up, the same thing often happens.
The New York Giants medical staff has taken some heat over the years for leading the league in injuries. Now the Buffalo Bills and Pittsburgh Steelers medical staffs are being questioned.
It would be entirely unfair to place blame on anyone without a thorough analysis of the particular injuries. Certainly the Bills defense has taken four hits already this year, but are they the fault of the medical staff?
Indeed Buffalo’s first and second round draft picks have been injured. Shaq Lawson aggravated a pre-existing shoulder injury and had surgery. Reggie Ragland tore his ACL. IK Enemkpali has now met the same fate. Manny Lawson injured his pec, but at least his season is not over.
The medical staff doesn’t cause injuries. There is some evidence of effectiveness in soccer of ACL prevention exercises in young players, but it has not been proven in football. Clearly traumatic ligament tears are not the fault of the medical staff. ACL tears are rarely partial and it was too much to hope for that Ragland’s season could be saved.
We don’t know the dynamics of the Bills decision to draft Shaq Lawson given his shoulder issues. In my 2016 draft medical guide, I indicated that Lawson had a labral tear and would need shoulder surgery. If this was obvious to someone who didn’t examine Lawson, it is unfathomable that the Bills medical staff didn’t know it. The question is what stock management placed in the medical assessment and what played into the decision to initially risk playing with the injury. In my time in the NFL, my club has drafted players with poor medical grades based on perceived value. Just because a player with medical risk was drafted high doesn’t mean the team didn’t know about the problem.
In Pittsburgh there are questions about Ladarius Green and his headaches. Some are asking if the Steelers bungled the $20 million free agent signing. The replacement for retired Heath Miller has yet to practice and also is coming off ankle surgery. Some fans question why the Steelers medical staff would allow Green to be signed and whether they should have been able to predict his lack of availability.
I know the Steelers to have a top quality medical staff that has been involved in the leadership of the Pro Football Athletic Trainers Society and NFL Physicians Society. There is no way they did not have access to Green’s medical records as all 32 teams are on the same electronic medical records system. It is highly unlikely the medical team “missed” the ankle injury or lingering signs related to previous concussions with the Chargers.
To suggest his previous team did not properly document headaches or concussion symptoms would be extremely hard to believe. First, this was not a trade and there would be no benefit to a club to downplay medical findings. Second, the penalties for inaccurate medical records go way beyond any potential NFL fine or discipline. Falsifying, altering or purposely under reporting medical findings could result in state Medical Board action and/or civil litigation with career threatening implications for a medical provider. This is why I say the new NFL penalties for violations of medical protocol will have little affect.
Word has come out that Green reportedly never told the Steelers about his headaches when he was signed. This makes it near impossible that the medical staff is to blame. It is possible the player was not having headaches when signed or under reported symptoms to the team. To blame his previous club for allowing Green to play through headaches would be saying the independent and unaffiliated neuro consultants were in error.
Unfortunately due to HIPAA privacy laws, the team physicians involved cannot come out and tell their side of the story in New York, Buffalo or Pittsburgh. This leaves their roles up to speculation and any public accusations or implications cannot be refuted by the medical staff.
The Jaguars are poised to simultaneously add three first-round talents to their defense, but does their medical staff get any credit? Last year’s first pick Dante Fowler tore his ACL early in offseason but has rehabbed well. Jalen Ramsey had a post draft injury this year with knee surgery and has made a quick recovery. Clearly the Jaguars medical staff had some input in the evaluation for top of draft talent Myles Jack and his early second round selection despite medical concerns. I don’t hear any kudos coming to the Jaguars medical staff now that Fowler is back, Ramsey dodged a bullet and Jack seems to be performing well.
The blame game is one reason I started my media efforts. Most medical staffs are not allowed by their team to speak out and federal law prohibits the disclosure of private medical information. I am not here to defend anyone. I only try to provide an insider’s prospective of what may be happening.
Injuries always affect teams. So far it seems the injury bug has hit the Bills defense several times, and fortune has smiled on the Jaguars defense so far. In some ways, medical staffs are like long snappers. It seems when something goes wrong they get the blame, but when it goes right, the credit is given elsewhere.

Monday Morning MD: Achilles is the new ACL

The ACL used to be the dreaded injury, but now Achilles is catching up. Both injuries end seasons and necessitate surgery. Both are predominantly non-contact injuries that have not dropped in frequency despite the limited practice of the current CBA.
This week Seahawks players Brandon Cottom and Ronnie Shields suffered Achilles tendon ruptures essentially back to back during practice. The Lions Eric Ebron was feared to have suffered the same fate. Hopefully the latest report of no need for a boot means his Achilles is not torn.
Although it seems that way, Achilles tears are not more common than in the past, they just haven’t decreased with new CBA practice limits. This makes sense as Achilles are non-contact injuries, so limiting padded practices doesn’t decrease the occurrence. In fact, as practice tempo increases, the tendon is more at risk.
As players get bigger, faster and stronger, the Achilles tendon stays the same size. Essentially, it is like planting a bigger tree in the same size pot and thus something has got to give. In fact, the Achilles girth of an NFL athlete is no different than that of the average person.
The only good news is that recovery continues to improve. Cowboy Gavin Escobar has made a quick recovery and was not placed on PUP. Arian Foster has done well so far in Miami. I am less worried about his Achilles recovery than the fact that he will be a 30 year-old running back.
Achilles injuries are caused with a sudden eccentric load with an explosive first step or change of direction. As the size of players and speed of the game increase, Achilles tears have become the new ACL.
MMMD 1: No requirement for injury reporting
During the regular season, injury reports are the norm. In the offseason and preseason, injury updates are not mandated.
All injury information at this time of the season is provided at the grace of teams, coaches and players, as there is no mandatory reporting. Packer fans fretted about Jordy Nelson’s ACL recovery when he was placed on PUP without a given reason. However, the player himself later revealed it was a “hiccup” to his left knee, not the right side which had ACL surgery.
The in-season reporting requirements are far from full disclosure. As predicted, the Colts were never fined for the non-disclosure of the rib injury to Andrew luck. Therefore, in the preseason, we are left to guess when Jamaal Charles, Jimmy Graham and Dion Lewis will come off PUP.
MMMD 2: Reggie Ragland limbo
The Bills have already temporarily lost their first-round pick Shaq Lawson to shoulder surgery. Now their second-round selection is in jeopardy of missing the season.
There was early worry about an ACL tear and an inconclusive MRI added to the mystery. In my NFL experience, a gentile lachman exam was always more accurate than a MRI. We always knew whether an ACL was torn or intact before we left the field. I suspect the Bills know as well.
The key is whether the exam shows the knee to be stable or unstable. A partial ACL tear that is stable will mean a good return for this season. A partial ACL tear where the knee is unstable means surgery and IR.
Lets hope for the best as we await the second opinion. The Bills already know, but it is fair for the player to be sure before deciding his fate for 2016.
MMMD 3: Thomas Rawls comes off PUP
There has been much confusion about the Seahawks starting RB and his ankle injury. Despite early reports of no surgery, I always said surgery was necessary. That has now been confirmed by Pete Carroll this week.
The PUP stint was expected. Now look for Rawls to move forward with a productive season. After all, his injury is similar to the ones previously suffered by Danny Woodhead and Darren Sproles. Those two certainly have not looked back after their surgery and recovery.
MMMD 4:Different outcomes for pectoral injuries
The key to pec injuries is whether they involve the tendon or muscle .
William Jackson of the Bengals tore his pec tendon, thus will need surgery and be placed on IR. Manny Lawson of the Bills is thought to have a pec muscle injury and thus hopefully will be available soon.
Coaches, players and reporters often confuse pec tendon and muscle. The key is to determine the location of the tear as tendons detach and need surgery while muscle doesn’t hold suture and can heal with time.
MMMD 5: Hall of Fame game cancelled
In a sign that the NFL is serious about player safety, the first preseason game was cancelled due to poor field conditions. This certainly caused much embarrassment and millions of dollars but good to see the league acting on behalf of safety.
There have been five major medical changes for 2016. Among them is the addition of a Field Surface and Performance Committee that would be responsible for this type of issue.
MMMD 6: Cupping takes center stage
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With the marks left behind on Olympic athletes, cupping therapy will likely become the new rage. Kinesio tape has been around for decades but exploded into the public eye with the 2012 Olympics. Now the centuries old Chinese cupping therapy has come to the forefront with the 2016 Olympics.
There is no scientific evidence that cupping or kinesio tape works. Then again, ankle taping comes loose within the hour and many pregrame IVs are given to already well hydrated NFL players. Never discount the placebo affect.
MMMD 7: ProFootballDoc scorecard
Dolphins fans worried about a long absence for Jay Ajayi when reports of a knee bone bruise surfaced, but my prediction of a quick return fortunately came true.
Cowboys fans worried and sent me video of Devin Street’s injury and fortunately it turns out to be a mild injury as expected.
When Corderelle Patterson of the Vikings landed on his shoulder, there were fears of clavicle fracture and serious injury. By video, it appeared to be an AC joint sprain and he is already back at practice.
Seahawk Thomas Rawls indeed entered camp on PUP and now has quickly come off the list and is ready to go after his ankle fracture that required surgery.
Adding these four to the previous 12-0 record takes the 2016 scorecard to 16-0 but one miss still takes us below last season’s 94.6% mark.

Monday Morning MD: Top five medical changes for 2016 season

Health and safety continues to be the highest priority for the NFL. Last year, I chronicled the top five medical changes for 2015. What does the league have in store for medical improvements for the 2016 season?

  1. New Chief Medical Officer

The often-criticized league medical advisor was forced to retire by the commissioner. Critics have been calling for his head since he lied on his resume, downplayed head injuries, made himself lead author on concussion papers as a rheumatologist and led the league Mild Traumatic Brain Injury committee into being disbanded. For decades, he was the only physician at league headquarters on Park Avenue.
The transition has been coming for a long time. Even before the appointment of an outside chief health and medical advisor last year, his public role has been reduced.
I hope two things happen with the transition. First, hopefully both sides can stop with the politics and focus on meaningful improvements to player health. Second, I hope the league hires a strong replacement that is well respected and above reproach.
This will be a key hire. No offense to the current advisor, but she has a full-time job outside the NFL and only works with the league one day a month. Directing health and safety efforts for players is more than a full-time job.

  1. Fines and loss of draft picks for teams

Violation of NFL medical protocol now has defined penalty parameters. The new rules put teams and medical staffs on notice. Although this new penalty system has made much news, I am not sure it changes the game.
First, the potential of fines and/or loss of draft picks won’t change the behavior of NFL doctors. A physician’s fear of being sued if the standard of medical care is violated will always be much greater than any league penalties. The maximum first time penalty is $150,000 and paid by the team, while a malpractice lawsuit could directly cost the doctor millions.
Second, the threat of fines and loss of draft picks were always there. I am not a legal expert but I believe the commissioner has the power to fine a team or dock draft picks for any transgression. Certainly, monkeying with medical protocol would be considered conduct detrimental to the league and a threat to the integrity of the game. The commissioner has always held the power of discipline in these issues. The only difference now is the penalties are defined.
It is a huge positive that the NFL and NFLPA showed good cooperation in coming up with this new system. However, the reality is that it may not change much.
Contrary to popular opinion, I think NFL doctors will welcome the new fine system. It will give medical personnel further reason to preach safety protocol in case any players, coaches or management want to push the envelope.

  1. Second “eye in the sky” to be added

Going forward, there now will be two ATC spotters up in the booth in addition to the video assistant. When the “Edelman rule” of a medical timeout was first introduced last year, I indicated one person would be hard pressed to keep up and human errors would be made.
Although the single spotter was not solely to blame for the Case Keenum situation last year, a second spotter could have helped. Not only does it help to have a second pair of eyes, a second mind to bounce video off of is helpful.
The single spotter was asked to keep up with the action, review previous plays, notify sideline personnel of injuries and instantaneously determine medical timeouts. Now one ATC can follow the game and keep up, and the second can review video, notify medical staffs on the field and coordinate requests when they call up. It would be a mistake to assign one spotter to look for injuries on the home team and one for the visiting team. The two need to work in concert.
Both spotters are human and ultimately I still predict here will be eye in the sky and medical timeout controversy this year as I said before. However, there should be fewer problems with a second person in addition to the video replay assistant. It is still an impossible job, but two sets of eyes are better than one with all the action that happens.

  1. Designated for return player can be named later

Previously a player upon initial roster move had to be declared to be on injured reserve (IR) and ineligible to return the same season or be placed on injured reserve-designated for return (IR/dfr) and eligible to play again. Now teams still have one IR/dfr spot but they can designate that player to come back from IR. In other words, the medical staff no longer has to predict recoveries and general managers no longer need to worry about using the single designation too early in case a star is later hurt.
The Steelers medical staff had the best intentions that Maurkice Pouncey would return from an early season ankle fracture/dislocation. They could not predict that their star center would get an infection and need seven subsequent surgeries and never recover enough to return during the same season, thus wasting their lone IR/dfr designation.
The new procedure leaves all IR players “alive” for potential return until a team uses the single IR/dfr designation. This keeps IR players motivated to rehab and around the team in hopes of a return. It also takes hindsight out of medical predictions on potential recovery.

  1. New safety committee

Over the years, the NFL has had multiple committees dedicated to player safety including a Shoe Committee and the current Head, Neck and Spine Committee. There is even a Foot and Ankle Committee. Now add the Field Surface & Performance Committee to the list.
The new group will be charged with performing research and advising on injury prevention, improved testing methods, and the adoption of tools and techniques to evaluate and improve field surface performance and playability.
Future
As the regular season approaches, the only thing we know is the NFL will continue to change in the quest for health and safety. These five improvements won’t solve everything but at least yearly progress is being made.