Monday Morning MD: The most important draft medical info still to come

 
Medical is the most important information a team can get at the NFL Scouting Combine. The Combine may be over but the pre-draft medical data won’t be complete for almost two months.
Players coming off surgery or with active medical issues are asked to return to the medical rechecks in six weeks. Essentially this is the main group of players at risk to drop in the draft due to injury. The return visit allows all 32 teams to assess players’ recovery and improvement.
Revisiting Indianapolis will be key for the former Notre Dame star linebacker and Butkus Award winner, Jaylon Smith. Unfortunately what was feared, has come true with revelation of a nerve issue at Combine.
Although nerve recovery is quite finicky, the majority of improvement usually happens early. It is also important to get a second data point to see which way Smith’s knee is heading and how quickly. Remember the injury is still fresh and the timing of the second look at the rechecks essentially doubles his recovery time from injury/surgery.
If the peroneal nerve has incrementally improved by then, that would be a good prognostic sign. If the foot drop remains unchanged in six weeks, that would portend a long and difficult road for recovery. Making progress is the key. Even without the nerve issue, it would be important to recheck Smith for his status after ACL and LCL surgery.
Please note that it is absolutely inaccurate that Smith’s tweet could cost him millions. I never said such a ridiculous and presumptuous statement. No team or physician is going to base their medical opinion on my (or the player’s) tweets. All 32 teams will rely on their exam of the player. Let me be clear, Jaylon Smith self-revealing a video inadvertantly showing an AFO (ankle-foot orthosis) and indicating a peroneal nerve issue did NOT cost him anything. Teams were going to find out anyways. The injury will cost him millions, his post has nothing to do with it. Let’s stop ridiculing him for trying to make a good impression. Instead, Smith should be applauded for his great attitude. We are all rooting for him.
I always find the herd mentality interesting. A week ago, no one worried about Smith’s knee and had him a consensus top-10 pick. Now many have his career over and compare him to Marcus Lattimore who never made it to play in the NFL. Sure both had serious knee injuries, but they tore different ligaments and cannot be directly compared.
For weeks, media had the wrong ligament identified saying Smith had a multi-ligament injury that included his MCL when the video clearly showed LCL injury. At Combines, it was confirmed as an ACL and LCL tear. Media last week had his nerve as completely healthy. Now the pendulum has swung the other way. In a week’s time Jaylon Smith’s projections have gone from a top pick to never playing football again. Let’s give this kid a chance. Let’s wait for rechecks and all the medical info to come in. Let’s not shovel dirt on his NFL career yet.
MMMD 1: Injury inevitable at Combine
Unfortunately someone is injured every year at Combine. Cardale Jones pulled up lame during his second 40-yard dash and did not finish the workout.

In 2014, fellow Buckeye Carlos Hyde suffered a similar injury during his Combine run. Offensive lineman Brandon Shell injured his quad during his 40-yard dash this year. Another common, but much worse, Combine injury is a pectoral tendon tear during the bench press, which needs surgical repair. Others have even torn the ACL in pre-draft workouts as well.
Injuries are inevitable, even at the Combine. At least Jones’ appears to be minor and he still has a chance to participate in his Pro Day in two weeks.
MMMD 2: Hands don’t grow
It is no secret that players prep for the Combine like high school students study for the SAT exam. What is unusual is working on your hand size with massage therapy and stretching. Teams care about a quarterback’s hand size because it is thought to correlate with decreased fumbling and better grip in inclement weather.
Brandon Allen’s hand measured at 8½ inches at the Senior Bowl and improved to 8 7/8 at the Combine measurement. It is impossible to “grow your hand”, but it is possible to make it measure larger.
Hand size is recorded by spreading one’s fingers and measuring from the tip of the thumb to the tip of the pinkie finger. In reality it is more of a “pianist’s reach” than true hand size. Because this method essentially documents finger span, stretching could improve the measurable even though it is impossible to enlarge the size of your hand in a month.
MMMD 3: Tony Romo proposed surgery
Will he or won’t he? Plate or Mumford procedure? Those are the pending questions for the Dallas star QB.
Here are the undisputed facts. Neither procedure is mandatory. Both are prophylactic in nature and attempt to decrease future clavicle fracture risk. The choice is one or the other (or none); both will not be needed.
The purpose of the plate (and screws) is to strengthen and protect the collarbone. In the short term, this will help. The question is what happens in the long run and is there a stress riser at the end of the plate. The other procedure is to remove the end of the clavicle to decrease the transmission of force when tackled onto the left shoulder.
The Cowboys medical staff is to be applauded for doing what it can to prevent a fourth clavicle fracture. The proposed surgeries do not indicate a failure of any current treatment.
MMMD 4: Offseason is a time for optimism
It is rare to have a negative injury update in the offseason. Not saying positive information is untrue or not warranted, just that when no regular injury reporting is required, voluntary reporting of bad news is harder to come by.
I like seeing the good news parade: Jordy Nelson is ahead of schedule from ACL surgery, Luke Keuchly’s shoulder surgery went well, Jimmy Graham is doing great after patellar tendon repair, Terrell Suggs and teammate Steve Smith, Sr will be ready for 2016, and Chiefs edge rushers Justin Houston and Tamba Hali had successful knee scopes.
I am not saying these reports are incorrect. Only noting that good news is easy to come by in the offseason.
MMMD 5: Be wary when not hearing optimism
The corollary to the above is to be careful of what you don’t hear. Antennas should go up when positive spin is not seen.
The Steelers have been non-committal on a timeline for Le’Veon Bell’s return. Perhaps they are just being careful to not put pressure on their star running back; however, the worry is that his return might be delayed. MCL and PCL surgery is a more difficult recovery than from an ACL.
I hope the reports of Larry Donnell being forced into early retirement for his neck are not true. However, offseason bad news is worth monitoring.
MMMD 6: A rose by any other name…
“What is in a name?” said William Shakespeare. Apparently J.J. Watt cares about the name as he asked people to stop calling his injury a sports hernia.
Indeed the term sports hernia has progressed to athletic pubalgia and now the term core muscle injury is being used. The injury has not changed, but the scientific names for it have evolved. Sports hernia may not be the latest medical term used, but for the lay public, it is still acceptable. In this case, Watt prefers the old terms not be used for him.
MMMD 7: ProFootballDoc scorecard
In the offseason, medical evaluations are more sparse. There is one injury clarification. Indeed Thomas Davis does not need his forearm plate and screws removed prior to next season as some indicated. That updates the 2015 scorecard to 166-10 but does not change the 94.3% correct rate for the season.
I am not sure if I should go to the effort to continue to keep weekly score for 2016. With a 2014 year at 92.6% and vetting each injury prediction in 2015, there may not be a point to keep track in 2016 but I will await your comments before I decide either way.
In the meantime, I choose the Super Bowl as the start and end of an injury season. With Jaylon Smith indeed having a LCL (not MCL) injury and nerve issues (will only count it only once), that starts 2016 season at 1-0.
 
 

Monday Morning MD: The medical exam is what matters, not reporters sources

 
This is the season of optimism. All medical reports and leaks about players with health conditions are by nature positive. Since sources typically come from the camp of the player or by permission from the athlete, they universally paint a “glass half-full” picture.
Medical is the most important part of the NFL Scouting Combine. Media reports do not influence these opinions. Team medical staffs rely on what they see and feel during the medical exam.
No matter what is said, clubs and docs don’t listen anyways. When I was a team doc, I never even read any media reports about the draftees. Even letters from personal physicians are taken with a grain of salt.
Let’s take the example of Butkus award-winning linebacker Jaylon Smith out of Notre Dame.. The projected top ten pick suffered a horrific knee injury during the Fiesta Bowl. By video, it was clear he suffered a multi-ligament knee injury that included his lateral collateral ligament (LCL). This injury carries risk of peroneal nerve damage and is significantly worse than an isolated ACL tear.
An optimistic report said surgery “went about as well as it possibly could have” with “full recovery” and “the nerve was healthy and in good condition”. Reading between the lines, a LCL and ACL surgery that “couldn’t have gone better” will still not be ready at the start of the NFL season in the best case scenario. Even the positive statement about the nerve worries me as normally there is no reason in surgery to inspect the peroneal nerve unless there is concern for damage or the athlete presented with symptoms of nerve injury.
I have not examined the standout linebacker and I certainly wish him well. I would be thrilled to be wrong about his injury but his rookie year in the NFL could be a “red-shirt year” to get his knee better. If Smith takes all of 2016 to recover and returns to full form in 2017, that would be a great result from a multi-ligament ACL/LCL injury.
Described as “best talent in the draft” and “sure-fire top 10 pick”, many pundits still have Smith going high. I would be surprised if Smith were a first-round pick based on the severity of the injury. Todd Gurley was a smart 10th pick last year, but his ACL injury was much less severe and he still missed the first five games of the season.
The medical exam will provide an early answer, but don’t expect to get definitive news out of Indianapolis this week on Smith’s knee. He likely will defer full knee exam to the recheck Combine like Gurley did last year. Only six weeks from surgery, Jaylon Smith and his agent won’t allow doctors to tug on his knee yet.
MMMD 1: What to watch for at Combine
Charles Robinson of Yahoo listed his top-10 red flag players headed into Combine and four of them were due to medical reasons. Jaylon Smith was already discussed above.
Based on my experience, the other three should have a more favorable physical exam. Myles Jack (meniscus repair), Laquon Treadwell (ankle fracture-dislocation) and Corey Coleman (sports hernia) will likely have minimal medical downgrades.
Every year there are always some medical surprises at the Combine. Usually a handful of players will have significant medical issues or need surgery. Medical news will make headlines all year long.
MMMD 2: Nick Chubb fortunate to have more collegiate eligibility
The star Georgia running back is a true sophomore and is not draft eligible. That is a good thing as he will need the time to get healthy. His injury was much worse than his predecessor Todd Gurley.
Chubb’s multi-ligament injury is similar to that of Jaylon Smith and he will need extra time to recover. Time is on his side and video of good progress has surfaced. He has his junior year to recovery and if he can return to form in his senior season, he still can be a top draft pick in the future.
MMMD 3: Re-evaluating the Combine process.
Tom Pelissero reported that the NFL ponders changes to the annual event in Indianapolis. Some of those changes could involve the medical evaluations process.
I have attended 19 Combines as a NFL physician and the medical part has been essentially unchanged for decades. Sure electronic medical records are now used, many of the MRI’s are currently performed on-site and functional movement screens were added, but the process is still somewhat archaic. With multiple doctors from each team getting a chance to evaluate every player, this is why the “meat-market” term is used. Some medical evaluation improvements might be a good thing.
MMMD 4: No head athletic trainer turnover
Many say the NFL stands for “not for long”. That is clearly is the case for coaches, players and all jobs in the league. Even medical staffs are at risk.
I can’t remember an offseason where there was no change at head athletic trainer league-wide. All 32 teams retained their lead medical position. This is not quite as unusual as having no head coach turnover but it is still remarkable.
MMMD 5: Luke Keuchly shoulder surgery
The Panthers star linebacker underwent labral repair surgery but should be ready for the season opener. It is not a surprise that Keuchly needed surgery as he wore a shoulder harness in the playoffs and Super Bowl indicating instability.
Keuchly was not listed on the Carolina injury report. This is not unusual as not every injury is listed, especially when it is not affecting practice or playing time. This is the same reason why I said that the Colts non-reporting of Andrew Luck’s rib injuries would not result in a fine to the team.
MMMD 6: Thomas Davis forearm picture
A picture showing a fresh surgical incision and significant swelling posted after Super Bowl created a stir. It was likely taken immediately after surgery but many incorrectly assumed Davis played with a forearm swollen like a football.
Now a more recent picture shows how well Davis is healing. There are no reports of complications and the plate will stay in his arm. Kudos to Davis and the Panthers medical staff.
MMMD 7: Retirement season
Some big names are riding off into the sunset this offseason: Jared Allen, Marshawn Lynch, Charles Woodson, Jarod Mayo, Justin Tuck, Jon Beason and Health Miller to name a few. Peyton Manning and Calvin Johnson may join the list.
None of these retirements are similar to Chris Borland where he walked away after his rookie year with future head injury concerns. Some have more football left in them but these are all veterans.
Congrats to these players and thanks for the enjoyment they provided.
Follow David on Twitter: @profootballdoc
Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.

Monday Morning MD: Medicine has to catch up

We have to do better. Despite a decade of head injury in the headlines, there is still much more we don’t know about concussions than what we do know. We are a long way from prevention. There is still no proven treatment. The diagnosis and return to play is very subjective. There is not even a definitive method to determine CTE (chronic traumatic encephalopathy) except for examining the brain after death.
As an example of how little we know, concussions are still all lumped together as one diagnosis. It’s like the 1960’s for knees when every injury was a sprain. There were no MRIs, very little treatment and arthroscopy didn’t exist. Doctors didn’t understand the importance or function of the ACL and a tear ended your career. Surgeons routinely removed meniscus with open incisions thinking it served no function and inadvertently created arthritis. Surely all concussions are not the same, just like all knee injuries are not the same. One day soon I hope we can categorize different types of concussions. Perhaps a temporal lobe grade 2 concussion will be treated with a different protocol than an occipital lobe grade 3 injury.
I pen this column on the flight home from attending the “celebration of life” of yet another professional athlete that has taken his own life. I have the misfortune (and fortune) of knowing three friends, all who once were at the top of their sport and now are no longer with us. Although the average sports fan would recognize their names, their identities are not important to this narrative. The fact that they all died young in their 40’s and left behind families is tragic.
This is not a political piece. I am not hyping the dangers of CTE nor downplaying concussions as part of the game. I am not anti NFL in its handling of head injuries nor pro NFL. Not all of my three athlete friends who committed suicide were even football players. One friend was tested and definitively found to have CTE by multiple centers. One was not tested to my knowledge. It is too early to know if my most recent friend to pass away had CTE.
Head trauma is a widespread problem and not limited to football. Boxing, hockey, soccer and action sports are just a few of the other disciplines that have been implicated. This is not just a sports problem as the military has a significant concussion issue as well. The NFL has a chance to become a societal leader here: not just for football at college, high school and youth levels, but for all sports and the military.
Although they did not play the same sport, I do know my three friends had something in common. Among the different friendship circles, each would be consider charismatic, happy, carefree, easy going and loved by all. Hardly the profile I thought would put someone at risk to commit suicide.
These athletes were not outliers with drug and alcohol problems. All three were upstanding citizens who were pillars of their communities. The scary thing is that I have since found out that these three aren’t the only ones to have considered suicide. I know of several others who have been depressed enough to consider it. I was surprised to have another professional athlete friend confide in me after Saturday’s ceremony that he too has considered suicide. Even a recently retired Pro Bowl player who I thought had the best perspective on life, a great wife and two young boys had his retirement struggles. http://www.theplayerstribune.com/nfl-retirement-nick-hardwick-chargers/ If it can happen to him and these three, it can happen to all of us. How many others are out there that have not come forward for help?
Psychologists suggest impulse control is what prevents many of us from taking that fatal step in a time of darkness. Perhaps what made these athletes great was their commitment and “go for it” attitude. Possibly that is what contributes to their no longer being here.
In medicine, we demand proof before we come to an absolute conclusion. That makes scientific sense; however, when lives are at stake and there is mounting evidence, we need to act quickly. When a fire starts to burn the immediate goal is to extinguish the flames and worry about how it started later. Let’s focus on the problem at hand and not just who is responsible for the cause. When there is a potential cure for a deadly cancer, we don’t wait for conclusive proof before implementing treatment. We should take effort to care for those suffering from the effects of head injury while scientists determine the cause of CTE. Even if we prevent every concussion and potential CTE case going forward, we have a generation of at risk athletes and military personnel to deal with.
CTE has become the buzz letters but even if no CTE, it doesn’t mean no long-term symptoms from concussions. Recently NHL enforcer Todd Ewen died of a self-inflicted gunshot wound and was found not to have CTE, yet by report had memory loss and depression. http://www.nytimes.com/2016/02/11/sports/hockey/autopsy-shows-the-nhls-todd-ewen-did-not-have-cte.html?_r=0 On the other hand, the presence of Tau proteins (how CTE is diagnosed) does not mean someone will have symptoms.
Researchers should all work together and share data. It’s not about who gets credit. The disease process of CTE was discovered in the 1920’s, not in the last decade. Let’s stop fighting over the brains of the deceased and collaborate. Stop pointing the finger at fault and find a solution. That is how science is advanced.
As an orthopedic surgeon, I don’t have the knowledge of the human brain to find a cure for concussions. As a team physician and sports medicine doctor, all I can do is promote awareness and provide resources for former athletes. As a part-time media member, I hope to change the concussion landscape to one that looks for solutions rather than finding blame. As a friend to former players, all I can do is encourage them to talk to each other. They will be surprised how many others share their experience.
As a professional athlete or an everyday guy, please reach out to your friends and colleagues. Guys keep their feelings inside. If you talk to your buddies, chances are some with have gone through or are going through the same things.
I don’t know if concussions were all, part or none of the reason my three professional athlete friends are no longer with us. I am not sure it makes a difference. All that matters is we need to focus on how to prevent a fourth.

Monday Morning MD: Injuries not an excuse

MMMD 2.8.16
Injuries not an excuse
Everyone wants the game decided between the white lines. No one wants the “what ifs” of an injured key player or a referee’s blown call. Although Super Bowl 50 was not a mistake free game, fans got what they wanted. The better team (or should I say the better defense) won and no one is making excuses.
This was an essentially healthy Super Bowl. Sure there were key players from both teams that were on injured reserve, like Kelvin Benjamin, Charles Tillman, and Ryan Clady (all three out from ACL tears). However, key injuries on both clubs played and all were able to contribute.
There were no excuses coming from the Panthers. Thomas Davis played well as expected just two weeks after breaking his forearm. Jared Allen played despite a fractured foot. Coach Ron Rivera dismissed the ideal that Corey Brown leaving with a concussion changed the game.
The Broncos trio of injured defensive backs, T.J. Ward, Darian Stewart and Chris Harris all played. Peyton Manning played without obvious effects of his plantar fasciitis.
Concerns about the grass field at Levi’s Stadium being suboptimal or causing injury were unfounded. Sure there were some slips but a loose turf/poor footing actually helps to reduce traumatic injury.
Even with the halftime show and the post-game trophy presentation, the field seemed to hold up to my post-game inspection.
I am happy Super Bowl 50 involved no cart offs and few injuries. There was no concussion controversy like last year with Julian Edelman that led to the new medical timeout rule. Corey Brown did enter the concussion protocol, despite originally the calf being the main concern.
A positive injury spin for the golden Super Bowl is the way I like it. I wish every game would be more like this one.
MMMD 1: MVP for a reason
Of course Von Miller’s game changing play is what earned him the Most Valuable Player award. His 2.5 sacks and two forced turnovers were key.
The reason for his spectacular play is that he is finally 100% Although he played well last season, the second season back from ACL is usually the better year. I tell my patients it takes a minimum of 18 months to forget about your knee.
When I asked Miller about his knee last year during Super Bowl week, he claimed his knee was good, but when pressed, admitted there was more improvement to come. No matter how hard someone works, you just can’t speed up the biology of the ACL graft incorporating and becoming a ligament again.
MMMD 2: Ups and downs of being there in person
Although I sorely miss seeing the broadcast and don’t have access to replay, there are up sides to being in San Francisco. I learned a lot by being there asking the right medical questions and observing first hand.
There were reports of a laser healing Jared Allen’s foot fracture. When asked about it, the Panthers DE said he didn’t know if it was the laser that helped him or the myriad of other treatment modalities.
Thomas Davis had no swelling and no protection on his forearm during the week. I doubt the picture circulating of his “football-like” forearm was a current one. The photo Davis posted seemed to be taken well before arrival in the Bay area.

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I always suspected that Chris Harris, Jr. had more that a bruised arm. He confirmed he had a nerve injury that caused him considerable pain but won’t need surgery.
Reggie Bush explained at the NFL Honors red carpet that his surgery was more than simple arthroscopy. He had meniscus repair where his cartilage was sewed and requires more recovery time than trimming but he should be ready well before training camp.
Jamal Charles appeared on track for a second successful ACL surgery. In person, he had excellent flexion of his knee while making the rounds on radio row. Range of motion is the first step after ACL reconstruction and Charles seems well on his way.
MMMD 3: Athletic trainers are hardworking and underappreciated
As Broncos teammates, coaches and staffers were celebrating and passing around the Lombardi Trophy in the locker room, the athletic training staff was still hard at work. They emerged for a quick minute to get a group picture in front of a Champions banner, but then quickly returned to training room duties.
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Athletic trainers rarely get the spotlight they deserve. Even in defeat, the Panthers medical staff certainly deserves praise and Stephania Bell’s piece does just that.
Athletic trainers are the first ones to arrive and the last to leave. They are the unsung heroes of football.
MMMD 4: Head Health Initiative
Results of the NFL’s Head Health Challenge were on display during Super Bowl week. There was promising technology to provide an underlayer for artificial turf to lessen the blow as one’s helmet impacts the ground.  Two types of new helmets to help protect against concussions were in the works. Finally, two new diagnostic tools are being developed. One is a blood test and the other is a portable mini-EEG. Both have potential for sideline usage.
The hope is by next Super Bowl, some of these new products will be in use in Houston.
MMMD 5: Two people fired over JPP medial record leak
As expected the hospital realized it had a problem and started an aggressive investigation that included examining computer access. HIPAA privacy laws were broken by the hospital and whoever leaked the information.
Two people who had inappropriately accessed the information were fired. This does not mean either of them leaked the information to a reporter. They could have just done it out of curiosity. The actual source of the leak could have gotten away with it as he or she may have had legitimate access to the info but was wrong to let media know about it.
MMMD 6: Two best parts of Super Bowl week for me
I ran into Mike Pereira and had a nice chat. I told him how I describe what I am doing in media as the “medical Mike Pereira”. He was flattered and liked the idea. He sees a definite growing roll for medical analysis as has happened with rules analysts.
I also got a great look throughout Levi’s Stadium. This was the only current NFL stadium that I have not been to. The 49ers new stadium was finished after I resigned from head team physician duties in 2013. Not sure what difference it make but now I can once again say that I have been to all current NFL stadiums.
MMMD 7: ProFootballDoc scorecard
Other than adjustments when new info comes to light, this will be the final self-scoring update for the 2015 season.
Thomas Davis played and played well as expected. Chris Harris, Jr, confirmed he had a shoulder nerve issue as postulated. Both Broncos safeties started as indicated two weeks ago. Corey Brown did have a calf issue before he was entered into the concussion protocol.
The previous 160-10 (94.1%) record  now ends the football year at 165-10 (94.3%). This is similar to the 2014 season total of 137-11 (92.6%). The low 90s percentage is about equivalent to picking 15 out of 16 games correct each week. Video analysis will never be completely accurate or replace a hands-on examination, but I believe it gives a reasonable first impression.

Monday Morning MD: Why have concussions increased 58%?

 
Case Keenum
MMMD 2.1.16
Why have concussions increased 58%?
The NFL announced concussions diagnosed during 2015 regular season games jumped to 185, up from 115 in 2014. Last year, the NFL announced the opposite, a 25% decrease in overall concussions. Why the conflicting trends in head injury?
Overall, there were 271 concussions during the 2015 season, up from 206 in 2014 This season, total concussions were up 26% over the average of the last three years.
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The NFL panel on the injury data results conference call cited more screening, better detection, improved record keeping and more self-reporting of concussions as the reason for the 2015 increase. Crediting rules changes as the reason for the 2014 drop in concussions, the NFL said players were “changing the way they’re tackling” and “changing the way they play the game”. The contrasting explanations for this year’s increase versus last year’s decrease seem too simplistic.
Don’t get me wrong, I don’t think there is a continuing concussion conspiracy in the NFL. I would even applaud the NFL for being forthright with the bad news in pointing out the worst statistic of a 58% jump in concussions during games when they could have cited a much lower 32% overall increase in concussions. It is difficult to generalize injury data without a closer inspection of the information. I don’t doubt there is increased screening, detection, record keeping and self-reporting. I don’t doubt that some players have made a conscious effort to avoid helmet contact. It is also possible to just have “bad luck” year with more concussions.
Although I think all of these reasons play a role, I feel there may be an additional factor. I agree there has been a culture change towards concussions but I witnessed it happening well before 2015. As early as 2012, then 49ers QB Alex Smith self-reported a concussion (and subsequently lost his starting job). The final NFL panel speaker referred to this culture change happening over the last three to five years, not just 2015. The Rams head team physician spoke of “co-lineman…notifying us when they think something may be awry”, although that certainly did not happen with Case Keenum when two Rams linemen tried to help their stumbling QB up.
In addition to the above-cited reasons for more concussions, I think the medical atmosphere has changed. There is more scrutiny, criticism, and lawsuits targeting the NFL and team physicians. I think it is only natural for medical personnel to react and be even more careful. In the end, taking an increasingly cautious approach may be a good thing, but it can skew the statistics.
This increased caution results in the fact that twice as many players were placed into the concussion protocol. There were also twice as many “call downs” this season (2.8 per game vs 1.4 last year). The threshold to diagnose a concussion has also been lowered.
When a player has been determined to have a concussion, they seem to be returned more slowly in 2015. Most concussions now miss the next game (average time 10-12 days) whereas last year it seem more returned the next game. Very few, if any, players who were concussed Sunday returned to play in a Thursday game this year, where that seemed to happen more regularly last year. Also just look at the increasing number of “cart-offs” for non-head injuries this year as a sign the medical atmosphere has become more cautious. In the past, most games did not see a cart on the field; however, this season “cart-offs” were a regular occurrence.
The increase in concussions is alarming and needs further evaluation as to why it is happening. Recently, former Giants safety Tyler Sash was diagnosed with CTE. He only played two years (27 games) in the NFL, but played 16 total years of football. This is why in addition to protecting its own players, NFL physicians have a societal obligation to take the lead on football safety at all levels. A more cautious approach is a good way to start.
MMMD 1: Thursday games do not lead to more injuries
The injury data also touched on the rate of injury in short rest games. Many have felt that Thursday games pose additional risk.
Although the sample size is limited, the NFL data indicates there is one less injury with Thursday games compared to those on Sunday or Monday. Across the last four years, there has not been an increase associated with mid-week games. This data does not address if the already injured athlete has enough time to recover properly.
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MMMD 2: ACLs same while MCLs higher
The NFL also reported on some common knee injuries. ACL tears were about the same across the last four years.
On the other hand, MCL injuries had a 25% jump. This means that one third of teams have a medical collateral ligament sprain each week, which is not surprising based on my experience.
MMMD 3: Player health survey misleading
The Associated Press released a non-scientific survey of 100 players that showed only 47 thought their best interests were being protected.
Don’t mistake this for a player health survey as the question lumps NFL teams, coaches and doctors together. 39 players who thought the team, coaches OR doctors didn’t have their best interests at heart answered negatively. The key is did they feel the team doctor didn’t have their best interest or was it the team or coach?
The CBA requires the NFL and NFLPA to jointly perform a scientific league-wide player medical satisfaction survey. This survey was professionally administered during the season and I eagerly await the results.
MMMD 4: Both teams on track for a healthy Super Bowl 50
A lot of injuries “heal” in the two weeks before a Super Bowl and that is indeed the case again this year.
The Panther’s no longer even list Jared Allen (foot fracture) on the injury report. Ryan Kalil’s has practiced and indicated his knee won’t be an issue. Expect Jonathon Stewart and Mike Tolbert to be full go. Even Thomas Davis, who broke his forearm and had surgery, will be ready to play with a cast/splint. Davis will be able to tackle, wrap and grasp; however, his chances at an interception may be hindered.
The Broncos and their pair of safeties should be healthy too. Darian Stewart has a mild MCL and should play alongside TJ Ward (ankle). Peyton Manning’s plantar fasciitis is not gone but largely behind him as evidenced by his 12 yard run in the AFC Championship Game. His weak triceps is the same as it has been due to chronic nerve damage from neck issues.
MMMD 5: Offseason surgeries the norm
News came that Aaron Rodgers had surgery, but he is not alone. In my time as a NFL team physician, there were always more surgeries after the season than during the season. The Packers QB reportedly had a clean up knee scope and should easily be back for OTAs.
On average, a team will have about 10 surgeries at the end of the season. Most procedures are clean up and preventative in nature. Offseason is where a team medical staff tries to take care of any ailing issues and perform any preventative procedures, like the one being discussed for Tony Romo’s clavicle.
Since there is no requirement to disclose offseason surgeries, often the public is kept in the dark or we find out late. This leads to unnecessary speculation and worry when a routine offseason surgery is later discovered.
MMMD 6: NFL team physicians have “real jobs” and “real lives”
Most incorrectly assume that a team doctor’s primary job is for the team. Not only do team physicians have their own separate practices, typically far less than 10% of their livelihood is tied to the club.
When the Patriots head team doctor resigned last week, some incorrectly assumed that he was forced out as a result of New England leading the league in injuries. By video, the Pats injuries were largely traumatic and unrelated to the medical staff. Along with the athletic training staff, many potential season ending injuries successfully returned to play, like Rob Gronkowski (knee) and Julian Edelman (foot).
There is no question that there is prestige involved with any team physician job, but the reality is the doctor gets the team job because of his successes rather than becoming successful because of his NFL appointment. For example, Dr. Matt Provencher already had a prestigious position leading sports medicine at Massachusetts General Hospital prior to being named the Patriots head team physician two years ago. Now he is moving on to another prestigious job in Vail that will be a better fit for his family and four kids.
The team doc job is essentially a full-time job with part-time pay that is done after hours and on weekends. Team docs have calculated their time to be over 2000 hours per year, which is equal to a 40hr/week job.
It is incorrect to assume a team doc’s resignation is code word for being fired. After all, the Combine evaluations are one of the most important tasks for a team physician and my understanding is that the Patriots are happy to have there soon to be former team doctor join them in Indianapolis before he moves on to his new life in Colorado.
MMMD 7: ProFootballDoc scorecard
The Pro Bowl is not supposed to generate injuries so nothing new to grade this week. Tyler Eifert did leave the stadium with a walking boot, but I doub there is anything serious. With one game left the season long record is still 160-10 (94.1%).
I document these numbers on a weekly basis and welcome readers to go back to inspect the validity of the analysis. Please tweet at me or comment below if you don’t agree with any of my self-assessed scoring. That is the whole point of making this process public.

Monday Morning MD: A lot of injuries "heal" in the two weeks before a Super Bowl

MMMD 1.25.16
A lot of injuries “heal” in the two weeks before a Super Bowl
How in the world is Thomas Davis going to play with a broken arm in 14 days? He already promised reporters that “I guarantee you I will not miss the Super Bowl.” Don’t doubt the man that has overcome three ACL surgeries. In fact, I would count on him overcoming the odds to play.
NFL players prove their toughness week in and week out through the grueling season. Come playoffs, that determination to play through injury increases. When it’s time for the Super Bowl, that extra week seems to have “magical” healing powers. Players and medical staffs pull out every trick in the bag, accept some reasonable medical risk and do what they need to play.
Was it the new platelet rich plasma (PRP) treatment or sheer will that allowed Hines Ward to play in Super Bowl XLIII only two weeks after a knee MCL sprain? Terrell Owens went against medical advice to play in Super Bowl XXXIX, six weeks after ankle surgery for two torn ligaments and an associated fracture.
By video, Davis has an isolated ulna fracture, commonly referred to as a “nightstick fracture” from a direct blow. As TE Daniel Fells leaped, his knee “karate chopped” Davis’ forearm much like a martial arts demonstration where a black belt snaps a piece of wood. Such a mechanism of injury is unlikely to also break the accompanying radius bone. If both forearm bones were broken, there would be no way for Davis to play.
Davis was placed in a short wrap/splint, indicating a relatively stable isolated break. An unstable forearm fracture requires long arm immobilization of the joint above (elbow) and below (wrist).
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This victory podium picture is evidence that Davis’ injury is not near the elbow joint. It is impossible to play in a long arm cast. Since one is not needed, he has a chance to play in Super Bowl 50.
Expect surgery to be announced for Davis. Isolated ulna fractures tend to sometimes heal poorly in a cast. The plate and screws inserted will provide early stability and allow motion while the bone heals. A short cast/splint will provide protection against another direct blow.
It has been reported that Davis would play if “it’s a pain tolerance issue”. Without surgery, the ulna is at risk to displace and he would need a long arm cast. Surgery stabilizes the bone, shortens the cast and essentially converts this injury into a pain issue.
I have not seen Davis’ X-rays and there is no guarantee that the heart and soul of the Panthers defense plays. However, during my career as a NFL team physician, I have operated on two players with isolated forearm fractures that have returned to play in two weeks after surgery in a short cast. (Player names purposely withheld due to HIPAA privacy laws).
Certainly what will happen to Davis is not the standard of care in the community; however, it is the standard of care in the NFL community. In his 11th season, this will be his first Super Bowl and he will have the “might not get back here again” mentality. A re-fracture might mean more surgery but would likely not end his career or create permanent disability.
I have worked two Super Bowls, but my teams have never made it to play in one. Even so, I witnessed the power of an AFC Championship game where Philip Rivers played six days after knee surgery with an ACL tear. I can only imagine what happens during the two weeks before a Super Bowl.
MMMD 1: Other Panthers injuries
Jared Allen did not play with a broken foot, but he will not want to miss his only Super Bowl chance in his 12 seasons. The “healing powers of the two weeks before the big game” applies to him as well. If he has a base of the 5th metatarsal fracture, he will play. If Allen has a more traditional stress/Jones type fracture, it will become a coaching/effectiveness decision.
Roman Harper did not return with a laceration and eye injury. Unless his vision is affected long term, he will play in two weeks. Even if he had an “eye socket” (zygomatic arch or orbital floor) fracture, I doubt that would keep him out.
Same goes for the knee injuries of center Ryan Kalil and fullback Mike Tolbert. Kalil finished the game and Tolbert joked he was just tired when he exited.
MMMD 2: Broncos injuries
The Denver defensive backs are the biggest concern. Both starting safeties exited the game. Darian Stewart has a knee MCL sprain but will find a way to play. TJ Ward re-injured his ankle but it appears mild. CB Chris Harris, Jr. was limited but played better than expected. He left arm was strong enough to hang on to Julian Edelman for a key fourth down stop.
Peyton Manning’s plantar fasciitis is not gone but worry about it should be over. He had the Broncos longest rush of 12 yards for most of the game. Arm strength is still the main health issue and that will unfortunately never change.
MMMD 3: Patriots injuries finally catch up to them
New England had a great season considering that they lead the league in injuries by at least one metric. Injuries eventually catch up to all teams, including those coached by Bill Belichick.
Injured defenders Jamie Collins, Chandler Jones and Dont’a Hightower all played but Jerod Mayo was placed on IR. Rob Gronkowski returned after a big hit to his left thigh and battling through cramps. Julian Edelman was seen limping in the locker room and I hope that doesn’t mean a second surgery like the one needed for Dez Bryant.
No excuses, injuries are a part of the game. The Patriots did well to come this close to another Super Bowl.
MMMD 4: Cardinals relatively injury free
Health does not guarantee success, as Arizona was mostly healthy. Carson Palmer’s finger was not an issue according to Jay Glazer before the game and Bruce Arians after the game. Arizona was considered injury-free other than those they have lost already to injured reserve.
If they could have won, they would have gotten RB Chris Johnson back from short-term injured reserve. A Super Bowl return would have been the latest ever for a player to come off IR/dfr.
MMMD 5: Tony Romo surgery?
The Cowboys quarterback is set to have a CT scan this week in anticipation of potential surgery. A prophylactic procedure is contemplated to help prevent future collarbone breaks. Romo has had a total of three fractures to the same clavicle, two this season.
Short term, a plate could make a clavicle stronger. Long term, it could weaken the bone and act as a stress riser. At 36 years old, Romo and the team seem more worried about the immediate future. A custom plate will likely be needed as the standard shapes will not fit well given the previous fracture deformity. The plate could be removed in the future but not before this season.
Surgery was a consideration after the initial break. It would have provided early protection against re-fracture. I have not seen the X-rays and am not second-guessing the Cowboys decisions. It is possible the configuration of the original fracture and/or patient choice lead to a decision for initial non-surgical treatment.
Either way, Romo will be healed for 2016. The question is how many more years before the Cowboys need a new starting QB?
MMMD 6: Draft season revving up.
Draft talk has already started. This is the NFL’s second season.
There will be 107 players entering the draft with college eligibility remaining. 11 have graduated but could still play another year. 96 underclassmen have declared for the draft. Last year there were 74 underclassmen. The trend of an early exit from college continues.
Indianapolis will continue host the Combines through 2020 with a newly signed contract. Any move to Los Angeles for Stan Kroenke’s new kingdom will have to wait.
MMMD 7: ProFootballDoc scorecard
As the season has one game remaining, I will continue to add to the current totals. I welcome any comments/criticism about how I self-grade.
Jamie Collins and Chandler Jones did indeed play, while Jerod Mayo did not. Even though Mayo’s placement on IR may have involved personnel decisions, it still counts as an error on my tally sheet. Julian Edelman’s post-game X-ray was indeed precautionary.
Thomas Davis confirmed his forearm fracture. Gronk was not injured when he pulled himself from the game but instead had cramps and muscle issues. Darian Stewart was listed as questionable, but as anticipated, did not return to the game.
The 154-9 (94.5%) record last week now becomes 160-10 (94.1%). Thanks for following along.

Monday Morning MD: Don't be fooled by appearances

 
Injuries are not always what they seem to be. First impressions often can fool fans to needlessly worry, or trick viewers that everything is ok. These emotional over reactions intensify during playoff time.
Just eliminated Pittsburgh fans went thru both undue angst and false hope. When Ben Roethlisberger was carted off last week, Steelers nation feared the worst. Add in the reports of torn ligaments and despite explanations that Big Ben’s arm strength would be fine, every warm up toss was needlessly scrutinized during pregame until he launched a first play pass that traveled 53 yards in the air. On the other hand, there was undue confidence that DeAngelo Williams would play these playoffs after seeing him jog on the sidelines immediately post-injury in Week 1, yet he was inactive for both playoff games.
To avoid these misimpressions, I try to rely primarily on injury video and not a player’s reaction. Although not perfect, studying film to determine mechanism and severity of injury is much more informative than the team’s standard announcement of body part and “questionable to return”.
Panthers fans pointlessly fretted when Greg Olsen received significant sideline medical attention after his collision with Kam Chancellor. By video, it was a stinger that is initially quite painful but subsides quickly and indeed the star tight end returned to finish the game.
During a victory celebration, Patriots nation went into an unwarranted frenzy when reporters saw Julian Edelman headed for a post-game foot X-ray. Edelman played well nine weeks after his foot surgery and had no visible re-injury during the game. It is common to monitor healing fractures with serial imaging. The quick trip to get a picture seemed unalarming to me and likely was done to avoid the extra hassle of a Monday special trip to the doctor’s office for routine follow-up films. New England fans probably also have the memory of the last time they faced the Broncos when Rob Gronkowski was writhing on the ground in pain yet his injury turned out to be relatively mild.
Rather than react, I try to model after Mike Pereira, the current FOX rules analyst. He uses his insider knowledge as a former NFL referee to objectively and accurately look at the mechanics of the play. Even on the rare occasion that the call goes the other way, his logic and analysis are impeccable. I attempt to use my insider medical knowledge as a former NFL team physician to analyze injury video and not get fooled by player or teammates reactions to an injury. When it comes to injuries, I can only hope to be as good as Pereira is at explaining calls.
We are human and tend to be prisoners of the moment when a player goes down. Analytics is the new buzzword in sports. Nowhere can analytics be more helpful than when looking objectively at injuries.
MMMD 1: Patriots continue as most injured team
Despite leading the league in injuries, New England moves on to the AFC Championship Game. The five injured offensive starters (Brady, Edelman, Gronk, Amendola and Vollmer) all played well in victory.
Now the worry is on the defensive side with Jamie Collins, Jerod Mayo and Chandler jones all exiting with injury. By video, Collins’ oblique muscle injury was confirmed and he is likely to play next week. Jerod Mayo with a shoulder injury has a chance to be active as well. Fellow LB Dont’a Hightower needed surgery, yet finished last season wearing a brace and Mayo could do the same.
Chandler Jones’ knee is the bigger worry. I saw only limited video and one angle but the fear is patella subluxation or cartilage issue. He was announced with a non-specific knee sprain and headed for MRI with hopefully good news to follow.
MMMD 2: Jared Allen foot fracture
After the Panthers victory, word came of a potential season-ending foot injury. Another report confirms the injury but provides some optimism of continuing to play since he finished the game with the small fracture.
By inference, Allen appears to have a 5th metatarsal fracture. It is possible to play through an avulsion at the base or a stress related Jones fracture where the cortex (boney wall) is still intact. However, even if he can play, his effectiveness will be limited. It will be very hard to come off the edge or even provide a bull rush. At best, the injury will turn Allen into a more static player.
MMMD 3: Battle of injured running backs
The return of Jonathan Stewart from foot injury and Marshawn Lynch from sports hernia type surgery was a microcosm of the Panthers versus Seahawks game. Stewart after a one-month absence for foot injury ran for 109 yards and 2 touchdowns while BeastMode was rusty after a two-month layoff.
Certainly the Panthers dominated from the start, but the somewhat sloppy Carolina field may have something to do with why Lynch struggled and Stewart excelled. Poor footing affects someone coming off a abdominal/groin muscle injury more. An unstable plant requires more core muscle strength. On the other hand, a soft field helps dampen stress on a sore foot. Lynch medically will be fine but likely has seen his last days in a Seattle uniform. Stewart admitted to being sore, but will be ready to host the NFC Championship Game.
MMMD 4: Bruised lung for Randall Cobb
The Packers star wide receiver was knocked out of the game and then his team was knocked out of the playoffs. As if we needed a reminder of how rough football can be, Cobb was injured without contact from another player. He leaped to make an all-time catch and fell hard to the ground.
By video there was blood around his mouth. True hemoptysis (coughing up blood) could be dangerous, while spitting up blood much more common and benign. Cobb turned out to have a bruised lung (pulmonary contusion) and was hospitalized. While potentially serious, he was released the next day. Likely the overnight stay was precautionary, especially with the long flight home to Wisconsin.
The good news is there should be no long-term issues for next season or this offseason once he fully recovers.
MMMD 5: Another Manning versus Brady matchup
For the 17th time, we get to see our era’s premium QB matchup. For the last 13 years, the AFC quarterback in the Super Bowl has been Peyton, Brady or Big Ben with the lone exception being Joe Flacco.
Manning undoubtedly still has plantar fasciitis, which will not improve until the offseason. Ironically having the bad wheel might have helped. In a key play, he fell to the ground untouched and as coverage relaxed, got up to make a key completion. His arm strength is what it is with all of the neck issues and will not change.
Brady is healthy despite a reported high ankle sprain suffered two weeks ago. He showed no signs of problems as he even had a rare scramble for a contested touchdown but was ruled out just short before he sneaked it in on the next play.
Both will be healthy enough to play in this epic, and probably final, quarterback matchup.
MMMD 6: Medical potpourri
The Cardinals late use of short-term IR is one game from paying off. They placed Chris Johnson on IR/dfr with a tibia fracture and his first eligibility to return is for the Super Bowl. If Arizona prevails and CJ2K plays again, the latest ever invocation for this relatively new roster designation would pay off.
When there is no tomorrow, players suit up and try. Jeremy Maclin was heroic to try to play but he was clearly hampered with the ankle (and knee). He surprised most by even suiting up but played limited snaps and had two catches.
Russell Okung appeared to aggravate a previous shoulder injury. He had a 2014 labral tear and was using a brace when his left shoulder appeared to sublux (shift out of place). He is a free agent and may need labral repair surgery that carries a six-month recovery
Cliff Avril left the game with a neck injury but returned to the sideline sans uniform.
Sebastian Vollmer played effectively with his high ankle sprain. Earlier in the week, he was filmed limping in practice and was a big question mark. He and the Patriots gave up no sacks versus the vaunted Chiefs pass rushers which likely was the key to victory.
Justin Houston barely played and seems still hampered by his knee. Despite his statements that he only came out of the game last week to “adjust his knee brace”, Houston clearly has not been the same player. Hope he can get better this offseason.
Rob Gronkowski played well despite a report of needing an injection at the hospital on Thursday. I have no insider information but I can’t think of a knee injection that would need to be done two days before a game at a hospital that couldn’t be done in the training room. On the other hand, Gronk was listed as having a back issue as well and an epidural steroid injection at the hospital would make sense with his previous disc issues. Indeed a report indicated his back, not knee, was the bigger issue.
Arthur Moats left the game with a pec injury. Hopefully it is a muscle strain. If it is the pec tendon, then surgery will be in the Steelers linebacker’s future.
Micah Hyde left his game with a hip pointer. He could have been ready in a week but his team was eliminated after another heroic “Hail Mary” Aaron Rodgers comeback.
MMMD 7: ProFootballDoc scorecard
Big Ben indeed played and had minimal problems throwing deep. Greg Olsen did turn out to have a stinger, alternately described as a burner. Julian Edelman did return from foot surgery to have a big game. Tom Brady had no ankle issues. Gronk’s issues did seem to be more back than knee. Jamie Collins has been confirmed with an oblique muscle strain. Micah Hyde had a hip pointer and Justin Houston indeed seems to have aggravated his knee issue.
The previous record of 146-9 (94.2%) now improves slightly to 154-9 (94.5%).
Follow David on Twitter: @profootballdoc
Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.

Monday Morning MD: Can Big Ben dodge a third injury bullet?

Ben Roethlisberger has been carted off with what appeared to be a season-ending injury three times this season. He returned from a knee and then foot injury. Will he make it back from a throwing shoulder injury next week?
The Steelers quarterback is like a “cat with nine lives” playing through multiple injuries including a significant motorcycle crash in 2006. This season in Week 3, he suffered what many feared to be an ACL tear. Instead, he returned five weeks later from what turned out to be an MCL sprain and bone bruise. In Week 9, Big Ben was carted off again with what could be a season-ending Lisfranc fracture/dislocation but it turned out to be a lesser sprain. This Saturday, he was carted off with an injury to his throwing shoulder.
Some initially worried that it was a clavicle fracture similar to what Tony Romo suffered twice this season. By video, it appeared to be a classic AC joint sprain, which is also commonly called a separated shoulder. Multiple reports now confirm the video impression, but will Roethlisberger make another “phoenix” style rise from the ashes and play in the Divisional Round?
The injury is at the junction of the acromion and the end of the clavicle, thus the acromioclavicular (AC) joint sprain. Ligaments that hold the joint together are injured and often the end of the collarbone is elevated. As bad as it sounds, many QBs have played through this injury on the non-dominant side. The issue here is that Big Ben’s throwing shoulder is the one injured.
I believe that Roethlisberger will play and be reasonably effective for next week’s playoff game. He did return to lead the Steelers to victory after the Bengals took the lead. He was announced as day-to-day after the MRI. I expect him to be able to make most throws, although his deep ball may be slightly affected.
The team medical staff already is aggressively treating his swelling. Big Ben’s return is a pain and functional issue where there is minimal risk for long-term problems. I don’t expect him to practice until late week and even then it is likely to be limited. He will have an extra day of rest as their game is on Sunday and the Steelers will use all the legal medication at its disposal to get him ready.
Earlier this season in Week 11, Tyrod Taylor finished the game with a mild AC sprain on his throwing shoulder and returned to play the following week. I have no doubt Roethlisberger will do the same. After all, it’s the playoffs and we are talking about Big Ben.
MMMD 1: Will Antonio Brown be ready to play?
Assuming Big Ben plays, will he have his number one target to throw to? Brown suffered a concussion and his status is up in the air. Just because he suffered a vicious hit does not mean he will be ruled out. Just like sometimes a relatively innocuous looking blow, like with the Packers Sam Shields, has a player out for a month. Return to play is judged by symptoms and not how bad it looked.
Concussions are like snowflakes in that no two are the same. There is no way to predict this early in the week if Brown will be cleared to play. The 2015 trend seems to be to hold players out longer but they do have an extra day here. The Steelers’ longtime neurosurgeon has had his share of controversy including with his recent portrayal in the Concussion movie, but I believe he is a good doctor and will do the right thing for Brown and his family.
MMMD 2: Can Jeremy Maclin return during playoffs?
When the Chiefs star WR was down on the turf, the head team ortho performed what appeared to be a positive Lachman test, which is indicative of an ACL tear. The team immediately ruled Maclin out with a knee injury and significant fears were related by national reporters. It turns out we were all fortunately wrong and a MRI showed no tear to the ACL, which would have been his third time on the same knee.
After all that knee talk, the focus is now on a high ankle sprain. The ankle alone is enough to knock Maclin out this week. Although the ACL is not torn, it is unlikely the knee had no injury. The combination makes Maclin doubtful for the next game and potentially the playoffs.
MMMD 3: Julian Edelman finally ready?
The Divisional Round will mark nine weeks from Jones fracture surgery for the Patriots WR. With the average NFL return at 6-8 weeks, expect Edelman to play. The bone won’t be fully healed but with the screw in place, he should be quite effective although not 100%.
There was a report of Edelman using a steel plate in the shoe to provide additional bone stability. This is commonly done in the NFL for lineman but poorly tolerated by skill position players. My expectation is Edelman was using the plate for protection during practice. I doubt he will use it during the game. It would be a bad sign if he needed it to play as it would inhibit his mobility given the multiple cuts and jerk routes he runs. A steel plate is akin to playing in a stiff soled dress shoe or work boot.
MMMD 4: Peyton Manning set to start but plantar fasciitis not gone
No question the plantar fascia is improved but also there is no way the injury is completely healed. The Broncos medical staff will have to stay vigilant throughout the playoffs. Full healing will only come in the offseason.
I am not suggesting that Denver is making the wrong decision and should start Brock Osweiler. After all, this weekend QBs will playoff experience were 4-0 against QBs making their first playoff start. For the first time, all four wildcard visiting teams defeated the division-winning hosts. The plantar fasciitis will be something to watch.
MMMD 5: Cold weather game
There is no question the extreme cold in Minnesota affected the game, but as expected, no one got frostbite or became hypothermic. This was old school football with a black and white TV.
Conditions were not optimal but with protective gear and heaters/warmers, there was no real medical safety risk. Stationary fans and sideline personnel are more susceptible to the cold as player’s “engine’s are running” and warm.
MMMD 6: Medical potpourri

Adams appeared to suffer a mild MCL sprain

Davante Adams was not injured on the tackle or the fall. Rather he got hurt when the wash came and his own player fell on him and tangled his foot causing what appeared to be a mild MCL sprain. The Packers WR should have a chance to play next week.
Marshawn Lynch was a surprise scratch when he didn’t travel to Minnesota. Next week marks 7.5 weeks from sports hernia type surgery where expected recovery is six weeks. BeastMode should be ready for the Panthers.
Justin Houston denied re-injury to his knee. He did continue to play after tweaking it but just didn’t look his same dynamic self. Hope it was just rust but it bares watching.
Tom Brady’s ankle is expected to be a non-issue. No worries here.
DeAngelo Williams should be ready to contribute with his ankle and foot injury. Expect there will be some running back by committee.
Now that J.J. Watt’s season is over and his chronic groin has been re-injured, it is time to get healthy. Offseason sports hernia type surgery is pending.
Ryan Mathews had groin surgery for an injury that was first reported in Week 6. This is all part of the offseason parade of surgeries that is routine for most teams.
Colin Kaepernick had surgery on his shoulder, knee and thumb. None of the procedures should prevent him from a successful 2016 season wherever he is.
Reggie Bush is moving forward with his lawsuit against St Louis for the concrete around the field where he injured his knee.
MMMD 7: ProFootballDoc scorecard
It was a good week for me as I was happy to be deceived by the appearance of the Maclin injury. I will gladly count the mistake to avoid his third ACL tear. His hip pointer was a non-issue (already counted) as expected.
Big Ben did not have a clavicle fracture and was confirmed with an AC joint sprain. Seattle punter Jon Ryan returned to play despite the top of his helmet coming down to break his nose after a bad snap. Reggie Nelson has a significant low ankle sprain. Davante Adams has a mild MCL. Tom Brady was confirmed with a mild high ankle sprain. Andy Dalton got his cast off but still did not play. J.J. Watt was unable to return after his second groin re-injury.
Last week’s total was 139-8 (94.5%). Adding in this week’s error makes 146-9 (94.2%) for the season.
Follow David on Twitter: @profootballdoc
Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.

Monday Morning MD: Which QBs will be healthy for the playoffs?

Half of the AFC playoffs starting quarterbacks have health issues. Which ones will play and be effective? Tom Brady limped off an interview podium post game. Peyton Manning continues with foot issues. Andy Dalton hopes to get his cast removed.
Ndamukong Suh rolled onto the back of Brady’s legs and he limped off the field. Video analysis in real time correctly indicated Brady would stay in the game as fortunately, his foot was not planted and pinned. He played on after being tended to by team personnel. Of note, Brady’s “personal guru/body coach” was on the sideline but did not participate in his care.
Although Brady avoided more serious high ankle sprain, he will be sore and was limping significantly after the game. Don’t be surprised if he is spotted in a boot, as it is often a means to control swelling. With the bye week, I fully expect Brady will be good to go and the ankle will have minimal affect on the playoffs going forward. This seems to be now confirmed.
Many narratives had Peyton Manning being done, but careers are not ended by plantar fasciitis. The HOF QB made a second half appearance and rescued the Broncos from five turnovers to clinch the division and home field advantage throughout the playoffs. Interesting that days ago some called for retirement and now he is the unquestioned Denver starter for the playoffs.
Manning’s foot injury is not behind him. There is no way to cure a lingering issue during the season. The hope is he can continue to manage his plantar fascia issue. His arm is still weak but his mind is still strong.
Andy Dalton hopes to have his thumb spica cast removed today at his doctor’s visit. Even if it comes off, a removable splint is likely to be put on. Any fracture takes a minimum of 4-6 weeks for early healing and the Wild Card Round is at the four-week mark.
With Dalton’s apparent base of the thumb fracture, the issue will be gripping the ball. He also needs to be able to take a snap and handle the ball for hand-offs. Medically, it is unlikely for a cast to come off Monday on a throwing hand and that quarterback plays just five days latter. The Bengals will have to rely on AJ McCarron to get them out of the first round. If that happens, a Dalton return could happen.
Brady and Manning have first round byes. Hopefully we will see all three injured QBs playing in the Divisional Round.
MMMD 1: DeAngelo Williams back for playoffs?
The Steelers have had their share of injuries this season. Ben Roethlisberger has had two absences with a MCL injury and a Lisfranc sprain. Le’Veon Bell had surgery on his MCL and PCL. Now Bell’s replacement was knocked out of the regular season finale.
By video, Williams has a mild high ankle sprain. Fortunately, his foot was not planted when fallen on from behind. Not all high sprains mean extended absences, as it depends on severity. I am expecting this one to be short.
Post game, Williams was in a boot, but the good news is he was not on crutches. Overnight swelling will be the key, but even with a short week, I believe he has a good chance to play; however, there is no guarantee of full effectiveness. Earlier this year, Fred Jackson did return for the Seahawks six days after a mild high ankle sprain.
MMMD 2: Beast Mode vs AD?
The Vikings victory sets up a potentially epic running back match up. Both Marshawn Lynch and Adrian Peterson have health issues, but expect both to play in the Wild Card Round.
Beast Mode will be six and a half weeks post sports hernia type surgery where the average NFL return is six weeks. He is slated to practice with the Seahawks this week. I am optimistic that Lynch will play although no one, including Seattle, can know for sure.
AD missed a good part of the NFC North clinching victory with lumbar strain/back spasms. As there was no sign of radiculopathy, expect the recovery from low back muscle injury to be quick and Peterson should be in full form.
MMMD 3: Busiest medical day of year for 20 teams
For the teams whose seasons are now over, today marks the busiest medical day of the year. Exit physicals involve the examination of all players to document injuries and establish a plan to get healthy. MRI machines will be humming all day today and into Tuesday. More surgeries happen in the offseason (up to 15-20) than during the season. Often during my time as head team physician, I would have a full week of player surgeries scheduled immediately after the final game.
Just like “Black Monday” for coaches has become “Black Sunday Night”, the medical timelines are also sped up. Team executives want to know the status of their players immediately as they plan roster moves and for the draft.
MMMD 4: Careful with 5th metatarsal fractures
Jones fractures are known to be problem fractures due to a lack of blood supply. Dez Bryant is having more foot surgery to ensure healing, not for re-fracture. There is no way for the bone to completely heal in the 6-8 weeks that most athletes return to play. Up to 20% of the time (Julio Jones, Kevin Durant), a second surgery is needed. Dez should have plenty of time to heal for 2016.
Julian Edelman and the Patriots will be careful. He will be nine weeks from Jones fracture by the time he plays in the Divisional Round. Edelman’s underneath, quick cut and change of direction style puts extra pressure on the 5th metatarsal bone. This is his second Jones fracture and he knows the recovery process. Edelman will play and hopes to be close to 100%.
MMMD 5: Injured players still have responsibilities
I don’t know if Johnny Manziel was in Las Vegas the night before a game or not. I do know he had responsibilities Sunday even though he was ruled out of the game due to concussion. As is common, Manziel wasn’t required to be at the game but he was required to attend a medical check Sunday morning, which he missed.
Missing a medical appointment is a fine-able offense. It will be interesting to see if the Browns choose to fine Johnny Football or if they are too busy trying to hire a new general manager and head coach.
MMMD 6: Medical potpourri
Muhammad Wilkerson did indeed suffer the severest form of high ankle injury. After the syndesmotic ligament tears, the next step is fibula fracture. The pending surgery is more for the torn ligament than the bone. The only good news is this injury should only have a small impact on his free agency. Wilkerson should be healed and in full form by start of training camp 2016.
J.J. Watt celebrated his cast/club removal with a big day (3 sacks, 2 batted passes, 8 tackles, a forced fumble and fumble recovery). “So today is a reminder of what it is like when I have both hands.” Hands do make a difference and this is why Jason Pierre-Paul will be good but has an uphill battle to be great again.
Texans make the playoffs but will have to play without their starting left tackle. Duane Brown torn his quad and leg gave way, which explains why he lost the collision with a smaller linebacker. He will need surgery and will return for 2016, but don’t be surprised when he starts the season on PUP.
Tampa fullback Jorvorskie Lane had the gruesome injury of the day. He fractured his tibia and fibula necessitating rodding surgery. This is similar to the injury Patriots FB James Develin suffered earlier this year. Paul George, Julius Randle and Anderson Silva are other notable professional athletes who have returned from the same injury. It is still unbelievable to me that Lane would not have immediate access to pain medicine at the stadium, but that is the law of the land.
Sean Lee decided not to play with his hamstring injury and cost himself a $2 million bonus. “I didn’t feel like I would be effective enough to help the football team.” Much respect to Lee for having honor for the game. I hope the Cowboys respect Lee and find a way to honor his bonus.
This column is reserved for NFL coverage but Notre Dame linebacker Jaylon Smith was a projected top ten pick. With his gruesome bowl game injury (postulated to be PCL and PLC knee ligament tears), his draft stock is sure to unfortunately drop.
Seahawks Jeremy Lane has an oblique muscle injury. This is essentially a rib injury and hurts just as much. Many remember his forearm fracture after his Super Bowl interception, but most forget he tore his ACL on the same play. He came back for that and he will find a way to play through this injury.
MMMD 7: ProFootballDoc scorecard
Patrick Chung and Devin McCourty both escaped more serious injury to return to play this week well before the playoffs. Marshawn Lynch did not return in 3 weeks or by the end of the season but is on track for the typical six week return. Tony Romo will not need a plate for his collarbone. Despite having sickle cell trait, Geno Atkins played without issue at the altitude of Denver last week.
Jorvorskie Lane needs surgery for a tib/fib fracture. Muhammad Wilkerson has the severest form of high ankle injury with fracture. Tom Brady, Jeremy Maclin and Adrian Peterson were all correctly pegged in real time to be minor injuries.
Adding to the 129-8 (94.1%) record, we end the 2015 regular season with a 139-8 (94.5%) mark. I will continue the tally throughout the playoffs and Super Bowl for a complete season count.
Follow David on Twitter: @profootballdoc
Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.

Monday Morning MD: Does HGH use for Manning neck issues make sense?

 
The big story Sunday was off the field with the accusation of Peyton Manning and others using human growth hormone (HGH). I am going to keep to the medical aspects of this breaking story and leave the rest to the real reporters.
Would HGH use even have helped Peyton Manning to recover from his neck issues? There is no proven evidence it would have. Manning had cervical fusion and decompression surgery. As an orthopedic surgeon, there is no established benefit for HGH use here.
HGH is known to help with growth of muscle, bone and cartilage (primarily in kids). Peyton’s issue was radiculopathy where the nerve to the arm was compressed. There is no proven role for HGH in radiculopathy.
Could it have been used to help strengthen his weakened arm? I suppose that is possible but that performance enhancement usage is also unproven. A 2010 study showed that HGH did not improve strength, power or endurance, but it did help speed in sprinting sports. Absolutely no one has accused Manning of having speed.
Besides it not making sense to take HGH for neck surgery recovery, it is a shame that Manning has to defend himself. Federal HIPAA privacy laws are being violated here by the pharmacy intern/tech and/or the clinic. Although HIPAA doesn’t not apply to the reporter or media outlet, the secret recording should matter since that is illegal. Knowingly driving a stolen car makes you an accomplice. Knowingly spending money stolen from a bank is against the law. It should be illegal to spread illegally obtained material that was unlawfully recorded or obtained by violating HIPAA.
I have no idea if Peyton’s wife, Ashley, was prescribed or used HGH. Anti-aging clinics are often equivalent to HGH clinics. It is typically illegally prescribed for cosmetic, weight loss and fertility purposes. Often these clinics are shut down and my guess is the Indianapolis clinic will face significant scrutiny.
I don’t pretend to know if Peyton did or didn’t take HGH, but it doesn’t make medical sense in relation to his neck issues. It is a shame that because a source (who has since recanted) made that statement, we have this doubt about Manning. One cannot take it back when the “fire alarm” has been pulled. Accusations are easy to make and often makes for a sensational splash. It is hard to prove a negative where one didn’t take something. I hope any exoneration makes the same news flash, but I doubt it.
MMMD 1: Why Brees plays with plantar fasciitis but Peyton can’t
As expected, Drew Bress played well while leading the Saints to victory with his partial plantar fascia tear. Why has Peyton Manning been out six weeks?
Brees’ injury appeared to be an acute partial tear suffered on one play last week. Once the overly tight plantar fascia tears, after the swelling and pain subsides, the problem is cured. The Saints medical staff seems to have done a good job managing this with tape, orthotics and medication/painkillers.
Manning’s injury is chronic and has developed overtime. The initial announcement of taking a week off led people to believe a quick recovery was in order; however, that is never the case with chronic plantar fasciitis. In hindsight, Manning might have better served to have a plantar fascia release surgery and taken six weeks to recover.
People forget that Peyton did play through his plantar fascia injury for weeks, like Brees is doing. The difference is that Manning was ineffective due to his weakened arm from neck issues. Being unable to step into throws affects Manning much more than Brees. Just like the playoffs last year, Aaron Rodgers played well with his calf injury but Manning struggled with his quad issue.
For those worried about the long term, there is no real risk for Brees to tough out the end of the season. Manning’s bigger 2016 worry is father time and arm strength rather than his foot as well.
MMMD 2: Sickle cell non-issue for Geno Atkins in Denver
Geno Atkins will play in tonight’s showdown for a playoff bye. The Bengals defensive lineman is one of many players to have sickle cell trait but he should have no issues at altitude.
Atkins played in Denver in 2011 without problems. I am sure Cincinnati’s medical staff will watch his hydration and monitor his reps.
Ryan Clark famously missed a playoff game in Denver but that is the exception. The average NFL team has one or two players with sickle cell trait, thus Atkins will not be the first player with sickle cell trait to play in Denver without issue. Sickle cell anemia would be a real concern at altitude but it would be unusual for anyone with the disease to even make it to the NFL.
MMMD 3: Concussion movie poorly attended
After all the commercials and publicity, the Concussion movie opened in sixth-place this past weekend. Its popularity was well behind Star Wars and even was bested by Alvin and the Chipmunks. Perhaps Christmas Day is not the right time to release such a serious movie.
Despite inaccuracies (CTE was discovered in 1920s), admitted “Hollywood” spin and complaints from Dave Duerson supporters, I hope the movie continues to serve as a catalyst for more concussion research. Lets not let individual agendas get in the way of progress.
The National Institute of Health should continue to take the lead as it is in the best position to coordinate efforts. The NFL was accused of tampering with NIH decisions but that turned out not to be true. Lets get politics out and let scientists do their job.
MMMD 4: Patriots finally get some injury luck
New England has been among the league leaders in both victories and injuries. Sunday, their third left tackle was injured but the early news seems to be positive.
Sebastian Vollmer had his left ankle rolled up on, was carted off the field and immediately ruled out. The best-case scenario of a high ankle sprain still would have him out for weeks but that is much better than a season-ending fracture.
Depending on the extent of ligament damage seen by MRI and the amount of swelling, Vollmer should be back this season. The question is when and if he will make it for the Patriots first playoff game in the divisional round.
MMMD 5: Playoff teams overcome injury
The Patriots and Steelers have overcome their share of injuries. The Chiefs have won nine straight games after losing Jamaal Charles. The Jets successes may be tied to Geno Smith’s off-field injury, which cemented Ryan Fitzpatrick as the starter.
Four of the six current AFC playoff starting QBs are surprises: AJ McCarron, Brock Oswwiler, Brandon Weeden and Fitzpatrick. Depth has never been more important.
6: Medical potpourri
As expected, Carson Palmer’s index finger was a relative non-issue as he led the Cardinals within reach of potential home-field advantage.
By video, Matt Hasselbeck separated his throwing shoulder. An AC joint sprain was later confirmed.
At this point, Andrew Luck (two months out from kidney laceration) is the more likely starter as the Colts hope to get to 8-8 and win a playoff spot.
Dez Bryant was inactive due to a foot injury. I hope this is unrelated to his Jones fracture. NFL athletes typically return at 6-8 weeks( Bryant came back week 7), but this doesn’t mean the 5th metatarsal is completely healed. If this is related to his previous injury, it could signal further surgery.
Jadeveon Clowney left the game with a foot injury and was in a boot post-game. By video, there was no clear injury mechanism. I hope that means it is a minor injury.
Tamba Hali had surgery on his thumb and was inactive this week. He certainly will be ready for the playoffs, if not Week 17.
Ryan Tannehill had blood in his urine last week and was cleared to play. Blood in the urine is not unheard of in the NFL but I am sure the Dolphins medical staff took all precautions.
Kenbrell Thompkins was carted off with a non-contact injury. Thankfully it was only his calf but that still puts him likely out for the final game.
MMMD 7: ProFootballDoc scorecard
Tyrann Mathieu unfortunately did tear his ACL. So far, Vollmer avoided season ending injury. Hasselbeck will likely miss the finale with an AC joint injury. Brees played through his foot injury. Marcus Easley was initially reported as a leg injured and carted off with a fracture type splint. By video, it appeared to be a knee ligament injury which was later confirmed. T.J. Yeldon was unable to play with his MCL.
Fortunately, Adrian Peterson’s high ankle sprain was mild and he played this week while Palmer played well with his finger injury but they were already correctly tallied last week.
Thompkins avoided ACL injury with his non-contact open field injury. Although, I didn’t formally make the call of a tear, my tweet was misleading and I will count it as a mistake.
Last week’s 129-8 (94.1%) tally is now 135-9 (93.75%).
Follow David on Twitter: @profootballdoc
Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.