The Training Room

The Training Room

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

Despite being hated by Patriots fans, the commissioner may have actually helped New England win this and more future Super Bowls.

How did a 39 year-old quarterback outlast a young defense that in the first half was flying to the ball and applying pressure without blitzing? The Patriots had more than twice the offensive plays

Despite being hated by Patriots fans, the commissioner may have actually helped New England win this and more future Super Bowls.

How did a 39 year-old quarterback outlast a young defense that in the first half was flying to the ball and applying pressure without blitzing? The Patriots had more than twice the offensive plays as the Falcons. The lopsided time of possession difference was even worse than the stats indicated (40:31 vs 23:27) as New England’s 14 more incomplete passes added little clock time but substantial real time on the field. Atlanta defended for an unprecedented 93 plays. Brady passed more times than Matt Ryan even touched the ball. By the fourth quarter, the pass rush seemed to wear itself out and the tight coverage began to trail.

Don’t forget that the offense led by Brady was on the field the same number of plays as the “rise up” young defense. Why did the aging quarterback not seem tired? Brady is dedicated to his training regimen but there may be more to it.

The four-week forced hiatus where he not only missed games but had to be away from the facility and could not practice may have helped the veteran QB and his team in the long run. The Patriots with Brady only playing a 12 game season still ended up with the playoff bye and home field advantage.

The early rest and shortened season may have helped Brady during the playoffs and Super Bowl. He certainly doesn’t need the added reps. Perhaps it played a role in his strong 4th quarter as the Falcons defenders ran out of gas.

Bill Belichick used a boxing analogy at the MVP ceremony this AM saying “the mark of a true champion is winning after getting knocked down.” Staying in fight game analogies, this contest seemed like the famous rope-a-dope fight during the 1974 “Rumble in the Jungle”. The young George Foreman came out strong and punched himself out as Muhammad Ali conserved energy and stayed strong to finish the fight in the end.

During my time with the Chargers, LaDainian Tomlinson never played in preseason games. He didn’t suit up his rookie year due to a holdout. The newly announced Hall of Famer played so well his rookie season and became so valuable, the team decided to not mess with success. During his illustrious career, he always sat out preseason games. Perhaps this season will set the new precedent for the Patriots.

Father Time catches up to all of us. Perhaps the shortened season model is something Brady and the Patriots will adopt going forward to combat the effects of age. Inadvertently, the most hated man in New England may have helped the Patriots to their fifth Super Bowl and perhaps extended the career of Brady into winning more.

MMMD 1: Did injury play a role in who ultimately won?

By video, it was clear that Alex Mack would not be 100% even before the news of a broken/chipped fibula. He played surprisingly well but did give up the key sack to Trey Flowers that prevented the Falcons from icing the game with a late field goal.

Julio Jones was also still hampered by his turf toe injury. He made a spectacular catch but had a subpar performance for him with only four catches. Jones is reportedly still undecided on offseason surgery.

The lengthened pre-game and halftime made it harder on both Dwight Freeney and Chris Hogan who were playing through muscle injuries. Freeney recorded a sack but missed a short portion of the game with his calf and undoubtedly was not 100%. Hogan recorded 4 catches with his thigh issues but was not nearly as productive as during the AFC Championship Game.

Dont’a Hightower played through a likely left shoulder labral tear and has been using a harness/brace. He effectively used his left arm to make the pivotal strip sack resulting in the key Falcons fumble.

MMMD 2: Athletic trainers and doctors deserve rings too

The medical staff plays a vital role in not only health and safety, but also in a team’s winning. It is right that they too will be awarded with Super Bowl rings.

There is no better example of medical helping a team win than this year’s Super Bowl. The key play was Dont’a Hightower’s strip sack fumble. Despite a likely labral tear (which will need offseason surgery), he made the game-changing play with his injured arm. Doctors and athletic trainers had him safely on the field with a shoulder harness that provided stability yet did not restrict his motion to prevent reaching Matt Ryan to cause the turnover that launched the Patriots to victory.


This is nothing new for the Patriots ATCs as they have enjoyed many Championships. The head team doctor is a rookie this year, as was the lead physician two years ago when New England last won it all. In my 17+ years in the NFL, my team never even made it to the big game. But trust me, I am very happy for them as I know how much work is put in and how special it is.

MMMD 3: NFLPA agenda

Each year at the union players press conference, there seems to be a main agenda push. This year, the call is for teams to follow the concussion protocols exactly. For years, the mantra has been changing and advancing the head injury rules. Now, the players seem happy with the rules and want them strictly enforced.

Recall only two years ago, there was controversy over a big hit on Julian Edelman. That was the genesis of the medical timeout rule. Last year a second concussion spotter was added. Sideline replay, neutral independent physicians, standardized testing, mandatory rules for going to the locker room are just some of the many changes.

It is noteworthy that no new rules are being requested. Last year the commissioner announced a structure for penalties to teams of fines and/or draft picks for violations. To date, no one has been penalized.

The Dolphins were recently warned over their handling of Matt Moore.. The Chiefs are being investigated now over their handling of Chris Conley. I know Kansas City has a quality medical staff and the head athletic trainer is the current President of the Pro Football Trainers Athletic Society. I do not know the specifics of their care during the Division Round game in question. However, don’t be surprised if penalties are assessed for the first time as that is the push of the NFLPA.

MMMD 4: Pain medication lawsuit

News broke during Super Bowl week that the Falcons were worried about their reliance on painkillers in 2010 and how the team spent nearly three times the league average on narcotics. I am not an attorney and I do not know details about the pending lawsuit but I don’t believe this story is not nearly as explosive as it sounds on the surface. In fact, it is my understanding that some teams, including the Falcons, have been dropped from the legal action (although they could be added back in).

To me, the emails show that Atlanta executives acted as soon as they realized their team used more pain medication than the rest of the league. Medical staff changes were made to make sure this problem didn’t go forward.

The Falcons should be applauded not criticized for their actions. In medicine, there is something called peer review. Any internal criticisms and actions to improve medical care are exempt from attorney discovery. The purpose is to encourage the process of improving patient care and to remove the fear of plaintiff attorney discovery. Here it seems like the Falcons found a problem and then acted to correct it.

MMMD 5: Medical Mike Pereira

As most of you realize, I am not a trained professional writer or full-time media member. I have a “day job” as an orthopedic surgeon. I hope this and my almost two decades of experience as an NFL team physician gives me the unique perspective that you enjoy. Hopefully, I can be as good at analyzing injures as Pereira is at breaking down the rules.

I have written a 1500 word article for over three straight years with a one main and seven subtopic format including through the offseason. Add in watching games, keeping up with news, speaking to other reporters, my SiriusXM sport medical analyst duties and my Real Football Network work. It is almost a 40 hour a week second job..

I enjoyed my time at Radio Row and the game. I especially enjoyed taking the media bus all week long. Every ride provided a nice opportunity to randomly meet a fellow media member that we have been mutually following. I was so surprised and flattered that a few fans recognized me and even asked to have their picture taken with me.

MMMD 6 Mrs. ProFootballDoc

I have to thank my wife as she has been so supportive. She takes the kids every Sunday so I can do football. This past week she was single parent for the week as I attended Radio Row and the Super Bowl. She is eight and a half months pregnant and still managed to take the kids to Disneyland for her birthday. There is NO ONE like her.

I also want to thank my co-stars on the Periscope broadcast, Davis and Dylan. My weekends are free again so more Daddy time on the way.

MMMD 7: ProFootballDoc scorecard

This marks the end of my tally of initial impression right/wrong for this season. There may be adjustments as new information is revealed but any subsequent injuries will not count to this total.

This year concludes with a 95.1% record (203-10) of correct injury predictions. Last year the final record was 94.3% (165-10) and the year before that was 137-11 (92.6%). The number of first impression assessments have gone up slightly as well as the percentage correct. With a three-year track record, I am not sure if I will track it again next year as the concept seems to be proven. Using video and insider medical knowledge is at least 90% accurate.

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Monday Morning MD: “Witch hunt” season is on

As the numbers of games dwindle, there is more time to deal with unfinished business. Thus the administrative “witch hunt” season is on.

The Dolphins were admonished (but not penalized) over their handling of Matt Moore during the Wild Card round. There was no criticism of the care he received. The Unaffiliated Neurotrauma Consultant participated

As the numbers of games dwindle, there is more time to deal with unfinished business. Thus the administrative “witch hunt” season is on.

The Dolphins were admonished (but not penalized) over their handling of Matt Moore during the Wild Card round. There was no criticism of the care he received. The Unaffiliated Neurotrauma Consultant participated and agreed with the treatment and return to play process. Bear in mind it was a road game where the UNC is local to the Pittsburgh area and probably a Steelers fan. The purpose of the UNC is to first hand witness and provide player protection. Despite the UNC not requiring a locker room evaluation and agreeing with care, the team medical staff was still criticized for not following the concussion protocol.

There was the perception of rushing Moore back into the game since he only missed one play. With the referee and TV delays, I timed that Moore was out for exactly five minutes before he returned, which is the equivalent of seven or eight plays of real time. A sideline screening exam takes two to three minutes. Blood in the mouth is considered by the league to be a sign of concussion requiring locker room evaluation. Apparently there was a trace amount on Moore, but not enough to concern the Dolphins or independent doctor. Of course the slight blood could have come on a different play but on this technicality the Dolphins were criticized and warned of future penalties.

Now attention is focused on the Chiefs for their handling of Chris Conley in the AFC Divisional Round. With last year’s announcements of potential team penalties/fines for medical staff transgressions, it seems the NFL and NFLPA are destined to find someone to punish. The Chiefs head ATC is the current president of the Pro Football Athletic Trainers Society, which makes him a high profile target. Add to that the fact that he has been in the news this season and previously related to head injury and sets the Chiefs up to be a prime candidate to become a scapegoat.

I do not know the details of what the Chiefs did or did not do in their evaluation of Conley. This is why I have advocated for transparency. Why not let the UNC describe what happened on the field, sideline and locker room? Referees talk to a pool reporter after the game to help explain what the officials were thinking. Allowing the UNC to do this might clear up the perception that players were not cared for and might even apply more pressure to do the right thing with the doctor knowing he/she will have to answer publicly for it.

Currently the NFL does not have a full-time medical officer. Normally that person would jointly conduct the investigation with the NFLPA physician. With only one physician involved, penalties become more likely as the NFLPA physician has no counter. It is like only one side having an attorney in court or only one side having an expert witness in trial. The outcomes potentially get skewed.

Protocols are guidelines not rules. The NFL and NFLPA should stop practicing medicine and allow the UNC and team physicians to operate. They should allow them to speak to clear up misperceptions. If the independent physician is complaining, that should be fully and aggressively investigated with full representation from both sides.

MMMD 1: “Witch hunt” part 2

There has been lots of conjecture on fines/penalties for the Seahawks not disclosing Richard Sherman’s MCL injury. I have explained why I feel Seattle will escape punishment. Sherman has now confirmed my thought that the MCL injury was minor. Thus, there was no requirement to list it on the report.

Now the Steelers are undergoing scrutiny for not listing Le’Veon Bell’s groin injury. Last year, the Colts were investigated for not listing Andrew Luck’s rib injuries, but no penalties resulted.

The reality is there are many more injuries on every NFL team than listed in the injury report. The speed limit is 55mph but everyone on the highway is going 65mph. Only the ones going 75mph will be ticketed. Or as Mike Garafalo tweeted at me, the “Ferarri’s” (star players) get all the attention from the cops but the “Kia’s” (average players) are ignored when it comes to getting pulled over.

MMMD 2: Everyone will play in SB51, but how well?

Everyone gets healthy in the two weeks before Super Bowl. Fortunately, both the Falcons and Patriots are relatively injury free.

The Falcons have no one listed on the game status injury report. Julio Jones is still dealing with his turf toe and is said to have two ligament injuries and a mid foot issue. This is the same foot that has had two previous 5th metatarsal fracture surgeries. I do not think the extra week will allow Jones a full recovery. Despite a monster Conference Championship game, don’t expect a repeat performance. Center Alex Mack, by video, suffered a high ankle sprain and finished the NFC title game but has now missed considerable practice. No doubt he will strap it up for the big game.

Of course the Patriots will miss Gronk (on IR for back surgery) but everyone else should play. Nate Ebner is on pace to be cleared from concussion and may accomplish an unprecedented feat. In the last six months he will have played in the Rio Olympics (for USA rugby) and now a Super Bowl. All of his many teammates listed as “questionable” should be available as well.

It is the Super Bowl. Everyone will be available.

MMMD 3: Teddy Bridgewater not back for 2017?

A small uproar was created when it was reported that the Vikings QB would miss next season. This is a case of don’t shoot the messenger. Jason Cole correctly quotes the typical recovery time from a knee dislocation, where multiple ligaments are torn, to be a year and a half. When NaVorro Bowman torn his ACL and MCL, he missed the following season and still struggled after that. There is optimism for Jaylon Smith after his multi-ligament knee injury but he is still wearing an AFO indicating a nerve problem. The point is that all knee dislocation/subluxation injuries are far harder to return from than the average ACL tear.

There is no guarantee for 2017 for Bridgewater. Typically there is always offseason injury optimism but head coach Mike Zimmer has said he does not have a timeline for return. After all, did the Vikings trade for Sam Bradford just for one season, or were they also buying insurance for the next year and beyond?

MMMD 4: League injury data

The annual NFL injury data was released early instead of at Super Bowl week. The league data showed concussions remained essentially the same over a five-year span with 244 total this past season. ACL tears remained constant over the last five years with just under two per team as the average. MCL tears also were similar, averaging just under five per club. With the new touchback rule, there was not a big statistical change on kick-off related injuries. If anything, knee injuries increased. Thursday games continue to have fewer injuries than Sunday games.

MMMD 5: Three unusual situations

Cyrus Kuoandjio had hip surgery after a fall at home. Details were not released but the implication is a potential hip fracture. That is not unusual for grandma, but extremely unusual for a young healthy NFL player. We will need to wait to hear more details on whether there is some underlying pathology or if this truly was a fluke. Dexter McCluster was signed by the Chargers and had a previous forearm fracture and re-broke it with an at home luggage incident.

Josh Doctson is still dealing with his Achilles tendonitis. I am sure the Redskins medical staff has tried all sorts of conservative care, modalities and likely PRP/stem cells. If he doesn’t turn the corner soon, surgery to debride the Achilles may become an option.

Ryan Tannenhill finally had surgery ruled out this week. He injured his ACL and MCL but only recently determined that no ACL reconstruction was needed. There are reports of him flying to Germany for treatment despite PRP and stem cells being legal and routinely used in the US. Players will literally go to the ends of the earth if there is a chance for something better.

MMMD 6: Hardest part of retirement

Steve Smith, Sr. on the “Know Them From Adam” podcast talked about one of the hardest adjustments to post-NFL life. He singled out medical care. Indeed now he will need a new set of doctors. All player’s (and sometimes family) needs are met by the team doctors. Most times, the physicians make “house calls” and come to the facility. There are even preferential appointment times for the dentist. Indeed, life after football involves getting to know what a doctor’s waiting room is for.

MMMD 7: ProFootballDoc

I did not watch the Pro Bowl and thankfully there are rarely injuries in that all-star game. Having covered two of these exhibitions, anyone with the slightest of medical conditions is pulled for safety. No injury analysis this week and thus the 95.1% accuracy rate stands.

I am in Houston this week for Super Bowl and the media activities. I hope there will not be a need, but will be at the big game to provide live injury analysis from NRG stadium.

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Monday Morning MD: History repeats itself

Another AFC Championship game in Foxboro. Another opposing star running back is injured early and sits dejected on the sidelines with an oversized jacket to stay warm. The Patriots advance to another Super Bowl.

When Le’Veon Bell left just after the start of the game with a groin injury, it reminded me of LaDainian Tomlinson’s

Another AFC Championship game in Foxboro. Another opposing star running back is injured early and sits dejected on the sidelines with an oversized jacket to stay warm. The Patriots advance to another Super Bowl.

When Le’Veon Bell left just after the start of the game with a groin injury, it reminded me of LaDainian Tomlinson’s early exit with MCL injury. Both came into the game with their injuries but could not continue. Both sat helplessly trying just to stay warm as their teams lost to the host Patriots. Both incidents just had the same look and feel.

Injuries are always a big part of the game. Would the Steelers been able to hang tight with the Patriots if Bell stayed healthy? Would the Chargers have prevailed in 2008 if LT would have been healthy?

A groin injury is debilitating for a running back. Not only does it make it hard to cut, it robs a player of his burst. The cold didn’t make it any easier. Bell could have limped through his game like LT could have hobbled through his, but clearly it was the better move in both circumstances to play their capable back-ups.

Is it just luck for the Patriots that their path to the Super Bowl was made easier by the opposing team’s key injury? Certainly, to some extent New England makes it’s own luck by having the best record in the NFL.

The only thing these Patriots have in common with the 2008 team is QB Tom Brady and K Stephen Gostkowski, plus of course the head coach. In fact, there are 30 new players out of the 53 since the last Super Bowl victory just two years ago. We shall see if it will yield the same results as the Falcons seem to be a formidable opponent.

I provided medical coverage for two Super Bowls but my team never made it to the big game in my almost two decades. The Patriots had a new team doctor when they won it all in 2015. Again they have a first time team doctor this year. Will history repeat itself?

MMMD 1: Everyone plays

When it comes to the Conference Championship games, no one wants to miss the chance to help their team get to the Super Bowl. After all, next comes an extra week of rest before the big game or an offseason of rest. This is what drove Philip Rivers to play fresh off a knee scope and with a torn ACL in 2008.

All three injured Packers wide receivers (Jordy Nelson, Davante Adams and Geronimo Allison) played. Also Morgan Burnett (quad) and Christine Michael (back) suited up as well.

It was obvious that James Harrison would play and so did his flu-ridden teammates. I doubt a 3am wake up had much effect for an evening kickoff. Besides, in my experience, players don’t get up to leave their rooms with a fire alarm without team security personally performing the evacuation.

MMMD 2: Everyone will be ready for SB51

Barring any surprises, it should be a healthy game in Houston. The additional week before the big game should allow all players to be near top form.

Julio Jones with his turf toe/foot issues will be a player to watch but I anticipate he will be fine. Alex Mack finished the game with his ankle spatted and should be in good shape in two weeks.

Martellus Bennett will need ankle surgery with his bone chips/fracture but that should be a minimal issue. Chris Hogan had a big game despite coming in with quad injury and then having hamstring issues where the two weeks will help here.

Here is hoping both squads remain at full strength and the better team wins.

MMMD 3: How did Jordy Nelson play with multiple broken ribs?

When it was reported that the Packers WR was on the second bus on Sunday, that confirmed to me he would play. Players that are game-time decisions, arrive early on the first bus to test the injury out. Ones that know they won’t play take the 3rd bus.

The much talked about Kevlar vest is not the main reason Nelson could play. Any protection doesn’t eliminate the pain of twisting, reaching, blocking or even deep breaths. Often rib blocks are utilized where the intercostal nerves are numbed with injections. This allows a player to move without pain and is an entirely legal form of medication in the NFL. Pain pills are used less frequently than people think, as a player’s mind needs to be clear to play this complex game.

MMMD 4: Seahawks won’t be penalized

Pete Carroll said Richard Sherman had a “significant” MCL but he was never on an injury report. This led many to expect a Seahawk penalty to come.

I don’t think it will happen. Teams are not required to report all injuries. Trust me that every team’s injury list is longer than the one that is published.

Only significant injuries are required to be reported. This is where the semantics come into play and Pete Carroll is obviously not a physician.

Medically, it is impossible for any CB to play with a significant MCL injury. Of course you can argue that any mild MCL is a significant issue for a defensive back. However, if the MCL was medically graded as mild (even though the coach described it as significant), that will be the loophole that allows the Seahawks to escape league penalties.

MMMD 5: Zach Orr gets lucky

Unfortunately the Ravens budding star linebacker was forced to medically retire from football. In reality, Orr is quite lucky. He has a dangerous congenital C1 condition that was discovered after a routine work up for a stinger.

He had unknowingly played his entire career with the potentially deadly problem. One wrong hit and a C1 problem could easily be fatal and there is no reason to take chances.

In the end, Orr is lucky to have discovered the issue and that he didn’t play one play too many. That is the bright side of this unfortunate situation.

MMMD 6: Pro Bowl replacement season

This is the annual ritual where players tap out due to injury. The Pro Bowl game is always a game of musical chairs to the point that it is hard to keep up.

Alex Smith and Dustin Colquitt are now in. Jadeveon Clowney, among others, is out. With the game now the week before the Super Bowl, Conference Championship winners will all be out, while many of the losers will choose not to attend.

Also this week, many offseason surgeries were announced. Andrew Luck had a clean up throwing shoulder procedure. Meanwhile, Sammy Watkins finally had his much anticipated second foot surgery.

MMMD 7: ProFootballDoc scorecard

Sammy Watkins finally had the second predicted foot surgery. Ladarius Green missed as expected. James Harrison, Jordy Nelson, Davante Adams, Morgan Burnett, Julio Jones, Chris Hogan and Martellus Bennett all played as expected. Le’Veon Bell did not return. Alex Mack did injury his left ankle.

I was wrong in too hastily opining on T.J. Lang’s injury with only one view.

This slightly lowers the 203-10 (95.3%) record to 214-11 (95.1%).

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

Not all ACL surgeries go smoothly. Even ones done by renowned orthopedic surgeons can go wrong.

After tearing up his knee last year, Dion Lewis flew to seek out who he thought was the best to perform the procedure but still had a serious complication. After his initial surgery, his kneecap developed a fracture from

Not all ACL surgeries go smoothly. Even ones done by renowned orthopedic surgeons can go wrong.

After tearing up his knee last year, Dion Lewis flew to seek out who he thought was the best to perform the procedure but still had a serious complication. After his initial surgery, his kneecap developed a fracture from where the ACL graft was taken. He needed a second surgery with screws in his patella and missed a majority of this season.

The Divisional Round was his come back party. Lewis triumphantly scored three touchdowns in three different ways: receiving, rushing and special teams. He was a passing TD away from a historic cycle.

At the start of the season with Lewis missing, there were many questions why the Patriots could not get their star RB on the field. As I have always said, the truth comes out eventually. In fact, given the surgical complication, Lewis has made a tremendously quick recovery.

Medical staffs and especially team physicians are quick to get the blame. Their names are rarely mentioned when credit is due. When a second opinion doctor performs the surgery, their name is often announced with the obligatory proclamation that “surgery was successful”. When the team doctor does it, it is usually done in anonymity. In many ways the medical team is like offensive lineman or long snappers. Their names are often mentioned with blame but rarely with kudos.

I am glad this story has a happy ending but it serves a reminder that there is always risk in surgery and despite everyone thinking that return from ACL surgery is routine, there are definite pitfalls along the way.

Here are how the teams look from a health perspective headed into the Championship Games as well as the medical rundown.

MMMD 1: Packers injury outlook

The Jordy Nelson good news is that he has no organ damage, did travel to the game, and was on the sidelines. The bad news is he was moving very gingerly and I saw him clutching his ribs as he congratulated players on the first touchdown. Reports also said his current goal was to breathe normally again. With a week to go there is a chance, but far from a guarantee, that Nelson would play. If Green Bay gets to the Super Bowl, he would have an excellent chance of playing.

Morgan Burnett appeared to have a quad contusion. If the Packers can control swelling and maintain flexibility, he has a chance to play next week.

By video, David Bakhtiari suffered a mild right knee MCL sprain. He returned after being taped/braced. He should be fine moving straight ahead but likely will have some limitations side to side.

Slow motion showed DeVante Adams with a mild left high ankle sprain. He was taped and returned. Careful here with the swelling. I would expect a post-game boot and some missed practice but that he would try to go next week.

LaDarius Gunter appeared to have the wind knocked out of him and finished the game. I don’t seen any issues with him being 100%,

MMMD 2: Falcons injury outlook

Julio Jones left with a foot injury late in the game. The presumption is a re-aggravation of his turf toe. His coach said he could have continued but was pulled for the score. Jones will likely be limited in practice this week. This bears watching but the hope is Jones will be just fine.

Adrian Clayborn was reported to tear his biceps tendon at he elbow. Normally that is a season-ending injury that requires surgery. If Clayborn and the Falcons want to pull out all stops, he could try to play and have surgery after the season. It would be hard due to pain/swelling to play in the Championship game but he could play with some flexion and supination weakness in his elbow for the Super Bowl. Before you say this is far-fetched, ask Terrell Suggs. He played thru the second half of this season with a biceps tear.

MMMD 3: Patriots injury outlook

Chris Hogan appeared to have a thigh bruise and with good medical care should be good to go for the Championship Game.

Martellus Bennett survived a hyper-extension injury scare to finish the game and should be healthy.

Danny Ammendola continues his recovery from a high ankle sprain and another week should improve that.

MMMD 4: Steelers healthy

Big Ben is fine. The ankle scare when he was seen with a boot post-game last week is long behind us. As expected it was purely precautionary and he played and moved well.

Hope no injury news pops up as sometimes happens, but right now the big news in Pittsburgh is all about Antonio Brown’s social medial locker room post.

MMMD 5: Head coach younger than player

The Rams have a very young team but new head coach Sean McVay (age 30) is still younger than one player on his roster and the same age as two others. I am not sure what the NFL precedent is for this.

I don’t think this will be an issue. In my first eight years as a NFL team physician, there was at least one player on the team younger than me. That was an oddity but never an issue other than perhaps locker room banter.

MMMD 6: Will medical staff move with the Chargers?

Typically, the athletic training staff moves with the club. The doctors usually do not. NFL physicians all have full-time practices outside of the team that account for the majority of their income. With the move to Los Angeles, the UCSD medical sponsorship and the local team physicians will certainly change.

MMMD 7: Injury rundown

Chief WR Chris Conley took a vicious penalized hit to the head, yet returned to the game. Another example of how concussions cannot be judged by video. By the eye test, he certainly should have been removed from the game but the independent doctor allowed his return after examination.

Seattle CB DeShawn Shead likely tore his ACL. Unfortunately, that means surgery and starting next season on PUP.

Seahawk Germain Ifedi by video suffered a left high ankle sprain but will have plenty of time to recover for the offseason program

Jimmy Graham has made everyone forget about his patella tendon rupture playing very well at season end.

Mike Zimmer is just being honest on Bridgewater when he says “We don’t know when Teddy will be back”. Video posts show progress in rehab but he is a long way from a full return. A knee dislocation is among the severest of injuries.

MMMD extra: ProFootballDoc scorecard

I was on vacation with the family so I did not have my usual video capabilities in the hotel but thanks to the extra cameras and playoff coverage, many great replays were shown allowing me to still provide some input.

Davonte Adams returned from left high ankle sprain. David Bakhtiari returned from a mild MCL sprain. LaDarius Gunter avoided injury from a bad looking hit. DeShawn Shead appears to have torn his ACL.

C.J. Prosise did not play as expected and neither did Jordy Nelson. Big Ben’s foot/ankle was a non-issue. Blake Martinez was limited with his MCL.

This improves the 203-10 (95.3%) record to 211-10 (95.5%)

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

Will Big Ben or Jordy Nelson play this week? How will injuries play a role in who moves on to the Conference Championships?

Ben Roethlisberger made the collective hearts of Steelers Nation stop when he showed up at a post-game press conference in a boot. He injured his right ankle/foot on the final interception with

Will Big Ben or Jordy Nelson play this week? How will injuries play a role in who moves on to the Conference Championships?

Ben Roethlisberger made the collective hearts of Steelers Nation stop when he showed up at a post-game press conference in a boot. He injured his right ankle/foot on the final interception with 4:34 left to go in the fourth quarter up 18 points trying to extend a play. Big Ben was rolled up on with a plantar flexion sprain to his right ankle/foot. This is not a dreaded high ankle or Lisfranc sprain. Walking boots are commonly used as a precaution to help control swelling and will likely come off shortly. The Steelers QB may even skip a practice or two, adding to the drama. Recently, Roethlisberger has played through a meniscus tear, Lisfranc sprain and separated shoulder. I am expecting he is more hurt than injured here, thus Big Ben will undoubtedly be healthy and mobile when they face the Chiefs, but whether he has Ladarius Green as a target is up in the air due to concussion symptoms.


Jordy Nelson took a helmet to the left lower postero-lateral ribs and did not return. Not only is there worry for rib fracture, there is some concern for internal organ injury. He left the field on a cart with a primary care physician (not orthopedist). If there is a fracture (and there may be more than one), it will be difficult to play in Dallas this week for not only the pain, but the risk of injury to his spleen/lung/kidney. Without a fracture, Nelson might have a chance to play with medication/rib block and a flak jacket.

In other Packer news, Ty Montgomery who had recent ankle issues and was twisted up awkwardly and limped off the field. He returned to finish the game. By video, LB Blake Martinez injured his MCL. He had a similar injury in November. He could play and run well but would have trouble cutting.

Tom Savage has a good chance to get cleared from his Week 17 concussion but would still be the back up as Brock Osweiler has already been named the Texans starter.

Danny Ammendola returned to practice for the first time since the Week 13 apparent high ankle sprain. I expect him to be near 100% given he has had six weeks to recover by the time the Patriots kickoff.

The Cowboys should be at full strength with Tyron Smith coming off a mild MCL sprain and Morris Claiborne finally returning to action after a groin avulsion injury in Week 8.

I expect both Justin Houston (knee) and Spencer Ware (ribs) to both give it a go this week for the Chiefs.

Russell Wilson shed his knee brace and looks to finally be himself after knee and ankle issues for most of the season.

Let’s hope we see all players at full strength and may the better team win.

MMMD 1: Should Matt Moore have been pulled?

The Dolphins QB took a ferocious and penalized hit to the jaw. The internet was abuzz with outrage that he was returned to the game after missing just one play and thought that he could not have been properly checked for concussion.

I took a stopwatch to the sequence of events. With the prolonged time tending to Moore on the field and the adjudication of the multiple penalties, there was exactly five minutes of elapsed time between the hit and his next snap. If play had resumed immediately, Moore would have missed a handful of plays or more. He only missed one play due to the protracted stoppage.

Typically a sideline concussion screen only takes about two minutes. If positive, a full locker room evaluation takes approximately 10 minutes. The league appointed Unaffiliated Neurotrauma Consultant (UNC) was seen taking an active role. Remember, this is a local Pittsburgh area physician (who is likely a Steelers fan) and I would find it hard to believe he was influenced by the Dolphins’ desires to keep Moore in the game.

A hit to the jaw can cause a concussion. After all, that is why mouthpieces can decrease head injury risk. However, Moore was hit with more of a rotational force to the jaw torquing his neck and thus may have escaped concussion symptoms.

I don’t know the details of how the medical decisions were made but here is another reason for transparency. Referees are questioned by a pool reporter after the game. Why not let the UNC speak as to what he saw and what the medical thinking was? This would not be a patient privacy violation as the UNC is the league observer and is not there to treat the player and thus HIPAA would not apply.

MMMD 2: Changing of the guard?

Some are proclaiming Jadeveon Clowney as the new Texans defensive leader. Certainly he played well and with a skinny J.J. Watt in street clothes on the sideline, that was an easy narrative as we are prisoners of the moment.

Don’t count Watt out yet. First, the team is just being cautious after the second disc surgery. Second, I expect a full recovery, as disc surgery does not typically end careers. Third, it is easy for a workout warrior to lose muscle mass quickly but it is also relatively easy to regain weight with the start of lifting, if you have been that big before.

Expect a double-headed monster for the Texans defense next year, not a passing of the torch.

MMMD 3: Tyrod Taylor contractual controversy?

The Buffalo QB underwent sports hernia surgery as expected. The Bills announced Taylor “elected” to have the procedure. Is that wording posturing for the looming $27.5 million March contract guarantee?

Typically core muscle surgery takes 6-8 weeks to return to play but three months to be 100%. The March date comes in between this timeline.

By contract, the team physician will be the one to determine if Taylor is healthy. This does present a potential conflict. When I was a team doctor, I avoided these situations by asking the team to never inform me about the business side. It was my job to get all players healthy as soon as possible. The best player needed to be healthy to get on the field and the worst player on the team needed to be healthy to get released to make room for roster improvement. I did not want to be influenced by factors other than my medical judgment.

I hope the Bills ownership and Taylor can get on the same page

MMMD 4: Injury rundown

Dominique Rodgers-Cromartie suffered a thigh bruise early against the Packers. With a quad contusion and stiffness, it is hard to run and play cornerback. The challenge to get and stay loose was made harder in the cold and he was thus ineffective.

Jason Pierre-Paul will return to be 100% from his sports hernia surgery but there is no rush anymore as the Giants were eliminated.

Donald Penn reportedly has a small fracture in his knee but will not need surgery.

Ryan Tannenhill did not return from his ACL/MCL sprains. The MCL heals with conservative care but do not be surprised if surgery is announced for his ACL.

Jay Cutler’s shoulder labral surgery is recovering well. Whether the Bears will keep, cut or trade their QB, they need him healthy as soon as possible for all three potential reasons.

Trevor Siemian had left shoulder surgery. He finished the season but it is not unusual to have clean up procedures. This is why the end of the season is the busiest medical time of the year.

Terrelle Pryor had finger ligament surgery and is expected to have a full recovery.

Sammy Watkins finally is having his much anticipated second Jones fracture surgery. This time, likely bone graft and a larger screw will be used. Dez Bryant and Julian Edelman had similar second surgeries last offseason and recovered well.

Matthew Stafford will not need surgery on his mallet finger. The extensor tendon heals well with immobilization.

MMMD 5: Coaches union?

Brandon Marshall said, “It’s time for our coaches to unionize. We’ve had four coaches in the hospital this year. If people understood how many hours, and what it takes to be a head coach, how many hours they put in, it would be an issue.”

Perhaps instead of a union, it could be a competition committee issue. Even if hours were limited, coaches would take work home. However, that is still better for their health than long hours at the office.

MMMD 6: Jaylon Smith back in the news

The Cowboys high second round pick says he is still recovering and wearing his ankle foot orthosis (AFO) but can run a 4.5 40-yard dash.

I appreciate Smith’s optimism but I have never seen anyone in the NFL play with an AFO. Mike Ryan, a long-time NFL athletic trainer and now sports medical analyst for NBC, concurred.

A tendon transfer is not the answer either as those procedures are done to help everyday people to walk, not get around the corner to rush a QB.

I wish Smith the best and hope he can make history.

MMMD 7: ProFootballDoc scorecard

Matt McGloin was available but the Raiders played Connor Cook. Tom Savage was not cleared. Ryan Tannenhill was not ready to go. There was no way for Derek Carr to even travel to the game. Matt Forte did have a knee scope. C.J. Mosely had a calf strain and no surgery needed. JPP did not return. Tyrod Taylor and Sammy Watkins did have surgery as predicted. Jordy Nelson injured his ribs. Ty Montgomery is OK and returned. DRC had a quad contusion.

The previous 191-10 (95.0%) record is now 203-10 (95.3%).

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Monday Morning MD: Smart to sit?

To play or not to play was the theme of the week for both college football and the NFL. Leonard Fournette and Christian McCaffrey ignited debate when they decided to skip their college bowl games to prepare for the draft. Meanwhile the Cowboys and Steelers rested their stars in meaningless games as other teams played

To play or not to play was the theme of the week for both college football and the NFL. Leonard Fournette and Christian McCaffrey ignited debate when they decided to skip their college bowl games to prepare for the draft. Meanwhile the Cowboys and Steelers rested their stars in meaningless games as other teams played their starters.

Medically speaking, it is certainly smart to sit as it is the only way to avoid injury. McCaffrey’s teammate, Stanford QB Keller Chryst appeared to tear his ACL. Michigan’s high draft prospect TE Jake Butt tore his ACL which will affect his draft stock as there is no guarantee he will be ready for the start of the next season.

The key is what do the 32 NFL general managers think of the decision to miss bowl games. The natural question is: are they “me” guys more than “team” guys?

Sometimes the decision to miss the bowl game is clearly smart. Michigan’s Jabril Peppers was better off not playing for risk of making his hamstring injury worse and effecting his Combine as well as potentially being downgraded for not playing up to par.

On the other hand, not playing sometimes hurts. Florida State’s Dalvin Cook had a spectacular bowl game performance, which may have catapulted him to the top of the RB draft board. Meanwhile, Fournette could not respond to reclaim his top status as he had elected to sit.

NFL decisions to sit are made by the team not the individual player like in college. Weighing the potential of injury versus momentum/continuity is the playoff team’s dilemma. The Raiders clearly needed Matt McGloin to play to get more snaps but unfortunately he was injured.

If the argument is to always sit for meaningless games then the majority of the NFL would not play as most Week 17 contests had no postseason implications. In retrospect, the Cardinals probably wish they had sat David Johnson (details below).

There is precedent for NFL players to choose to skip meaningless “bowl” games. It is common for professionals to pull the injury card to skip out of the Pro Bowl. Tyler Eifert injured his ankle during the all-star game last year and needed surgery. He now says even if selected, he is never going back.

The bottom line is many things factor into a “play or sit” decision for the individual and teams. I certainly can’t argue with a player’s right to decide or a team’s necessity to strategize.

MMMD 1: Another QB concussion controversy?

Questions arose after Tom Savage was returned to play and then pulled due to concussion. It certainly looks fishy when the Texans QB is cleared and the head coach says at halftime he will play but he is re-evaluated and pulled from the game.

In reality, it is common to be fine and develop later concussion symptoms. It is routine for doctors to perform serial exams. Likely Savage had a routine re-check at halftime and doctors decided to pull him.

This is another reason that I have lobbied for more transparency. Why not let the doctors speak or at least issue a statement? Even referees are interviewed by a reporter post game. Understanding what happened would help clarify these situations and help dispel the distrust the public and media have for the NFL when it comes to concussions.

MMMD 2: Playoff QB injuries

With Savage in the concussion protocol, Brock Osweiler will be the likely Texans starter for the Wild Card round. The majority of head injuries are not cleared in one week. This will be a short week with the game on Saturday. Even if Savage was cleared late in the week, he would still miss practice snaps important for a first time starter.

Matt McGloin left the Raiders game with an apparent left AC joint sprain and later reports of trap muscle issues. It appeared that McGloin was not happy he was replaced and he was in uniform on the sidelines for the second half. It will be interesting to see if Connor Cook gets the playoff start and how much of this is coaching decision versus purely injury.

Matthew Stafford’s injury appears to be a mallet finger. I have suspected this by the type of splint but media had only reported dislocation with torn ligaments. A mallet finger is a tear to the extensor tendon at the tip of the finger and requires full-time immobilization in extension for six weeks or there is risk for surgery. Stafford can play through without long-term implications but a mallet finger injury is significantly harder to deal with than a finger dislocation as it affects his grip since he is not allowed to bend the tip of his middle finger. This could explain his declined performance post injury.

David Carr reports that brother Derek’s ankle ligament was not torn and the fracture was already healing. That may be a lay person’s interpretation but no way a bone starts to heal in three days. Also when your knee points “north” and your toes point “east”, the syndesmotic ligament is torn even before the fracture happens. Derek Carr will be back at 100%, but no way it will be in time for a potential Super Bowl appearance.

Ryan Tannenhill seems to be getting closer to playing but I think it will be beating the odds for him to be the Dolphins Wild Card round starting QB. Even if it is just a grade 2 MCL, it is a stretch to go from a cast and a crutch to playing NFL football in three weeks.

Aaron Rodgers seems to have put any worries about his calf strain and hamstring injury behind him. He moved and ran well during the Packers win to seize the NFC North crown.

Tony Romo played in a real game for the first time in over a year. He is completely healed and at no further risk for injury. What a luxury for the Cowboys to have an experienced back up like Romo.

MMMD 3: David Johnson escapes horrific injury

By video, many feared the worst for the Cardinals star RB. Fortunately, it seems to be the best-case scenario for Johnson with only a significant MCL injury with his ACL spared. He is unlikely to need surgery and should be healthy for the offseason program.

MMMD 4: Jets medical staff blamed

Muhammad Wilkerson appeared to criticize his team’s training staff for not having a plan as he returned from ankle surgery. He did acknowledge his responsibility in the process as well.

There is no question that hindsight is 20/20 and that medical staffs can look back and wish they had approached an injury differently. However, it is unusual to call out a teammate and indeed the athletic trainers are looked upon as teammates.

Undoubtedly the medical staff was consulted before Wilkerson was offered an $86 million contract while he was injured this offseason. If anything, he should thank the trainers and doctors for vouching for his ability to recover.

MMMD 5: Decreased injuries with more touchbacks?

The rule change to place the ball on the 25-yard line has decreased kick-off returns but has it reduced injuries? Bill Belichick cited the Broncos Kayvon Webster’s concussion as an example of how the new rule has not worked. Sometimes injuries can happen when covering teams ease up as they see the runner kneeling down, but blockers don’t know the play is over. Full speed versus half speed will result in injury.

I am eager to see the season long statistics on this rule change. The NFL usually releases this type of injury data during the Super Bowl week health and safety press conference..

MMMD 6: Non QB Injury rundown

Vic Beasley left shoulder “popped out” but he returned to finish the game with a brace. Don’t be surprised if he needs offseason surgery similar to what he had on the right side last year.

Zaire Anderson was placed on a spine board after a head down hit. Fortunately he was released from the hospital.

Donald Penn left the game with a knee injury but returned. He will likely play against the Texans on Saturday.

C.J. Mosely was carted to the locker room but I do not expect a serious left leg injury.

Sammy Watkins injured his hip that he had surgery on in 2015. The hip does not appear to be severe but he will need to address his 5th metatarsal lingering fracture which may need a second surgery to heal properly.

Quinten Rollins was placed on a spine board for head/neck injury but early reports indicate that he will be OK.

DeMarco Murray played with a plantar plate injury this season to become the leading AFC rusher. This is essentially a turf toe injury. He will avoid surgery unless the plantar plate is retracted.

Ryan Kerrigan exited with left hand/finger injury

Ty Montgomery left the game briefly with and ankle issue but returned to be effective.

Tyrod Taylor has a groin injury and don’t be surprised if he elects to have a sports hernia surgery.

Tyler Eifert had back surgery. It has been a rough year after his ankle surgery from the Pro Bowl injury.

Tyron Smith sat out with a mild MCL from last week where the knee brace may have saved him form more severe injury.

MMMD 7: ProFootballDoc scorecard

Only a few injury first takes this week as I was on vacation with the family in the mountains and did not have my usual set up and access to all videos. David Johnson fortunately with only MCL sprain. McGloin has an AC joint sprain and trap spasm. Quinten Rollins neck was OK. Tyron Smith did have a mild MCL.

Last week’s 187-10 (94.9%) is now 191-10 (95.0%).

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

The leader of the Raiders and Titans both were announced to have suffered broken fibulas. Unfortunately by video, the injury is more than just to the bone. Both were felled by the severest form of high ankle sprain where the syndesmotic ligament (holds the fibula and tibia together) is torn before the fracture even happens.

The leader of the Raiders and Titans both were announced to have suffered broken fibulas. Unfortunately by video, the injury is more than just to the bone. Both were felled by the severest form of high ankle sprain where the syndesmotic ligament (holds the fibula and tibia together) is torn before the fracture even happens.

Essentially both injuries are considered ankle fracture-dislocations where the talus (ankle bone) shifts out of place. The need for surgery is not for the fibula fracture as much as to reposition the bones due to the ligament tear.

Derek Carr was reported to be having surgery on Christmas Day, but was delayed due to holiday staffing issues and he is now reported to travel to Los Angeles for the procedure. Marcus Mariota was set to have surgery in the next few days after injury. The procedure is not an emergency and can be done in the first week or two.

The initial urgency for Carr’s surgery may have been born out of a desire to keep any slim hopes of a Super Bowl 51 return alive. Assuming the Raiders make it to the big game six weeks away, it would still be a considerable stretch to think that Carr would perform anywhere near his MVP candidate level. This is not just an issue of bone healing but one of the ligament and associated structures as well. Typically, this injury carries a six-month recovery, thus reports of earlier return seem optimistic to me. To cite the Charles Woodson or Terrell Owens early Super Bowl return from ankle fracture would be unfair comparisons as there is a dislocation component here for Carr.

The good news is that this is not a career-ending injury and both should return to essentially 100%. A good example is Darren Sproles who had a similar injury/surgery 10 years ago and continues to perform at a high level and is still known for his quick cuts as a running back. Both quarterbacks should be ready for the start of the 2017 season.

MMMD 1: Another broken leg

Tyler Lockett suffered a gruesome tibia and fibula fracture (graphic video here). Teammate Earl Thomas broke only his tibia and did not need surgery. Lockett broke both bones and likely has an open fracture with the description of blood immediately on the field.

This fracture is very unstable and requires early surgery. Fortunately the Seahawks were in Seattle, otherwise Lockett would have needed surgery before flying home.

Despite how horrific the injury seems, this is not a career-ending injury. Many others, including Patriots fullback James Develin last season, have made full recoveries. This is a similar injury to NBA’s Paul George and UFC’s Anderson Silva who both have returned to their sport. Lockett may not be ready for the start of the season as there is typically a 6-9 month recovery.

MMMD 2: Earl Thomas returning

Thomas likely suffered a non-displaced isolated tibia fracture and thus did not need surgery. He contemplated retirement at the time.

Medically, this was not an injury that ends careers. I would not begrudge any athlete who chooses to retire as I agree one needs to be “all in” to play effectively.

Fortunately for us as fans, Thomas has decided to return next season. Since he tweeted retirement thoughts on his twitter account immediately after the injury, it was appropriate that he used twitter to announce his return.

MMMD 3: Play or sit?

Christian McCaffrey and Leonard Fournette started much discussion with their decision to skip bowl games to prepare for the draft. Skipping games is a precedent that already exists in the NFL. Many players choose to miss the Pro Bowl. Tyler Eifert hurt his ankle there last year and needed surgery, which affected his season. He would not go back if asked.

Now the discussion of play or sit turns to the teams that have clinched post-season spots. For example, should the Cowboys sit their stars for rest and/or injury protection or keep momentum going? Does the season-ending injuries to Carr and Mariota make it more likely we see Tony Romo over Dak Prescott to finish the regular season?

MMMD 4: Return to play decisions

A.J. Green is unhappy he was not allowed to play. He made the trip to Houston for the Christmas Eve game with the expectation to suit up, while other injured players stayed behind.

Green was pulled from a team meeting and informed of the ownerships decision to not risk further injury and he subsequently flew home. The decision was based on fear that the tendon portion of the hamstring injury had not fully healed and further damage might mean surgery.

Return to play is always decided by a unanimous vote between the player, medical staff and the team. It is clearly within the ownerships rights to withhold the player, but perhaps communication of that intent prior to travelling to the game would prevent any hard feelings.

MMMD 5: Team doctors care for more than players

Todd Bowles was treated for kidney stones and gall bladder issues. With Gary Kubiak (complex migraine) and Mike Zimmer (retinal detachment), that marks the third head coach to be hospitalized this season which is a higher rate than for players.

Line Judge Sarah Thomas was knocked down and taken to the locker room. She did return to finish the Vikings at Packers game.

Head coaches and all team staff are cared for by team physicians. In fact, coaches’ physicals is a big part of a team doctor’s job. On game days, the home team medical staff is responsible for providing care to the game officials.

MMMD 6: Injury rundown

Aaron Rodgers left the game briefly with a stinger. This should not be a major deal if the Packers protection holds up. The calf injury seems to have progressed nicely.

Ryan Tannehill came out of his cast which is certainly good news. Still with the partial ACL/MCL injury, he may not be ready to go for the wildcard round.

Jay Ajayi fell on his left shoulder in overtime suffering a likely AC joint sprain that is hopefully mild and won’t have him missing time.

Carlos Hyde injured his knee and will be done for the season. MCL sprains do not typically need surgery and he will be healthy for the off-season program.

Justin Houston sat out, proving again that even though players return well from ACL surgery, the second season back is the fully healthy one.

Robert Griffin III left with a concussion but the Browns notched their first victory.

Jordan Reed did not play with his grade 3 AC separation which is usually a six week injury.

Ryan Matthews is reported to have a herniated disc in his neck. Even if he needs surgery, return from single level cervical discectomy/fusion is reliable in the NFL.

Derek Wolfe left with a neck injury that has plagued him in second half of this season.

Kayvon Webster was blind-sided, but riding off in the passenger seat of the cart is a great sign that his spine was OK. Of course his head injury will need evaluation.

MMMD 7: ProFootballDoc scorecard

Unfortunately the significant injuries to Derek Carr, Marcus Mariota and Tyler Lockett were easily seen on video. Will Gholston did dislocate his elbow missing this week. Kayvon Webster suffered a concussion but was spared neck or back injury. Earl Thomas will play in 2017 as expected.

The previous 181-10 (94.8%) record now improves slightly to 187-10, a 94.9% accuracy rate.

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Monday Morning MD: Injury decisions not made in a vacuum

How long before a grade 2 MCL sprain to return to play? The answer depends on many circumstances and the medical status is not the only factor in the decision. Obviously the sport, position, type of player, associated injury, time of season and many other factors come into play. At this point of the year,

How long before a grade 2 MCL sprain to return to play? The answer depends on many circumstances and the medical status is not the only factor in the decision. Obviously the sport, position, type of player, associated injury, time of season and many other factors come into play. At this point of the year, a team’s record and playoff position factors into return to play.

If the Dolphins were out of the playoff race, surely there would not be talk of Ryan Tannehill returning with an ACL/MCL sprain. Adrian Peterson accelerated his meniscus repair rehab to try to bolster the Vikings fading division chances. The Packers rested Aaron Rodgers during the week but they roll the dice on his calf and hamstring come game time to chase down the Lions. Sammy Watkins continues to suit up with a reported broken foot with the Bills still having a small glimmer of post-season hope.

Now that the Bengals are officially out of the playoffs, will A.J. Green still push to return from his hamstring injury? The eliminated Chargers likely will continue to play it safe with Melvin Gordon even though he is only three yards shy of a 1000-yard season.

On the other hand, the Patriots in control of a first round bye, can give Danny Ammendola all the time he needs on his presumed high ankle sprain. The division leading Falcons also take it slow on Julio Jones’ toe sprain.

Of course there are always the old school guys like Matt Forte. His Jets are long eliminated, yet he continues to play through a documented meniscus tear which will likely require surgery at season end.

The bottom line is that decisions on return from injury are never made in a vacuum. This time of year, the team’s standing usually factors into a player’s and team’s mindset and risk tolerance.

MMMD 1: Double good news for Packers

Green Bay continued its resurrection winning their fourth straight game and Aaron Rodgers came through without aggravating the recent calf or previous hamstring injury in the bitter cold of Chicago. His strong arm took over, often throwing off the back foot.

Rodgers looked better than he did with his December 2014 calf strain that lingered into the playoffs. He actually ran on some plays, something he refused to do with a similar injury two years ago. Hope his calf can hold up.

MMMD 2: Doubt the Dolphins can get their QB back

Miami got initial good news of ACL and MCL sprain on Ryan Tannehill but a sprain is a tear. Grade 3 sprains are complete tears. The hope is for lower grade sprains meaning partial tears.

Tannehill is reported to be in a cast with a slight ACL tear. He was seen using a crutch and walking with his left knee immobilized. Unfortunately, this is not the look of someone who will make it back before the end of the regular season.

I hope Tannehill can return. The Dolphins have said no surgery is needed now, but there still may remain the possibility of a procedure after the season. Only on rare occasions does a partial ACL ultimately not need surgery.

MMMD 3: Quick meniscus repair return

Kudos to Adrian Peterson and the Vikings medical staff for a fast three-month return after his meniscus was sutured. He played with a knee brace and was not particularly effective (6 carries for 22 yards) but neither was his team. This is not a knock on Peterson. It is very hard to miss three months of football, practice for three days and play well.

Hopefully he can help salvage the minimal Vikings playoff chances and stay healthy.

MMMD 4: Finger dislocation a regular occurrence

Derek Carr and Matthew Stafford have much discussed finger dislocations since they happened on their throwing hands. Both played reasonably well despite the injury.

When fingers are dislocated, by definition, ligaments are torn. Fortunately they heal and scar in without surgery in most cases.

Finger dislocations happen routinely. Michael Crabtree and Chris Hogan appeared to dislocate fingers recently and finished their games with key receptions. Often players reduce their own finger dislocations or have teammates help out with the reduction without coming off the field.

In my NFL experience, there is probably a finger dislocation every game that we don’t hear about. When it happens to a quarterback, then comes all the attention.

MMMD 5: Ravens with only DOUBTFUL players to play

We covered the ACTIVE rates of QUESTIONABLE players previously. DOUBTFUL players are essentially always inactive. The only three exceptions this season were all from the Ravens: Terrell Suggs, Steve Smith, Sr. and Alex Lewis. If your favorite player is listed as DOUBTFUL, count on him to be out, unless he plays for Baltimore.

MMMD 6: Injury rundown

Fortunately Week 15 seems to be one of the better injury weeks, but there will be the typical late injury announcements to follow.

Janoris Jennkins exited after a teammate’s knee to his back. It was announced there was worry for organ injury, which based on location would be either lung or liver. Hope he is OK.

Will Gholston dislocated his right elbow, but his season is not necessarily over. He is likely to return if the Buccaneers make the playoffs and could play in Week 17 in a brace.

Stephon Tuitt left the game early with a knee injury. By video, there is some worry for a meniscus tear.

Darius Slay left with a hamstring injury and will obtain a MRI.

Lamar Miller hopes to be fine after a late game ankle injury.

Austin Hooper is hoping for the best but fearing the worst on his knee injury.

Matt Forte saw limited action but played with a MRI documented meniscus tear that is likely to need an offseason scope.

Bryce Petty suffered a chest bruise but should be fine going forward.

Melvin Gordon is likely to return from hip/knee injury but not until completely healthy.

A.J. Green’s hamstring is nearly healthy but his team’s playoff chances are done.

Julio Jones initial turf toe diagnosis is now called a toe sprain. He missed his second game but should be back next week.

Danny Ammendola was seen in a boot still, likely meaning his high ankle sprain is still several weeks away, but he should return for the Patriots first playoff game.

MMMD 7: ProFootballDoc scorecard

Here is a quick review of some of this week’s calls. Matt Stafford played with a modified glove and minimal obvious effects from a finger sprain. Jared Cook is OK after a hard fall to ground and played this week despite possible lung contusion. Duron Harmon was not injured but momentarily short of breath. Jimmy Smith left with a high ankle and may be out for a few weeks. Haloti Ngata was not seriously injured and returned after a thigh contusion. Janoris Jenkins took a knee to the back. Will Gholston did dislocate his right elbow.

This slightly improves the 174-10 (94.6%) record to 181-10 (94.8%)

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Monday Morning MD: Tannehill ACL tear preventable?

The Dolphins were victorious staying in playoff contention, yet they lost big when their starting quarterback suffered a serious knee injury. Ryan Tannehill routinely stepped into a throw when Calais Campbell, who may have been pushed from behind, hit the QB’s lead leg.

Miami fears an ACL tear for their star signal caller. By video,

The Dolphins were victorious staying in playoff contention, yet they lost big when their starting quarterback suffered a serious knee injury. Ryan Tannehill routinely stepped into a throw when Calais Campbell, who may have been pushed from behind, hit the QB’s lead leg.

Miami fears an ACL tear for their star signal caller. By video, it was a classic lead leg hyperextension injury, the kind that has ended many quarterbacks’ seasons. Opposing QB Carson Palmer, back in 2006 when he was a Bengal, tore his ACL the same way on a long completion. Tom Brady had a near identical mechanism with his 2008 ACL. I was on the opposing team sideline in 1999 when Trent Green tore his knee ligament in similar fashion, after which Kurt Warner led the “greatest show on turf” to Super Bowl victory.

All of these examples were routine completions where the QB steps into the throw and transfers weight to the front leg on follow through. None of them were broken plays or excessively violent hits, although intentional contact to a quarterback’s legs in the pocket is now illegal for just this reason.

Would a knee brace have prevented these injuries? No one can be sure, but in college prophylactic bracing is largely mandatory on offensive lineman and often the lead leg for the quarterback. Some NFL players use it routinely as well, including Brady after he learned his lesson after his ACL tear.

Studies have shown some ability to prevent ACL tears with knee bracing. However, due to small sample size, there are no definitive statistics on how effective lead leg bracing is on NFL quarterbacks.

I am not definitively saying Tannehill would still be playing had he wore a prophylactic brace. The point is with known injury risk on such a routine play, wouldn’t it make sense to take the precaution? It might even give a QB more confidence to step into throws and keep his eyes up the field. Many quarterbacks, like Joe Flacco, routinely use a lead leg brace after their reconstructive knee surgery, but why not before to prevent the first injury?

The team knows before the MRI. The Dolphins will get the results of imaging to assess associated damage and confirm the tear before the formal announcement is made today. Obviously, Tannehill’s season is over, but there is a likelihood to be ready for Week 1 of 2017. The question is would a brace on the lead leg have saved the rest of this season for the Dolphins QB.

MMMD 1: Lions fans should not panic with QB finger injury

Finger dislocations are common. In my experience, on average, there is one or more a game. However, when it happens on the throwing hand of the star QB, everyone is understandably worried.

By video and reports, Matthew Stafford dislocated his middle finger PIP (proximal interphalangeal) joint. There should be no fracture or tendon injury. With every finger dislocation ligaments are torn, but once reduced, heal well with tape/support and do not need surgery.

This injury should not have a big effect on Stafford. In fact, he stoically never missed a play, but did don a glove afterward to improve grip. Derek Carr recently dislocated his pinky finger and has continued to play effectively (outside of a poor team performance in the cold this past Thursday). Even if a description of mallet finger with tendon injury is true (which does not fit the video), expect him to play through effectively.

Stafford played thru a 2011 broken index finger. If he can play through a fracture, which can be unstable on the 2nd finger, surely he can play effectively on a stable reduced dislocation on a less important for throwing 3rd finger.

MMMD 2: Aaron Rodgers déjà vu?

In December 2014, the Packers QB suffered what seemed at the time an innocuous left calf strain. The injury lingered and bothered Rodgers running ability throughout the playoffs.

Sunday on the third play, Rodgers suffered a right calf injury and although he noticeably limped, led his team to a dominant win. The injury likely was due to compensation for the left hamstring.

Calf injuries tend to linger so this one bears watching. Expect to see Rodgers throw well with his arm strength. He should be able to move in the pocket, but don’t expect Rodgers to take off and run anytime soon, including potentially during the playoffs if the Packers get there. This may be a repeat of the 2014 injury.

MMMD 3: Melvin Gordon hip

A star running back being carted off is always a scary sight. When the injury is to the hip of a young talented recent first-round pick, fears of a Bo Jackson career altering injury flash to mind.

By video, Gordon’s injury has no similarity to Jackson’s other than both were hip injuries. The Chargers RB was injured with extreme flexion, adduction and internal rotational twisting. The end of Jackson’s career was a result of significant axial load trauma instead.

With playoffs out of reach, the Chargers were smart to hold Gordon out pending a confirmatory MRI. I expect a posterior capsular sprain and it will be good to rule out any small avulsion fracture or labral tear.

My guess is that Gordon will return without surgery to get his 1000 yards rushing (he is 3 yards shy), but also expect the team to stop making him the work horse to save him for next year.

MMMD 4: JPP groin surgery

Jason Pierre-Paul was having a resurgent season after his 2015 fireworks injury. Now he is out for an extended period of time. Nowadays, traveling to Philadelphia is a harbinger of core muscle surgery and indeed JPP has a sports hernia fixed.

It would be optimistic to think JPP could come back and be effective unless the Giants made a deep playoff run. The recovery takes 6-8 weeks to return to play but several months to get to 100%. Don’t expect JPP back unless the Giants make a Conference Championship appearance.

MMMD 5: Jamaal Charles return?

Despite the disappointing ACL comeback earlier this season and now two knee surgeries, the Chiefs could get their star RB back for the playoffs. Charles is eligible to return off IR in Week 17.

This is not far-fetched. Both knee procedures were arthroscopic clean ups and the eight week short term IR timeline would fit nicely. Look for Kansas City to have a playoff boost from Charles.

MMMD 6: Injury rundown

Matt Forte left the Jets game early with lateral popping/crunching. His ligaments are OK but a MRI is pending. Don’t be surprised if this veteran has a knee scope when his season ends.

Jared Cook left with a chest injury after a hard fall to the ground. Hopefully there is no pneumothorax and he can return soon.

Chris Harris Jr was chop blocked on his right knee and suffered a MCL sprain. Thankfully his foot was not trapped and the injury appears minor as he returned to play.

Marcus Gilchrist collapsed onto his right knee. Unfortunately, he tore his patella tendon which is harder recovery than even ACL tear.

Su’a Cravens was reported to have a biceps partial tear. If the distal tendon is torn, that could mean season-ending surgery.

By video, Jack Mewhort left the Colts game with a MCL injury and I hope his ACL was spared.

Joey Bosa was evaluated for concussion and later neck injury. I hope this to be a temporary setback for the potential rookie of the year.

Derrick Johnson had Achilles surgery. Medically, this should not end his long and illustrious career.

Brian Cushing is reported to be playing through two spine fractures, which are likely to the transverse process.

MMMD 2: ProFootballDoc scorecard

Cecil Shorts unfortunately did tear multiple ligaments in his knee. Braxton Miller did injure his AC joint. Julio Jones did miss with his turf toe. Trevor Siemian did play with his foot injury. Sammy Watkins and Robert Woods were far from themselves. Derrick Johnson did rupture his Achilles. Charles Johnson did miss time with a hamstring injury.

Melvin Gordon hurt his left hip but it did not appear to serious. Joey Bosa appears to avoid serious injury. Randall Cobb has a mild high ankle sprain and returned. Ty Montgomery appeared to have a stinger. Chirs Harris Jr left temporarily with a mild MCL sprain.

I am documenting an error on Marcus Gilchrist. His season is over but with patella tendon rupture, not ACL tear. I probably should not have opined off only one replay angle.

The previous 161-9 (94.75) record for 2016 is now 174-10 (94.6%).

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Monday Morning MD: Earl Thomas season over

Three weeks ago two stars collided when Earl Thomas tackled Rob Gronkowski in one of the most talked about hits of the year. Now both headline players are done for the year.

Gronk was placed on IR on Friday (details in Item #1 below). Thomas, a leader of the Seahawks “legion of boom”, will soon

Three weeks ago two stars collided when Earl Thomas tackled Rob Gronkowski in one of the most talked about hits of the year. Now both headline players are done for the year.

Gronk was placed on IR on Friday (details in Item #1 below). Thomas, a leader of the Seahawks “legion of boom”, will soon follow suit after his lower leg injury last night.

This time the collision was between star teammates, when Kam Chancellor’s leg inadvertently “karate chopped” Thomas’ tibia bone. He tried to stand on it momentarily but couldn’t, yet refused to be carted off the playing field.

Pete Carroll indicated a “cracked tibia” and mentioned six weeks in his timeline, but Chancellor said it was a fibula but season ending. By video, the truth is somewhere in between: a season ending nightstick tibia fracture (with fibula intact).

The tibia is the much larger weight bearing bone in the lower leg. The fibula is the smaller bone. The recovery for an isolated fibula fracture is non-surgical and approximately six weeks (see Thomas Rawls). The healing for an isolated tibia fracture is about six months and usually means rodding surgery. Because the fibula was intact, the lower leg did not need an immediate fracture splint, yet it is still a serious injury.

Unfortunately, I don’t see a scenario where Thomas could return this season, even if the Seahawks make it to the Super Bowl two months away. Fortunately, he has an excellent chance at full recovery for the 2017 season. Famously, UFC fighter Anderson Silva and NBA star Paul George fractured both tibia and fibula and both made full returns. Other recent NFL players to come back after tibia fracture include Khiry Robinson and James Develin.

Thomas tweeted about possible retirement immediately after the injury. I would never blame a player who makes the decision to hang up his cleats, but the best safety in the league will be back next year, if he chooses to do so.

MMMD 1: Gronk career not over

With his eighth surgery consisting of a low back procedure, some are saying Rob Gronkowski may be done or on serious decline. No question a third disc surgery is concerning, but all were not at the same level (one L4-5 and now a second at L5-S1). Three at one level would beg the need for lumbar fusion, which would end an NFL player’s career. This does not seem to be the case.

The Patriots and Gronk/family are rightfully taking the cautious course. Gronk could return to play at 6-8 weeks post discectomy in time for the conference championship game or Super Bowl, but would not be at 100% until at least 3-4 months. Just like J.J. Watt could come back now after his second surgery on his same disc; however, the Texans are being cautious and looking at the long-term picture.

One can argue any player starts to decline as he approaches the age of 30, but I do not see this as a career ending deal for the 27 year-old superstar. Yes, Gronk will need to be careful and perform lifelong back stabilization exercises and he does risk back pain and degenerative changes long term; however, it would be premature to say his career is over or in decline.

MMMD 2: Hockey injury descriptions?

Julio Jones was described by his head coach as having a “lower body injury”. Normally such descriptions are reserved for the NHL, where a team indication of upper or lower body injury are all that is routinely given.

Although the NFL reports are far from complete, at least it requires a body part and is far superior to the NHL. With the NFL getting rid of “probable” designations, I hope this is not a sign of moving towards even less information.

MMMD 3: Sideline tent

During last week’s Monday night game, there was much intrigue over the Packers structure behind the bench. Cameras followed Aaron Rodgers entering the mysterious canopy causing fans to wonder.

This is simply a medical tent for potential evaluation and treatment. Rodgers entered for privacy to drop his pants to get a hamstring pressure pad wrap.

Several colleges have even bigger versions. I personally wanted to have one when I was a NFL team doctor. Ironically now, I would rather teams not have them as I would rather see what is going on.

Often it saves a trip to the locker room or provides a place to quickly relieve one’s self without running inside.

MMMD 4: Vikings get head coach back

Mike Zimmer had emergency eye surgery and missed his team’s game. This third procedure for a detached retina was likely more than a simple laser and may be his last chance to regain all of his vision. Opthomologists have quoted to me a 25% chance of permanent visual impairment if this surgery doesn’t go well.

Position, stress, airplane restrictions and temporary visual impairment are common. It has been reported that if Zimmer can now fly to Jacksonville for the next game and has resumed coaching duties. Even with the good news, there is no question he will be limited this week in terms of watching film and installing the game plan.

Zimmer and the Vikings should be smart and do whatever it takes to restore his vision as a priority.

MMMD 5: Medical marijuana in NFL?

Seantrel Henderson was suspended for marijuana use that he claimed was used to treat his known Crohn’s disease. The 10 game suspension was confirmed despite the medical reason for usage.

Although recreational and medical marijuana are becoming increasingly legal in various states, it is still strictly prohibited in the NFL. Currently there are no medical use exemptions. If players want this to change, it needs to be a topic for the next collective bargaining agreement (CBA). Don’t be surprised if that happens.

MMMD 6: Injury rundown

Let’s start with positive medical news. Eric Berry beat cancer just over a year ago and now his pick-6 and pick-2 literally won the game for his Chiefs.

Aaron Rodgers was limited but survived without re-aggravating his hamstring, which is tough given the cold weather and poor footing with the snow. If the Packers can continue a playoff push, this injury should be behind Rodgers if they make it to the post-season.

Derek Carr didn’t have any issues with his finger dislocation. He did not use a glove or buddy tape the pinky and lead the Raiders to a decisive comeback win.

Dennis Pitta had a career threatening injury when he dislocated his hip the second time. It took surgery and two years but he is finally back, as he had nine catches for 90 yards and two TDs, his first since the injury.

Clay Matthews and Justin Houston both played through AC joint sprains on Sunday.

Michael Bennett returned to play four and half weeks after his knee scope.

The worst injury of the day belongs to WR Cecil Shorts. By video, he suffered a multi-ligament knee injury which likely involves his ACL and MCL.

The Patriots likely will loose Danny Amendola for some time with a right high ankle sprain, but the hope is to be 100% for the playoffs.

Jason Pierre-Paul by video has a groin strain, which was confirmed.

Sammy Watkins played through his Jones fracture, which has still not completely healed. The Bills targeted him nine times but he only had three catches for 28 yards. At some point, one has to shut him down and have surgery again to get right for next season.

A.J. Green seems to be improving and on course for a late season return from a grade 2 hamstring injury.

Doug Martin limped off with an injury to the left side where the injury was obscured by a pile of bodies, but hoping/expecting that it is minor.

Trevor Siemian did not practice with his left foot injury and missed the start but I think he has a good chance for this week.

Charles Johnson injured his left hamstring and may miss some time.

An abdominal injury is trouble for any kicker and the Steelers replaced Chris Boswell with Randy Bullock temporarily.

MMMD 7: ProFootballDoc scorecard

There were three mistakes this week. They were not bad ones and I could argue that I was at least partially correct but I will take my lumps. There may have been more to Gronk’s injury than the innocuous Jets fall but he is done for the year with a disc injury. Despite the fact the Jordan Reed should return soon from his grade 3 AC sprain, he did miss this week. The Danny Trevathan injury turned out to be an ACL tear.

Jay Cutler’s season is over with labral tear surgery. Ryan Kalil is suffering the same fate. A.J. Green has a multi-week proximal hamstring strain. Daryl Williams has a left high ankle sprain. Steeler’s kicker Chris Boswell abdomen did keep him out. Derek Carr played well despite last week’s finger dislocation. Sammy Watkins does still have a fracture in his foot.

Dont’a Hightower avoided serious injury from a chop block as his feet were not planted. Andrew Whitworth suffered a mild MCL sprain and later returned. Luke Stocker appears to have a left high ankle sprain. Bucs WR Adam Humphries left due to a concussion. JPP had a groin strain confirmed. Michael Crabtree avoided serious injury. Charles Johnson exited with a left hamstring injury. Justin Houston played through his apparent mild AC joint sprain. Michael Bennett took longer than the original 2-3 week return as expected. Danny Amendola was confirmed with a high ankle sprain.

These new additions to the scorecard lower the previous 145-6 (96.0%) record to 161-9 (94.7%).

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Monday Morning MD: Solution for Thursday Night Games

Coming off the biggest Thursday with three Thanksgiving games there seems to be a renewed call to get rid of some midweek contests. Even John Madden is critical saying “it just doesn’t work”. The league is reportedly revisiting the subject to consider ending or limiting Thursday Night Football.

My suggestion that I first

Coming off the biggest Thursday with three Thanksgiving games there seems to be a renewed call to get rid of some midweek contests. Even John Madden is critical saying “it just doesn’t work”. The league is reportedly revisiting the subject to consider ending or limiting Thursday Night Football.

My suggestion that I first wrote about in 2014 is simple. Add a second bye week and pair all teams playing on a Thursday with a bye. This way, there would be 11 days before and still 10 days after.

Playing on four days rest and all of its problems would be eliminated. There would be no more health and safety concerns. Players like Andrew Luck who missed the Thanksgiving game with concussion could then play and improve the competitiveness of the game. There would be no need to schedule only regional matchups to avoid long flights and thus provide more compelling matchups. Teams would be able to install normal game plans and the quality of the product would improve.

Teams look forward to the bye week and there are often complaints that the singular break comes too early or too late. Byes are universally acknowledged to be good for player health and recovery so why not have one in the first half of the season and another in the second?

To alleviate the CBA and scheduling concerns of adding a week to the season, the league could get rid of one preseason game. The money lost doing that would be more than made up for by the TV revenue of an extra Sunday, Monday and Thursday game as well as an extra slate of games in the regular Sunday slots. Currently, it is impossible to follow all the nine or ten early games or the three to four later games and spreading 16 weeks of football over 18 weeks would barely be noticed.

A second bye week was tried in 1993 but that was over two decades ago and the league only had 28 teams at the time instead of 32, so it was like four teams were on a perpetual bye already in terms of scheduling.

Heck, if this happened, the league could even add a Wednesday night game and there would be no short week issues.

The bottom line is, I believe players would be in favor of adding a second bye and pairing Thursday games as long as it didn’t lengthen the season. Owners will be for it as there would be more dollars to be had. Fans would get one more week of meaningful football. In the end, this is a rare opportunity for the NFL to improve safety and increase revenue at the same time.

MMMD 1: Derek Carr finger dislocation

Finger dislocations are commonplace in the NFL. Often players will put their own fingers back into place without even running to the sidelines to seek medical help. Most linemen tape their fingers to help prevent dislocation. Most of us have seen the gnarled finger joints of ex-players.

Derek Carr’s right fifth finger dislocation brought lots of attention as it was publicly visible, resulted in a turnover, he ran off the field with pain, everyone always notices the quarterback and it was on his throwing hand.

By video, it was a pinky finger dislocation without associated fracture. The PIP joint is the most common one dislocated and once reduced is stable. Carr did go to the locker room for likely X-rays, tape/splint support, medication/treatment and returned with a glove to lead the Raiders to victory.

Although he will be more sore and swollen after the game, Carr will play next week against the Bills. There may be some practice time and game modification but he should still perform well. Note that Carr lined up in victory formation from the pistol, likely to avoid the pain from a direct under center snap on his top dominant hand.

MMMD 2: Brady and Gronk

Both Tom Brady and Rob Gronkowski started the game as expected and the Patriots were lucky to escape the Jets with a win.

Gronk chest issue and presumed pneumothorax was not a problem but he did leave the game early due to a back issue after a diving attempt at a pass. He did not return and was seen after the game walking stiffly and needing to use handrails on steps. By video, this is not a recurrence of disc herniation that has necessitated previous surgery. Back spasms can be tricky and this hopefully remains a short-term setback.

Brady seemed to be off his normal game throwing high several times. He was clearly bothered as the Patriots QB even supported and favored his right knee as he sat down on the bench. I don’t think this is related to the Kam Chancellor hit to the thigh from two weeks ago. In any case, I expect this to be a relatively minor issue going forward.

MMMD 3: Jordan Reed plays through severe AC injury

The Redskins TE returned from a grade 3 acromial clavicular joint sprain to accumulate 10 catches and two touchdowns. After going down hard on his left shoulder, Reed was seen with a sling on. However, with some treatment and medication, he returned for a big second half.

The bad news is that multiple ligaments around the end of the collarbone are torn causing significant pain, presence of an obvious deformity with a visible bump and he will miss significant practice time. The good news is Reed is unlikely to miss games, although he will have to play through pain despite the help of medication. The next game is the hardest as swelling sets in post-game. Ironically once the swelling subsides, a more severe grade 3 injury looks worse but is less painful than a less severe grade 2 sprain as the end of the clavicle is riding so high it no longer rubs against the acromion to cause pain.

MMMD 4: Both Justin Houston and Von Miller dominate after ACL

The Sunday Night Game featured two great pass rushers recovered from ACL surgery. Von Miller had a 2014 ACL surgery and Justin Houston is only 10 months out from reconstruction. Miller had 10 tackles (9 solo) with three sacks and four tackles for loss. Houston matched those numbers with 10 tackles (10 solo) with three sacks and five tackles for loss. Miller is the NFL season sack leader and Houston might be challenging for the lead if surgery on his November knee injury wasn’t delayed until February.

MMMD 5: Harvard player health study

The NFLPA has funded a Harvard study on NFL player health. The report was released last week including the top 10 recommendations.

The best recommendation is for the NFL and NFLPA to stop using health issues as bargaining chips in the CBA negotiations. The most obvious are that all involved should follow a code of ethics and continue to collect/study injury data. The least game-changing is the suggestion that players be supported in their right to a second opinion as that is already the case and second opinions are very routine.

The most controversial recommendation is the use of “player’s medical staff” not hired or reporting to the team. I see the potential ethical concerns but in reality they are not there. Just like this study has potential bias because it was funded by the NFLPA, doesn’t mean it is biased. If Dr. James Andrews can serve as a Redskins team physician and yet be considered ethical and above reproach, so can other team doctors. Besides a system of independent doctors would be very cumbersome and result in many delays. For example, I don’t see how Derek Carr or Jordan Reed return to play with their injuries this week under such a system. Of course you can make the argument they shouldn’t have, but I think both Reed and Carr would object to that.

MMMD 6: Injury rundown

LeSean McCoy played well as expected despite having surgery to relocate his thumb six days ago and rushed for 103 yards with 2 touchdowns and two catches for 31 yards.

Justin Houston, by video, suffered a mild left AC sprain when he caused the safety, but returned quickly to the game.

Odell Beckham Jr. had a thumb injury that did not seem to slow him down much.

Luke Willson was said to have a mild knee sprain, which was not the same side as earlier this year.

18 months ago, some feared Jason Pierre-Paul’s career was over due to the fireworks injury. Instead, on Sunday he had 3 sacks and fumble return over 40 yards for a touchdown, a first in the NFL in over four decades.

By video, Jordan Richards, Patriots safety, had a mild MCL. Luckily his knee was flexed and he avoided more severe injury and returned to play.

The mechanism for Danny Trevathan’s knee injury is likely to result in a right ACL tear.

Martellus Bennett seemed to re-aggravated right high ankle sprain that has bothered him since Week 5 but continued to play.

Derek Wolfe returned in three weeks with a brace and avoided elbow surgery for a fractured coronoid process.

MMMD 7: ProFootballDoc scorecard

LeSean McCoy played well despite his thumb. He performed better than Sammy Watkins who was also active. Tom Brady and Rob Gronkowski played as expected. Jordan Reed’s injury was more than just a mild AC and was announced as Grade 3 sprain. Jamison Crowder was OK with low ankle sprain and continued to play.
Josh Forrest was confirmed to tear a ligament in his knee. Robert Woods does have a significant MCL and missed the game. Andrew Luck was not cleared for the Thursday game. Marshall Newhouse did have a MCL sprain. Halapoulivaati Vaitai does have a MCL sprain. Demetri Goodson unfortunately is confirmed with a multi-ligament injury with ACL tear. Derek Wolfe did avoid surgery and returned in just under a month with an elbow brace. Blake Martinez missed with a confirmed MCL strain. Kelvin Benjamin returned to the game and caught a touchdown.

This slightly improves the 130-6 (95.6%) record to 145-6 (96.0%).

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Monday Morning MD: NFL players show incredible toughness every week

Few doubt how tough you have to be to play in the NFL. This week has many examples of how players react and play through injury.

LeSean McCoy got up and casually walked to the Bills sideline as if almost nothing happened. He missed the second half with a dislocated thumb, which could not be

Few doubt how tough you have to be to play in the NFL. This week has many examples of how players react and play through injury.

LeSean McCoy got up and casually walked to the Bills sideline as if almost nothing happened. He missed the second half with a dislocated thumb, which could not be reduced and now needs surgery. Yet, he is likely to play next week. The crazy part is this actually makes sense as by video, he dislocated his small (IP) joint without fracture. Once reduced with surgery today (as the flexor tendon blocks reduction). The thumb should be stable and relatively pain free.

No one even knew Giovani Bernard was injured but he reportedly tore his ACL on his final catch. Since the Bengals were down by four with under a minute to go and no timeouts, he hopped up to avoid a 10 second runoff then went right back to line up for the next play and even attempted to throw a block before the play was called dead. With the stoppage, Bernard then subbed himself out. Now he will need major surgery and will have to race to return for Week 1 of 2017.

A.J. Green’s season is likely over with a significant hamstring tear, yet his body language indicated a routine play with a minor issue. The injury appears to be high up and proximal hamstring tears take longer to recover.

Safety Eric Reid acted like nothing happened when by video, he tore his distal biceps tendon. He almost continued to play until stopped by a delayed timeout. Typically, this injury ends one’s season and requires surgery.

Terrell Suggs is delaying surgery and playing with just such a distal biceps rupture. Sunday he had a sure sack, but due to weakness to flexion/supination on his injured left arm, Dak Prescott stepped through the tackle.

Even long snappers got in the tough guy act. Clark Harris limped badly with a foot/ankle injury and was about to be driven off. He hopped off the injury cart to play, even though he could no longer even jog to cover punts.

In a bad injury week, there were plenty of examples of how the NFL is a real man’s game.

MMMD 1: Emotional Luke Kuechly

The former defensive player of the year was not showing weakness when he appeared to reveal vulnerability. Certainly he was red-faced and sweating from the game; however, Kuechly’s body was heaving to try and catch his breath, not blubbering in tears.

By video, he took a blow to the chest/sternum and was gasping for air from having the wind knocked out of him. He also hit his head and it is a known medical fact that a concussion can cause mood alterations. Combine the fear of not being able to breathe and the loss of emotional control from head injury and you get Kuechly’s reaction to injury.

MMMD 2: Seahawks RB carousel

Seattle leads the NFC West but will start its third running back in three weeks. Christine Michael was released after a mild hamstring issue. Now C. J. Prosise is injured.

By video, the worry was a scapula fracture for Prosise who did not return in the second half. Typically, a scapula body fracture does not need surgery but is very painful and leads to a 4-6 week recovery. A report surfaced that Prosise will not return until the playoffs.

Fortunately for the Seahawks, Thomas Rawls is finally healthy after an early season fibula fracture. This truly has been “next man up” after Marshawn Lynch retired.

MMMD 3 Accuracy of team reports

Two weeks ago, I documented the differences in teams’ use of the “questionable” designation. “Questionable” also seems to be the tag whenever a player initially exits for injury, but is it accurate?

Demetri Goodson suffered a horrific multi-ligament knee injury. (Video here but warning: graphic) The Packers officially classified him initially as questionable to return to the game. In reality, what is questionable is whether Goodson can return to a productive career as a cornerback. Best wishes to him.

MMMD 4: Who is ready to return?

Three quarters of teams have yet to use the single “designated for return” spot to bring a player off injured reserve. With six weeks left in the regular season, watch for more teams to start bringing players back.

Ameer Abdullah is seeking a second opinion and may be the Lions player to return off IR.

Sammy Watkins is slated to have a CT scan to assess fifth metatarsal bone healing and might be able to come off IR to help with Robert Woods’ absence.

Everyone has forgotten about J.J. Watt after his second back surgery. I know the club wants to be cautious but he is eligible to come off IR after today. I expect Watt to be medically healthy now and lobbying to help his team to the playoffs. The Texans lead the AFC South and if they beat the Raiders tonight, they would be in position for a possible playoff bye.

Branden Albert missed this week after surgery on a dislocated wrist and could be back next week.

Rob Gronkowski was not allowed to fly to California this week with a pneumothorax, but I fully expect him to travel and play against the Jets next week.

Mo Claiborne having torn “some bone off the pelvis” sounds ominous but it simply is a groin avulsion, which usually heals without surgery. A 6-8 week timeline from injury puts him back at Week 14-16. Hope his follow up MRI confirms this expected healing.

Look for lots of late season roster moves.

MMMD 5: Harvard health study

A comprehensive report with medical recommendations for the NFL and NFLPA was released this week. I promised to analyze the top ten recommendations but there were just too many injury issues this week to find the space in this column.

I will agree with one finding. Stop using player health as a bargaining chip in the collective bargaining agreement. My full thoughts are to follow in the coming weeks.

MMMD 6: Injury rundown

Zach Miller has a broken left foot and needs surgery.

By video, Robert Woods has a MCL sprain and is on crutches. He is likely will miss several weeks.

Cody Kessler is out with his second concussion of this season. Don’t be surprised if an extended absence is coming.

Fortunately, Leonard Floyd seems to have escaped significant neck injury. He took a head down hit and was sent off on a spine board.

Seattle FS Earl Thomas and CB DeShawn Shead both have hamstring injuries.

Dee Ford has a hamstring issue as well. Justin Houston has returned from February ACL surgery to help the Chiefs linebackers.

Ryan Matthews is reported to have a MCL sprain and Darren Sproles has a rib injury.

Laremy Tunsil left with a shoulder injury and did not return for the second half.

Rams LB Josh Forrest by video has a major knee ligament tear, which is likely the ACL.

Matthew Slater was knocked out with a left foot injury and seen post-game in a walking boot.

By video, Halapoulivaati Vaitai suffered a MCL sprain. Hopefully he can return in a week or two with a brace.

MMMD 7: ProFootballDoc scorecard

Even though Branden Albert finished last week’s game, he did have wrist surgery and missing this week but has a chance for next week. Tom Brady had no issues despite a scare. Rob Gronkowski was not allowed to travel with his pneumothorax. Jordan Howard avoided Achilles tear or other significant injury to play well. Kyle Long does have a high ankle injury requiring surgery. Kelvin Benjamin overcame mild AC sprain and returned in the same game.

Cody Kessler does have a concussion. The Leonard Floyd news is encouraging. Jake Ryan and T.J. Lang missed this week after being rolled up on last week. C.J. Prosise has a presumed scapula fracture. Eric Reid does have a left distal biceps tear. Nick Perry’s mild ankle sprain is OK and he returned to play.

This improves last week’s 117-6 (95.1%) scorecard to 130-6 (95.6%) through Week 11.

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Monday Morning MD: Offensive line injures aplenty

Fans may think of this week as a relatively healthy one. In reality there were plenty of injuries. A plethora of offensive players were hurt, just not the ones most fantasy owners and fans are interested in.

Offensive line injuries lead the way in Week 10. The trend began on Thursday when the Ravens left

Fans may think of this week as a relatively healthy one. In reality there were plenty of injuries. A plethora of offensive players were hurt, just not the ones most fantasy owners and fans are interested in.

Offensive line injuries lead the way in Week 10. The trend began on Thursday when the Ravens left guard was carted off and their center limped off. Alex Lewis’ right leg was placed in a vacuum splint after being rolled up on. Though early reports indicated no fracture, by video, Lewis has a significant high ankle injury that will result in an extended absence and may still need surgery. Teammate Jeremy Zuttah was much luckier with a standard basketball type low ankle sprain.


The trend continued Sunday when two linemen with the last name Long (no relation) suffered apparent season ending injuries. Kyle Long of the Bears was carted off in an air splint. By video, he suffered a significant high ankle injury with possible fibula fracture and likely needs surgery. Jake Long’s twice torn left ACL was spared but video evidence of a left Achilles rupture was later confirmed by his head coach. The Vikings have now lost their third offensive tackle and their fourth consecutive game after five victories to open the season.

Dolphins left tackle Brandon Albert was reported to have dislocated his wrist but finished the game in a cast. A wrist (lunate) dislocation means ligaments are torn, thus surgery is likely. Miami is on an 11-day west coast trip (played Chargers on Sunday and Rams up next) creating logistical difficulties but I hope the injury is not truly a medical dislocation.

Knee injuries knocked out the Packers David Bakhtiari and Buccaneers Evan Smith. Also Packers guard T.J. Lang, by video, left with a high ankle sprain. Meanwhile, Bears Bobby Massie left with a concussion.

This may seem like a good week of injures as the offensive stars stayed healthy. However, their protectors took their share of injuries.

MMMD 1: Injuries to stars narrowly avoided

Near miss was the theme of the day. Tom Brady avoided a hit to the knee, instead took a blow to the thigh just above. He avoided serious injury but instead will deal with a quad muscle contusion. Teammate Rob Gronkowski took one of his hardest hits ever but since Earl Thomas stayed away from the head delivering the blow, Gronk avoided concussion.


Larry Fitzgerald and Lamar Miller returned for the second half after brief absences. Jordan Howard’s coach said he hurt his ankle or Achilles. By video, Howard does not have a tendon tear. I am always happy to be reporting good news.

MMMD 2: Running back news

Christine Michael was active but limited with his late week hamstring issue. Doug Martin finally returned from his Week 2 hamstring injury and re-aggravation.

Dion Lewis was activated off PUP with his post-ACL patella stress fracture but was not dressed this week. DeAngelo Williams had midweek knee scope and is likely out longer than the initial three-week estimate.

MMMD 3: Tony Romo not active

The Cowboys QB is almost three months out from his L1 back compression fracture. He has been medically cleared.

No one is arguing that Dak Prescott should relinquish the starting job as the Cowboys now have the best record in the NFL. However, it was interesting that Romo was not even dressed as the back up. Even if Romo has not practiced with the first team, isn’t a rusty Romo better than Mark Sanchez who has yet to take a live snap as a Cowboy?

After the game, Jerry Jones said indeed Romo would be the backup next week. After all, every 2nd stringer is one play away from being the starter..

MMMD 4: Maurkice Pouncey heroic

The Steelers center tried to return last week after dislocating his thumb but lasted only one series. After thumb surgery, he is to be congratulated for not missing more time.

A snapping hand injury is like a throwing hand injury for a QB. With a cast and likely pins/screws to stabilize the thumb, Pouncey played with what could have been a 4-6 week injury. There were a couple of low snaps, but that could be forgiven. Kudos to the Steelers medical staff.

MMMD 5: NFL can go further for safety

As the league has begun its public relations campaign, I hope it continues to go further for safety. Commercials with Dean Blandino touting 42 rules changes including the elimination of the three-man wedge ran last week. This week featured a second ad pointing out sideline video, radio communication, hand held tablets with medical records and X-ray access.

These are all good advances. I remember getting multiple memos from the league saying cell phones are illegal on the sidelines. I argued they were necessary for communication to other medical personnel that may be in the locker room or with a hospital. The league now supplies all medical personnel with earpiece and radio.

A simple additional change is to not have mandatory charged timeouts when checking on player health. This would have prevented the Case Keenum situation from last year. It also would have helped with the Bills at Seahawks debacle Monday night at the end of the half. When medical came onto the field to check on the down kicker, the Bills were out of timeouts, meaning he had to leave for one play. Allowing medical checks without penalty of timeout would improve safety by removing the inhibition to check a player. Of course, the league would have to police for injury faking but if medical is a priority, this change should be done.

MMMD 6: Injury rundown

DeSean Jackson’s rotator cuff injury kept him out even with the bye week to recover. The hope is that there is no tear. Remember, a partial tear led to surgery and injured reserve for Eric Decker earlier this season.

Last week, people took note that Jimmy Graham was finally healthy after patella tendon repair. Now it seems his QB is fully healthy. Russell Wilson looks like his same old self while leading the Seahawks to a big win over the Patriots. His high ankle, knee MCL and pectoral muscle injuries seem to have finally improved.

The Steelers big free agent tight end signing finally played. Ladarius Green is off PUP and had three catches. It is unusual for a free agent to end up on PUP like he did since teams perform full physicals before inking deals, but that is all behind the team now.

MMMD 7: ProFootballDoc scorecard

Ryan Fitzpatrick did have a mild MCL sprain. Mike Evans did return from concussion in one week as expected. Eric Wood did suffer a high ankle fracture and need surgery. Justin Pugh did have a MCL sprain. Derek Wolfe will return soon from a hairline elbow fracture. Doug Martin did beat Jacquizz Rodgers back. Jake Long does have an Achilles rupture. Kyle Long does have a high ankle injury/fracture. Alex Lewis has a significant high ankle injury. Jeremy Zuttah’s low ankle sprain is not severe.

Credit Maurkice Pouncey and the Steelers medical staff for having him ready to play against the odds. Although the point of my tweets were correct about a snapping side injury for a center, he beat the odds and returned early so it will count as a mistake.

This makes the previous 107-5 (95.5%) record update to 117-6 (95.1%).

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Monday Morning MD: Teams take different approaches to injury reporting

This season, the “probable” category for pregame injury reporting was removed. Now players need to be either eliminated entirely from the report and deemed ready to play, or placed in the “questionable” category.

With the help of followers, I have gathered new injury reporting statistics. This season, approximately three out of every four (~75%) players

This season, the “probable” category for pregame injury reporting was removed. Now players need to be either eliminated entirely from the report and deemed ready to play, or placed in the “questionable” category.

With the help of followers, I have gathered new injury reporting statistics. This season, approximately three out of every four (~75%) players listed as “questionable” are active league-wide, compared to just over half (~55%) in the previous year.

At the halfway mark, it has become clear that teams take different approaches to injury reporting. I am not accusing any teams of manipulation or cheating; however, the numbers lead to stark contrasts. Over 90% of the “questionables” suit up for the Bengals, Panthers and Redskins. In contrast, under 50% of the same category are active for teams like the Titans, Jaguars and Seahawks.

Here is a full list of teams and the percentage of “questionable” players that are ultimately activated each week through the first half of this season.


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

Microanalysis will show many reasons for the differences. For example, the Bengals average only one player listed as “questionable” weekly but every player (a league low total of eight thru eight weeks) has been active. Some teams use the “doubtful” and “out” categories more liberally and thus have a higher percentage of “questionable” suit up.

I am an injury expert, not a fantasy expert. Thus I will leave it to the fantasy gurus to interpret the significance of the mid-season findings. However, there is clearly a big difference between how the Bengals who have activated 100% of their “questionable” players and the Titans who have only suited up 38% of theirs.

MMMD 1: Veteran leaders play through injury

Ben Roethlisberger, Terrell Suggs and Steve Smith, Sr. all played Sunday for the AFC North lead in the Steelers at Ravens clash. None of the three were at 100%, but most players are not at this juncture of the season.

All three have a history of toughness and early return from injury. Big Ben coming off knee scope and Smith dealing with a high ankle sprain will improve each week. Suggs who is putting off biceps tendon repair surgery will have to deal with elbow weakness for the rest of the year. Players will tell you that as the season marches on, 80% healthy is considered a good week.

MMMD 2: Joe Flacco breaks knee brace not knee

The Ravens QB scared fans when he came up hopping on one leg after an awkward slide. Fears of re-injury to his ACL or visual of a bone sticking out flashed through minds, but Flacco was fine. As he slid, his knee brace caught the turf and was mangled.


Teams have spare knee braces, although they may not be the exact custom model for each player. The Ravens were at home but even on the road, athletic trainers pride themselves as “boy scouts” who are ready for anything.

MMMD 3: More knee braces and Patriots health

Even on their bye week, the Patriots made health news. Bill Belichick explained why he has the offensive line wear knee braces. Essentially every major college mandates it but it is rarely required at the professional level. A few teams like the Patriots and Cowboys insist, but players resist due to the perception restricting knee fluidity. A brace cannot prevent all injuries, but could lessen the degree of injury.

Belichick also noted how his staff tries to prevent the avoidable non-contact injuries. Part of New England’s success this season may be having only three players on injured reserve versus the 19 from last season. The league average is approximately 10 IR players per season.

MMMD 4: Marijuana use in NFL

An ESPN survey of 226 players indicates 71% support legalization and 61% say fewer painkillers would be used if pot could be used. 22% claim they know a teammate who smoked before a game. 67% indicate the NFL testing for recreational drugs is not hard to beat.

Overall, players feel marijuana is better for recovery and pain control than pills. If players are committed to this, look for the next CBA to change the rules on marijuana usage.

MMMD 5: Medical sideline reporting improved

With the change in the Thursday night broadcast from CBS to NBC, the medical updates are much more precise. The difference from one week to the next was noticeable.

This is not a slight at the CBS sideline reporter, rather it is a compliment to the NBC sideline team that has a secret weapon. Longtime former Jaguars head athletic trainer, Mike Ryan, is on site behind the scenes providing his expertise. This is why reports now talk about specific tests and the anatomic references are all on point. Kudos to the NBC team for improving medical accuracy and the broadcast experience. The future is medical experts on broadcasts, like every network has a referee to help explain calls.

MMMD 6: Injury rundown

Maurkice Pouncey dislocated his right thumb and valiantly returned for one series. Look for surgery to be announced as dislocation is often associated with fracture. Unless he can move to guard or snap with his off hand, expect a 4-6 week absence.

Darrius Heyward-Bey suffered a midfoot sprain. His absence will be determined by severity but will likely be weeks.

By video, Allen Hurns had a left high ankle sprain but returned. His availability will depend on swelling.

Victor Cruz had a low ankle sprain that should not keep him out for long if at all.

Ryan Fitzpatrick injured his left knee and will get an MRI. By video, I am hoping for a minimal injury that could show a mild MCL sprain.

Cody Kessler had X-rays on his right leg that were negative and should not miss time.

Derek Wolfe hyperextended his right elbow and had a non-displaced coronoid process fracture. If the piece is small, he can avoid surgery and return in 4-6 weeks and possibly sooner with a brace.

Justin Pugh, by video, exited with a MCL sprain. His return with a brace will depend on severity and swelling.

Derrick Henry injured his calf in warm ups. Careful here, as medially, gastrocnemius muscle strains tend to linger.

Sammy Watkins is out of his boot but that doesn’t meant he is ready. Being placed on IR means he is out for at least another month anyways.

Mike Evans was initially cleared for concussion and later removed from the game. Hope he can return next week.

Jameis Winston’s knee injury is not expected to be significant.

Jamaal Charles’ menisectomy lends to a quicker recovery than the meniscus repair for C.J. Anderson. Charles has to now overcome swelling of the other knee, his IR status, age approaching 30 and a high salary cap number.

Doug Martin (hamstring) should be able to beat Jacquizz Rodgers (Lisfranc midfoot sprain) back for the Buccaneers.

Carlos Hyde missed another week with, by video, what seems to be an AC joint sprain.

MMMD 7: ProFootballDoc scorecard

Big Ben played in three weeks as expected. Terrell Suggs and Steve Smith, Sr also played. Sean Smith missed the game with left shoulder subluxation. It was time to worry on Jamaal Charles who had surgery and was placed on IR. Jameis Winston’s knee seems OK. Kwon Alexander had a stinger. Ty Montgomery sickle cell issue was only a one-week ordeal. Tyrann Mathieu did dislocate his shoulder. Barry Church is out 4-6 weeks with a forearm fracture. Corey Coleman missed six weeks with a broken hand. Referee Ed Walker tore his quad and Wade Phillips is OK but neither of these will count as this scorecard is for player predictions.

The previous 96-5 (95.0%) record improves to 107-5 (95.5%).

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Monday Morning MD: Time for transparency

Transparency is long overdue. Why not let the doctors speak or provide rationale for return to play decisions?

Once again we have another concussion controversy involving a quarterback. Last season we had Case Keenum. In the NFL opener, Cam Newton became the national focus. Now we have the Alex Smith situation.

The Chiefs QB’s

Transparency is long overdue. Why not let the doctors speak or provide rationale for return to play decisions?

Once again we have another concussion controversy involving a quarterback. Last season we had Case Keenum. In the NFL opener, Cam Newton became the national focus. Now we have the Alex Smith situation.

The Chiefs QB’s head hit the turf, lacerating his ear, and had to be helped up by Spencer Ware (who ironically later suffered his own concussion) and a referee. Smith passed a concussion test and was returned to the game. The QB later suffered a second blow to the head on the turf and was then deemed to have a concussion.

I am not suggesting that the Chiefs or any doctor did anything wrong here. I am saying the optics of the situation are not good when a wobbly QB is allowed to stay in the game.

The latest concussion controversy deserves explanation. Credit head coach Andy Reid for trying to address it post game (even though he erroneously said Smith passed both concussion tests). However, when pressed, coaches always use the “I am not a doctor” line and say I just followed the doctor recommendations.

Why not let the medical staff speak or at least release a statement? Of course the player would have to grant permission, but perhaps that would clear up the misperceptions. Maybe the physician, knowing he would have to publicly defend his decision, causes a further pause before a player is cleared.

I don’t believe in conspiracy theories. Certainly the unaffiliated neurotrauma consultant (UNC) who lives in Indianapolis was not incentivized to keep Smith in the game to help the Chiefs beat his hometown Colts. I believe the doctors are doing their best with an inexact science of diagnosing concussions. I have been there and know what a difficult job it is. It is impossible to get every “play/no play” decision correct, like it is impossible to expect a referee to get every call right. My point is why not let the public know about the process and what the doctor’s thinking was? Even the referee has to answer a pool reporter’s questions post game.

I am curious as to what the referees were thinking on this first hit. The umpire was one of two people there to help hold Smith up and referees are also charged with player health. I would also love to hear the UNC’s side of the story. Did the UNC see a wobbly Smith? Was he provided with the video replays? What lead him to clear the player? Even if a player passes concussion tests, visual evidence of a balance issue is enough to rule a player out.

The NFL has been accused of conspiracy and denial in the concussion crisis. Why not shed that image and allow some transparency in the current head injury decisions? Not allowing for comment just makes the situation look worse.

MMMD 1: Good injury week

Overall Week 8 seemed to be the least injuries for 2016, yet there were still plenty. The year to date has seen a slightly higher rate than average with 40 ACL tears and 32 Achilles ruptures.

Lets hope we don’t get Monday morning bad news. Or as seems to be the pattern this year, Wednesday bad news like we did for Adrian Peterson, Dez Bryant, C.J. Anderson and others.

MMMD 2: Two stars trying to return

Ben Roethlisberger and Terrell Suggs are both coming off injury and a bye week to face off in a big divisional game. Big Ben will be three weeks after a knee scope. Suggs suffered a biceps tendon tear.

There are varying reports of stitches and whether Roethlisberger will be ready. Medically, expect him to play. The sutures are in the skin, not the meniscus; therefore, will be removed and is a non-issue. Suggs is forgoing surgical repair to play through what may be his final season in the NFL.

MMMD 3: All meniscus tears not the same

Earlier this season we covered the difference between the Adrian Peterson and Big Ben meniscus tears. Now we have additional examples.

C.J. Anderson had his meniscus repaired, which means six weeks of rest and minimum three months of recovery. Michael Bennett’s return timeline after his cartilage trim procedure is set at 2-3 weeks. Trimming meniscus is like mowing the lawn where you can play football immediately after, while repairing is like laying down new sod where you need to keep of the grass to let the roots grow in.

MMMD 4: Time to worry for Jamaal Charles

Swelling when increasing activity after an ACL surgery is not unusual. When it does not go away for several weeks, the effusion becomes a concern.

Charles is now seeking a second opinion. Hopefully, rest, time, compression, medication and draining the knee will be enough. I hope there is no need for a post-ACL knee scope.

MMMD 5: Worst injury of the season

Texans right tackle Derek Newton ruptured both of his patella tendons last Monday. Even though there was a report of successful surgery to repair both tendons, he has a long path to return to the NFL. Three players have torn both patella tendons at the same time: Wendell Davis, Gary Baxter and Greg Childs. None of the three returned to their pre-injury levels of play. Hopefully, Newton can be the first.

The road game presented several difficulties. First, Newton did not have access to pain medicine immediately as the visiting team is not allowed to bring narcotic medication per federal laws and the home team medication supply is limited. Second, the 300+ pound lineman was essentially wheelchair bound and could not fly home with the team but instead needed special medical transport.

MMMD 6: Injury rundown

Broncos defensive coordinator Wade Phillips was knocked over on the sidelines and rushed to the hospital. Fortunately rumors of a broken leg were inaccurate and he passed all tests and was released.

Four players were concussed during the Chiefs at Colts game: Alex Smith, Spencer Ware, Joe Reitz and Vontae Davis. Statistically expect at least two of the four to miss next week’s game.

Jacquizz Rodgers injured his left foot but video was not clear as he was in a pile and the mechanism or severity could not be seen.

Ty Montgomery has a kidney-related ailment. It is unclear what type or how long he might miss.

Martellus Bennett continues to deal with a high ankle sprain. He injured it in Week 5 and still caught three touchdown catches. Here is hoping the bye week gives him a chance to fully heal.

Barry Church fractured his right forearm, the same side that he broke causing him to miss the last game of 2015. He likely will undergo plating surgery and return in 4-6 weeks.

Morris Claiborne has a significant groin injury. Sometimes one can play through or the Cowboys could make the decision to fix it now to be back by the end of season/playoffs.

By video, Charles Clay suffered a left shoulder AC joint sprain but returned to the game.

Sean Smith appeared to subluxation/dislocate his left shoulder. If he torn his labrum, that could mean surgery or trying to play with a brace as Charles Woodson did last year for the Raiders.

Duke Ihenacho suffered a scary hit in London. After a substantial time on the ground, was able to walk off under his own power.

Vontaze Burfict’s knee injury does not appear to be serious. By video, he suffered a contusion to the muscles in back of his left knee and he did return to the game. Meanwhile, Burfict inadvertently hit Rey Maualuga’s left arm but there was no fracture and he ultimately continued as well.

Russell Wilson was able to play through his pec, knee and ankle injury but not well enough to come away with victory.

Tyran Mathieu left the game with an unspecified shoulder injury. Hopefully the follow up news will be good.

Sammy Watkins is out of his boot. That certainly is a good sign but only a first step to return and there is no medical certainty that he can come off IR when eligible in a month.

MMMD 7: ProFootballDoc scorecard

By video, I did not expect Geno Smith to tear his ACL. Demarcus Ware did return after ulna plating surgery and even had a strip sack fumble with his right arm that was reversed. Lamar Miller played with what has been confirmed as a deltoid contusion. Antonio Brown’s hip contusion is confirmed to be progressing well for this Sunday and will not miss time. Duke Ihenacho, Vontaze Burfict and Rey Maualuga injuries are all less significant than originally feared. Derek Newton was confirmed with bilateral patella tendon ruptures.

Counting the missed ACL tear lowers the previous 89-4 (94.7%) record to 96-5 (95.0%).

Happy Halloween to everyone!


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Monday Morning MD: Easy to just blame the coach

When a player returns early and is re-injured, it is too simplistic to blame the coach for pushing a player to hurt. Bills head coach Rex Ryan faced that criticism when LeSean McCoy played through and aggravated a hamstring strain in a Dolphins loss on Sunday.

Mid-week, McCoy was originally declared with only muscle

When a player returns early and is re-injured, it is too simplistic to blame the coach for pushing a player to hurt. Bills head coach Rex Ryan faced that criticism when LeSean McCoy played through and aggravated a hamstring strain in a Dolphins loss on Sunday.

Mid-week, McCoy was originally declared with only muscle tightness that turned out to be “coach speak” for a mild to moderate strain per media reports. It would be easy for me to say “I told you so” after the Bills star RB left the game in the second half feeling pain after 8 carries for 11 yards. I did warn of ineffectiveness and aggravation but that is nothing the Bills medical staff would not be aware of and had considered. The offensive coordinator even said earlier this week, “I don’t want to do what we did last year. I don’t want him playing 85% re-injuring the hamstring and this thing lingering all year.”

Return-to-play decisions are not solely made by the team doctor or the head coach. Typically it needs to be a unanimous group decision between three parties: the medical staff, the team and the player. Any of the three has “veto power” and must share in the responsibility of all return-to-play scenarios.

The medical staff input is a combination of the doctors and athletic trainers. The team decision requires varying input from coaching (head coach, coordinators and position coaches) and management (general manager and sometimes owner). The player component includes the athlete, agent and often family. (Certainly agents have stepped up and prevented their guys from playing before.) All three combined parties must agree, otherwise a player doesn’t step on the field. Decisions like these are always joint discussions and are never made in a vacuum.

Ryan acknowledged, “We never play a guy our doctor and trainers don’t clear”. I am sure the medical staff was aware of and discussed risks of re-injury and ineffectiveness. McCoy accepted his role in the decision to play as well, saying “I felt good…I wouldn’t play, if I wasn’t 100%”.

Given this situation plus the Sammy Watkins, Aaron Williams and Shaq Lawson decisions to play through injury, it is inevitable critics will blame the Bills for allowing these players to push the envelope and get back to action prematurely, causing a bigger risk for re-injury down the line; however, that would not be telling the whole story. At least in this case McCoy himself acknowledges his role in pushing to play and admitted it might have been better to hold off.

MMMD 1: Geno Smith injury “not too significant”

The Jets Sunday starter exited with a left knee injury. By video, there was no major ligament injury but there is some worry for a meniscus tear (similar to Roethlisberger’s injury last week) that will be cleared up by a MRI. Smith himself indicated it wouldn’t be “anything too significant”; however, he spent the second half in street clothes on the sidelines. Unlike Big Ben who was cleared to play the 2nd half, doctors didn’t clear Smith to return as a precaution. The thought is Smith will avoid a knee scope and it doesn’t appear to be serious, even though he may not be the starter anymore.

MMMD 2: Steelers hope to get healthy with bye week

Antonio Brown took a knee to the quad and was hampered the rest of the game. Fortunately muscle contusions heal quickly and the week off comes at a perfect time for the Steelers star WR. With rehab, expect Brown to be 100% for the next game.

It would also help if Ben Roethlisberger would be throwing him the ball. Despite some doom and gloom reports of missing up to six weeks, I have never waivered (and a new CBS report agrees) from my feeling that Big Ben is most likely to return for the post-bye divisional games versus the Ravens.

MMMD 3: Giants injury designation faux pas

Odell Beckham Jr. and five other players were listed as “probable”, a designation that doesn’t exist anymore on the Friday injury report. Perhaps, the Giants share in the thoughts of fantasy players in wanting that category reinstated.

All six players were subsequently removed completely from the injury report, as downgrading to “questionable” would have proven the fallacy of the new system. Beckham did play as expected with a hip pointer, but he was seen working with trainers pregame and perhaps was not 100%. With the post overseas game bye, OBJ should not be hobbled for his next game.

MMMD 4: No Reggie Bush touchdown

It didn’t matter in the outcome of the game but it could matter for future safety. A play is dead when the ball carrier’s helmet comes off. Reggie Bush’s helmet was completely off just before he crossed the goal line yet he was still awarded the score.


Officiating guru Mike Pereira agreed. The NFL and NCAA rule are similar here except that the professional player is not required to leave the field for a play after his helmet comes off like the collegiate players. I would lobby that non ball carriers deserve the same protection. If the helmet comes off, any player should be deemed a non-participant meaning he can’t tackle, be hit, block or be blocked.

MMMD 5: 2016 Health and Safety Report

The annual medical update was released this week. The NFL has been far from perfect in dealing with head injury over the years but before anyone criticizes the league’s current action, they should read this comprehensive 39 page report of all of the health initiatives.

One piece of unfinished business is the NFL has yet to announce it’s new Chief Medical Officer.  The often maligned previous medical adviser was forced to retire in July but the new full-time position has yet to be filled.

MMMD 6: Injury rundown

Jay Ajayi was cramping and not injured. Who can blame him after two consecutive 200+ yard performances in Miami.

Russell Wilson still seems to be hampered by the knee and ankle injury, which I expected to be behind him after the bye.

Jamaal Charles was limited by knee swelling and only had 1 carry for 0 yards. Knee effusion is common after ACL surgery but the swelling usually goes away quickly. Only if it persists, is it time to worry.

Tevin Coleman left with a hamstring strain but it is difficult to discern severity off video so his absence is yet to be determined.

Brian Hoyer’s doctors were working Sunday despite the Thursday game this week. The Bears QB underwent surgery with plate and screws into his radius (forearm) bone. Contrary to popular belief, team doctor’s have “day jobs” outside of the NFL and likely the regular weekly workload made the off day schedule more convenient.

Ron Brooks of the Eagles ruptured his quad tendon and will need surgery. This injury is similar to patellar tendon tear and will require a minimum of 6-9 months recovery.

Aaron Williams left the Dolphins game in an ambulance for a precautionary MRI that was negative and flew home to Buffalo with his team. Jarvis Landry apologized for the penalized hit that may still draw a fine.

Jeremy Hill seemed to aggravate again what by video seems to be a left AC joint sprain.

Jerick McKinnon by video suffered a high ankle sprain but had a limited return for the Bears.

Josh Norman and Cody Kessler suffered concussions.

Jordan Reed was out again and admitted to hiding his concussion.

John Brown missed the game as his sickle cell trait work up continued. Expect a full return as most teams have at least one player with the trait that play without issue.

Saints special teams ace, Jake Lampman is hoping to avoid major knee ACL and/or MCL injury.

Josh Doctson was placed IR for recalcitrant Achilles tendonitis.

Dez Bryant cut his fingers making soup, but his knee and digits should be fine after the Cowboys bye this past week.

MMMD 7: ProFootballDoc scorecard
Please be clear that I take the time to chronicle the correct/incorrect video and injury analysis to publicly vet my stats. This allows readers and twitter followers the chance for a public audit of my numbers.

This week, Russell Wilson does not seem to be over the knee and ankle injury as I expected, thus will count as a mistake. Unfortunately LeSean McCoy did aggravate his hamstring. Carson Palmer played with his as expected. Jerick McKinnon had a mild high ankle sprain confirmed. Brian Hoyer did have an isolated radius and needed surgery, Dwayne Allen missed the Colts game with a high ankle sprain. Michael Bennett did avoid serious knee injury and played.

Add these into last week’s 83-3 (96.5%) drops the numbers to 89-4 (95.7%).

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Monday Morning MD: All meniscus tears are not the same

Ben Roethlisberger will need surgery but his season will not be over. Big Ben has a meniscus tear like Adrian Peterson; however, the Steelers quarterback will return in short order.

Not all meniscus tears are the same. A locked bucket-handle displaced meniscus tear like the Vikings running back had requires repair to prevent long-term problems.

Ben Roethlisberger will need surgery but his season will not be over. Big Ben has a meniscus tear like Adrian Peterson; however, the Steelers quarterback will return in short order.

Not all meniscus tears are the same. A locked bucket-handle displaced meniscus tear like the Vikings running back had requires repair to prevent long-term problems. Sutures require healing time measured in months. By video, Roethlisberger has a simple smaller meniscus tear that likely will be trimmed without the option for repair and his return will be measured in weeks. When laying down new sod, one must “keep off the grass”; however, after mowing the lawn, one can play football on the grass immediately.

The worst fears of injury were avoided. Roethlisberger described what he thought was a hyperextension injury but fortunately there was no serious ligament tear.

Big Ben will have had knee arthroscopy surgery by the time this article posts. Expect confirmation of a trimming procedure and a definite return this season.

With menisectomy (trimming) surgery, there is no wait for healing, thus, return is measured in weeks. Typically recovery is 2-4 weeks but given that Roethlisberger is not a position player and his recovery prowess is legendary, it is not impossible to return next week to play the Patriots. After all, Philip Rivers played New England in the 2008 AFC Championship game six days after a knee scope (and with a torn ACL).

However, the most likely return is after the Steelers bye the following week. I fully expect to see Roethlisberger play the division rival Ravens in Week 9.

There are many reasons to have immediate surgery. First, the tear can get worse. Second, playing on a meniscus tear can accelerate arthritis. Third, a cartilage injury limits playing effectiveness. Finally, with the quick recovery and the bye coming, there is no time like the present and Steelers doctors are acting quickly to make it happen.

Big Ben returned to play in the second half but there is no way he should continue to chance further injury without surgery first. I am sure if Roethlisberger had clinical signs of meniscus tear or mechanical symptoms, he would not have been allowed to return to play. Now that the meniscus tear is diagnosed, there can be no thought of playing through the injury.

Roethlisberger will return to 100% in terms of football. He will have some increased chance of long-term arthritis as a result of loosing some of the meniscus as cushioning, but less than without surgery.

An operation is never good news, but this type of meniscus procedure is really a positive scenario for Roethlisberger and Steelers fans. With a trim, Big Ben will have a chance to return very quickly.

MMMD 1: LeSean McCoy avoids serious injury

Like Big Ben, McCoy had a scare and clutched his right knee. By video, the Bills RB averted disaster and only had a mild MCL sprain. The key is that his foot was not fully planted or trapped. Indeed, McCoy returned for the second half and I don’t expect issues going forward.

MMMD 2: Odell Beckham, Jr. injures hip

The Giants star WR was injured within minutes of Roethlisberger and McCoy. Fortunately he too avoided major injury and returned for a big game.

By video, Beckham suffered a left hip pointer. The key is how swollen and sore he is this AM. Just because Beckham came back to play is no guarantee for next week. I expect the Giants to be aggressive treating this injury and thus a good chance to see Beckham in action next week in London. I do not expect the long flight to be a factor as teams fly on a chartered 747 and it’s like spending six hours in your living room. In fact, the Giants medical staff can set up a mini-training room on the plane as well.

MMMD 3: Terrell Suggs injured again

The 34 year-old pass rusher recovered from his second Achilles rupture, now he will have to deal with his second biceps injury. By video, Suggs ruptured his left distal biceps tendon at the elbow and Jay Glazer has confirmed the injury.

In 2012, he played through the month of December and into the Super Bowl with a right biceps tear. I suspect he will want to try to delay surgery and do the same now. Most players end up with surgery to re-attach the tendon to restore full flexion and supination (palm up rotation) strength.

Suggs has proven to be a quick healer and still can be an effective pass rusher. His ability to wrap and tackle may be hindered by this injury, but given his experience compensating and playing hurt on the other elbow gives him hope that he can do the same now.
MMMD 4: DeMeco Ryans sues over Achilles tear

The former Eagles linebacker ruptured his Achilles tendon in 2014 at NRG stadium and is now suing the Texans, NFL and stadium operators.

Originally the field was made up of natural grass pallets that were rotated into the sun for growth but the seams generated complaints. Subsequently the surface has now been switched to artificial grass.

Reggie Bush sued the St. Louis Rams stadium over his knee injury slipping on concrete and the case is still pending. Ryans returned to play during a subpar 2015 campaign but is no longer playing and seeks over $10 million in damages.

MMMD 5: Active does not always mean playing time

A big pregame topic is who will and won’t be on the inactive list. This week there was much discussion of to play or not to play for Arian Foster and Will Fuller.

Foster was called a game-time decision. The Dolphins RB was active but had minimal contribution with only 3 rushes for 3 yards.

Fuller was reported by Adam Schefter to be out. The Texans instead activated the wide receiver but he essentially did not play. Seems the Texans had no healthy scratches so Fuller was activated even though his effectiveness from hamstring injury was limited. In the end, the ESPN report was not wrong even though Fuller was technically active.

These are prime examples of where active does not equal effective.

MMMD 6: Injury rundown

Browns S Jordan Poyer was taken to the hospital with a concussion and diagnosed with a lacerated kidney. Expect a minimum one-month absence that could extend to season long.

Seahawks DL Michael Bennett suffered a scary looking knee hyperextension injury.


The hope is his ligaments were spared despite the gruesome appearance and only minor anterior bone bruise or posterior capsular stretch injuries.

By video, Colts TE Dwayne Allen left with a right high ankle sprain. His status for next week is in doubt.

Redskins TE Jordan Reed did not play as expected after his recent head injury. With his sixth reported concussion, it will be smart to take great care and consideration before return. The bigger concern is not when he will return but potentially if he will return. There is no absolute number of concussions when one has to retire but I hope Reed makes the right decision.

Today, Chiefs LB Justin Houston can come off PUP from his ACL. He has been cleared for football activities. If he is activated, he has two weeks to practice before potentially playing in Week 9.

Packers RB James Starks underwent an unusual Sunday AM knee scope surgery. The timing may have been necessitated by a family emergency last week. Usually in season arthroscopy are done early week to maximize return, as is the case for Roethlisberger (detailed above).

MMMD 7: ProFootballDoc scorecard

I am glad that this section generated some interest this week. A follower thought I should count Dez Bryant as a mistake as initially I only said MCL. His bone bruise is indeed related to the MCL but I will follow his advice and call that a mistake. It was correct that Big Ben did not have a major injury and returned to play; however, I will not count it as correct as he now has what I consider to be a minor meniscus tear.

Despite three touchdowns last week, Martellus Bennett did show up on injury report with an ankle as expected. Eddie Lacy did play through his high ankle injury while Steve Smith was inactive as no player listed as doubtful has been activated in 2016. Trevor Siemian and Terrance Williams played with AC injuries. Jordan Reed was out with concussion and although limited, Sammie Coates was active with index finger fracture and laceration.

There were three correct pure video impressions. Odell Beckham, Jr. was confirmed with a hip pointer. LeSean McCoy did avoid major knee injury. Terrell Suggs does have a biceps tear.

This takes last week’s 73-2 (97.3%) mark to 83-3 (96.5%).

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Monday Morning MD: High ankle is not always dreaded injury

The average fan knows and fears the high ankle sprain. We have come to know this injury can knock players out for extended periods of time. However, does every high ankle sprain lead to a player missing multiple weeks?

Like any injury, there is wide variety in high ankle severity. Yes, players can perform thru

The average fan knows and fears the high ankle sprain. We have come to know this injury can knock players out for extended periods of time. However, does every high ankle sprain lead to a player missing multiple weeks?

Like any injury, there is wide variety in high ankle severity. Yes, players can perform thru mild sprains while severe sprains can even lead to surgery.

Early in the game by video, TE Martellus Bennett suffered a high ankle sprain and was in obvious pain. He channeled his inner superhero and returned to play, catching three touchdown passes for the Patriots. How sore and how much swelling he has this am, will determine if he can also play next week.

Steve Smith Sr. also appeared to suffer a high ankle sprain.


He continued to play for awhile but ultimately limped off the field.

By video, Eddie Lacy also suffered a high ankle sprain. The Packers RB left the game but hopefully that has as much to do with the score at the time as the severity of the injury.

Meanwhile, high ankle injury can be very severe. Last week, Kevin White limped off under his own power but has been reported with a severe high ankle sprain with an associated fibula fracture. The injury to the Bears receiver has nothing to do with his tibia stress fracture from last year but he has been placed on injured reserve and likely needs surgery.

By video the worry is Trumaine Johnson may have suffered the same fate as White. The best case scenario is a severe high ankle sprain with a prolonged absence. The worst case for the Rams cornerback is season ending surgery if an associated fibula fracture is found. Neither possibility is good for someone playing on a franchise tag without a long-term deal.

We have chronicled both ends of the high ankle injury spectrum. Of course there are plenty of scenarios in the middle as well. Bottom line is the high ankle sprain is not always the dreaded injury it is made out to be in the media.

MMMD 1: Early stats for new injury categories

With PROBABLE being removed, what does QUESTIONABLE now mean? It used to mean a 55% chance of playing in 2015. Now with the two combined, the early returns show about a 75% chance to be active. It makes sense that when combining a 50/50 and 95% category that the results are somewhere in between. The challenge now is to figure out which players are truly questionable to play and which ones were always very likely to make it.

Of note, zero DOUBTFUL players have been active in 2016. Jay Cutler, Stefon Diggs, Dwayne Washington and others continued the no-go trend here. Seems like this should have been the better category to remove for the league.

MMMD 2: Browns can’t get started

Every offensive play starts with the snap. Cleveland can’t keep their centers or quarterbacks on the field. With the Cody Kessler injury to his chest/ribs, the Browns have now used eight players at these two positions. Kessler’s X-rays were negative so he has a chance to return next week.

Meanwhile, recently acquired backup QB Charlie Whitehurst was the fourth Browns QB injured when he hyperextended his left knee but hopefully escaped serious injury. Both Robert Griffin and Josh McCown suffered shoulder fractures previously.

MMMD 3: Trevor Siemian could return for Thursday

The Broncos starter was reported by Jay Glazer to have a grade 3 AC sprain and was inactive Sunday but that doesn’t rule him out for the midweek division clash versus the Chargers. The injury is to his non-throwing shoulder and contrary to some speculation, will not need surgery. With aggressive treatment and medication, I think Siemian has a good chance to play despite the high grade AC injury. Jimmy Garoppolo had a reported grade 2 injury to his throwing shoulder and missed 2 weeks but was healthy enough to back up Tom Brady and play in mop up duty this week.

MMMD 4: Gary Kubiak hospitalized after game.

I hope it is just illness and nothing more as flu-like symptoms sent the Broncos head coach off in an ambulance post game. In 2013, he collapsed at halftime as the Texans head coach and suffered a mini stroke. Hopefully this is all precautionary and Kubiak will be fine.

MMMD 5: Injuries no excuse

All teams have injuries and need to make adjustments. The Vikings head into their bye as the only undefeated team at 5-0. They lost their franchise QB, star RB, starting left tackle and others, yet still remain undefeated. Kudos to the GM, coaches and players for their success.

Versatility often helps a team as well. There is no better example than Texans LB Brian Peters. He had kick off duties Sunday and has even stepped in as long snapper. As they say in the NFL: the more you can do.

MMMD 6: Injury rundown.

Tevin Coleman had no issues with sickle cell in Denver. He tied the Falcons record for most receiving yards (132) for a running back as he helped hand the Super Bowl Champions their first loss.

A.J. Green was rolled up on late in the game but returned after six plays.

Jeremy Hill left with a shoulder injury after his previous chest injury but should not miss significant time.

Josh Norman injured his right hand/wrist and finished the game with a splint and tape.

By video, Terrance Williams had a mild left AC sprain, which he confirmed. He should not miss any games.

Cam Heyward will have a MRI on his hamstring to determine severity.

Letroy Guion said he had a complete tear of MCL from week 2 but returned this Sunday with a brace and will not need surgery.

WRs Randall Cobb and Chris Hogan had ugly looking hits but neither suffered significant injury, but likely both will be sore.

Tony Romo will have a repeat MRI Monday. Expect good news as compression fracture heals reliably. Despite a long list of injuries there is no medical reason for Romo to retire. With his replacement playing well, expect Romo back after the week 7 bye.

Dez Bryant was inactive Sunday but will beat Romo back as he does not have a true fracture.

Latavious Murray was out with a turf toe and his return is undetermined.

Senquez Golson was placed on IR as Lisfranc injuries are hard for defensive backs to play through.

Zach Ertz was active after his early season first rib dislocation. No surgery was needed and he should do well going forward.

Tyler Eifert has yet to play after a Pro Bowl ankle injury and surgery. His return is now delayed by a back issue.

Jacoby Brissett needed thumb surgery. Likely his ulnar collateral ligament injury kept the Patriots from having a full offense last week. Kudos for toughing it out and delaying surgery until Brady returned.

Josh Doctson’s Achilles tendonitis continues to linger. I am sure the Redskins are doing what they can but this is just one of those frustrating issues.

Eric Decker is still out. Optimists will say it is good news the team has not put him on IR for his partial rotator cuff tear. Pessimists will say he is done and needs surgery. The truth will depend on the extent of the tear, where greater than 50% thickness spells trouble.

MMMD 7: ProFootballDoc scorecard

Lee Smith was confirmed with an ankle fracture. Kevin White had a severe high ankle sprain with fracture. Randall Telfer did miss the game with a high ankle injury. Zach Ertz returned to play without surgery on his dislocated first rib. Sickle cell indeed was a non-issue for Tevin Coleman. Senquez Golson was placed on IR for long standing Lisfranc injury. Randall Cobb and Chris Hogan were ok despite nasty looking hits. Charlie Whitehurst knee hyperextension seems mild as expected. Martellus Bennett had a mild high ankle sprain. Josh Doctson Achilles tendonitis is lingering. Cody Kessler seems ok with no fracture.

This makes the previous 61-2 mark, now 73-2 (97.3%), but one or two misses will bring it right back to the 95% target.

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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

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%).

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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

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.

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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.


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% .

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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

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%.

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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

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. 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%.

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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

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%.

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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”.

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.

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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

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.

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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

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


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.

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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

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.


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.

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Monday Morning MD: PUP watch is on

After an offseason of speculation of who will be healthy and who will not, the PUP watch is on. The eagerly anticipated news of the week will be who is placed on the Physically Unable to Perform (PUP) list, but what does it really mean?

As previously explained, there are two types of PUP, Active

After an offseason of speculation of who will be healthy and who will not, the PUP watch is on. The eagerly anticipated news of the week will be who is placed on the Physically Unable to Perform (PUP) list, but what does it really mean?

As previously explained, there are two types of PUP, Active (for the preseason) and Reserve (for the regular season). The other designation is Non-Football Injury (NFI) which is used for injures not occurring during NFL football, which includes collegiate injuries.

One needs to be on Active/PUP even first, if only for a day, to be eligible for Reserve/PUP . Thus, is it not the end of the world if your favorite player is placed on PUP. For example, the Jets signed Muhammad Wilkerson to a big free agent contract but fans should not freak out, rather expect his appearance on PUP initially in case his ankle doesn’t respond as expected.

It says more when a player is not on PUP than when he is. The Ravens announced six players were not ready for training camp, including Steve Smith (Achilles), Terrell Suggs (Achilles), Elvis Dumervil (foot), Breshad Perriman (“partial” ACL), Trent Richardson (knee scope, hamstring) and Jumal Rolle (Achilles). Notably absent from this PUP list was Joe Flacco coming off ACL surgery. This speaks volumes to the team’s confidence in their QB’s recovery.

The Lions placed three players (WR Corey Fuller, TE Brandon Pettigrew, T Corey Robinson) on preseason PUP. The key is not that a player begins on PUP but when he comes off.

Jordy Nelson is reportedly doing well and had almost an entire calendar year to recover from his ACL tear; however, don’t be shocked if the medically conservative Packers start him on PUP. Sometimes, it is just the team taking the precaution and leaving the worst case option of Reserve/PUP open if there is a setback.

The Cowboys reportedly will start TE Gavin Escobar on PUP after a Week 15 Achilles rupture. The Bills will undoubtedly start Shaq Lawson on Active/PUP and convert him to Reserve/PUP to save the roster spot and get him back this season after shoulder surgery in May.

There are some big names coming off injury: Jamaal Charles (ACL), Dion Lewis (ACL), Jimmy Graham (patella tendon), Thomas Rawls (ankle fracture), Sammy Watkins (Jones fracture) and Julian Edelman (Jones fracture). Don’t be surprised if many of these names at least start training camp on PUP. The key will be how long they stay on the list and unable to practice.

The annual PUP watch is on.

MMMD 1: J.J. Watt’s back surgery isn’t the issue, rehab is

Although back surgery is nothing to scoff at, the herniated disc procedure for the two-time reigning Defensive Player of the Year is relatively straightforward. The rehab of the core muscles for this injury is more unpredictable.

While it is possible that Watt will play Week 1, it is very unlikely that he will be 100% until mid-season. The Chiefs’ Dontari Poe had a similar surgery and a late July 2015 time frame and indeed returned to play Week 1 but was not himself until much later.

The disc procedure was undoubtedly in the lower lumbar spine at L5-S1 or L4-5 level meaning it affects the player’s base. In my NFL experience, it is harder for a power player like a defensive lineman to return to full effectiveness than a skill position. After all, playing on the D line is like wrestling a bear (or two).

The Texans medical staff didn’t miss the injury and Watt didn’t delay surgery. Yes he played with a herniated disc (many players do) last season; however, it likely got worse, or extruded, leading the team and player to decide to be aggressive. Pulling the trigger now on surgery assures Watt being 100% for the critical parts of the later season.

MMMD 2: Bell suspension minimal real effect on Steelers

Le’Veon Bell is still recovering from his multi-ligament knee injury. In reality, the four-game suspension will just give him more time to recover and might not really be costing additional game time. Combined PCL/MCL injuries are harder to recover from than an ACL tear.

Bell was likely to start training camp on active/PUP and work his way back in anyways. The biggest significance is that he will have to find his own rehab and workout place as he will not be allowed to be with the team during the first four weeks of the regular season. The Steelers are likely to factor in the suspension in deciding when to activate Bell. This is not illegal, as when Bell is ready to play is a subjective decision anyways.

The bigger worry for Bell is that this counts as a second strike. A third violation would mean a one-year suspension. He needs to continue on random testing and this potential jeopardy could cost him in his pending contract status.

MMMD 3: A change in stance on Jaylon Smith?

The Cowboys have always expressed confidence in their high second-round pick’s nerve recovery. Has that now changed?

Jerry Jones remained steadfast in his comments that Smith is not behind in his recovery; however, he did say “if it comes around” not when. This is the first acknowledgement from the team that it might not. Let’s all continue to hope that it does.

MMMD 4: New IR/dfr rule

The amended injured reserve-designated for return (IR/dfr) rule should benefit clubs and players. In the past, a team needed to designate the single slot with the initial roster move. Last season, the Steelers wasted their only IR/dfr slot on Maurkice Pouncey, as he was unable to return after his ankle fracture as he ended up with seven additional surgeries due to infection.

This year, teams can place players on IR and not make the decision on which player they want to return until the player is ready to come back. This removes the worry of teams of using the designation too early in case a star player gets injured later or holding the spot and wasting it in the end. It also prevents using it on the wrong player, as in the case of Pouncey. This rule change is a good improvement.

MMMD 5: NFL medical director “retires”

Elliot Pellman, the longtime Park Avenue medical voice, has been asked to step down by the commissioner. Pellman and the NFL have made their share of mistakes over time. No one is going to shed a tear in his departure.

People seem to want a “scalp”, rather than focus on a solution. Now they have Pellman’s so lets focus on fixes. Hopefully this signals a new era where the NFL, NFLPA, concussion researchers and media stop playing politics.

The bigger issue is perhaps the NFL will now be forced to have a real medical advisor. I am not at all knocking current chief health and medical advisor, Betsy Nabel. However, working on a part-time basis one day a month is hardly enough time to tackle all of the health and safety issues in the NFL. Hopefully the new medical director can have the time and resources to truly lead the NFL where it needs to go.

MMMD 6: Dennis Green passes away

One of my early experiences as a NFL team physician was with the Dennis Green coached Minnesota Vikings in 1994. I had the fortune of taking my first NFL road trip with that special team. Besides Green, there were some great coaches on that staff including Brian Billick and Tony Dungy as well as future head coach Jack Del Rio who was playing at the time. Four players on that squad, Warren Moon, Randall McDaniel, John Randle and Cris Carter, would later be inducted into the Hall of Fame. I will remember Green fondly and may he rest in peace.

MMMD 7: ProFootballDoc scorecard

When Desmond Bryant of the Browns was announced with a pectoral muscle injury, I immediately indicated it was likely a tendon tear and surgery would be needed, essentially costing him the season. Unfortunately, this has come true, but the good news is he will recover 100% for 2017.

When Muhammad Wilkerson broke his leg last season, I tweeted he would recover well and it would not have a negative effect on his pending free agency. Indeed, the Jets resigned him to a big contract as expected.

This takes the 2016 record from 10-0 to 12-0.

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Monday Morning MD: Aaron Rodgers and the truth about ACLs

The Packers superstar made news with his comments about his 2004 anterior cruciate ligament (ACL) surgery. One of the NFL’s best and most athletic quarterbacks attributed some of his success to his cadaver donor being a “fast SOB” as he shaved almost 3/10ths of a second off his 40-yard dash time after surgery.

Known to

The Packers superstar made news with his comments about his 2004 anterior cruciate ligament (ACL) surgery. One of the NFL’s best and most athletic quarterbacks attributed some of his success to his cadaver donor being a “fast SOB” as he shaved almost 3/10ths of a second off his 40-yard dash time after surgery.

Known to have a unique sense of humor that even fools teammates, Rodgers comments were surely made tongue-in-cheek. It wouldn’t be the first time a player was kidding the media as Danny Trevathan joked about having someone else’s kneecap last year. In any case, Rodger’s quotes give us a good chance to separate the realities from the myths of ACL surgery.

Was Rodgers’ cadaver donor a “fast SOB”?

There would be no clear way for Rodgers to know whom the donor was. The only cadaver information typically available to the surgeon is the age, sex, cause of death and dimensions of the graft. Upon expiration, donors are screened for diseases before being deemed viable for tissue harvesting. There is no direct tissue typing or matching to the recipient. Details of the donor’s life, ethnicity, occupation or athleticism are not considered or available. In fact, Rodgers ACL graft donor could have been female.

Could someone else’s ACL make you faster post surgery?

No way the graft itself makes anyone faster. First, the actual ACL from a cadaver is never directly harvested for use due to size and geometry limitations. Commonly, the patellar tendon (with two attached bone blocks), Achilles tendon (with bone on one side) or all soft tissue grafts (like posterior tibialis tendon) are used. Second, the ACL functionally can’t make one faster. It serves to stabilize the femur to the tibia and thus actually could be said to “slow’ the knee down to prevent shifting.

Is it feasible to decrease one’s 40-yard dash time after ACL surgery?

Rodgers said he was a 4.95 (40-yard dash) guy and then ran 4.66 after ACL surgery. Yes, ACL rehab can make someone faster/quicker if the athlete was not performing maximally prior to injury. A fully trained athlete can’t be made faster; however, a sub-optimally functioning player can be helped. In fact it is possible for an uninjured player to go thru ACL rehab style training and have performance improve. I personally witnessed Philip Rivers become a better athlete after ACL surgery in 2008. I wish I could take credit for his increased speed/mobility but it was a result of his hard work with top Chargers athletic trainers. Rodgers is downplaying his own dedication to rehab post-surgery here.

How is it possible to play football for multiple years without an ACL?

Playing through an ACL tear is possible in certain circumstances. Rodgers played high school, junior college and into his time at Cal with a torn ACL. Rivers played in the 2008 AFC Championship Game six days after arthroscopic surgery with a torn ACL.

The ACL is like an internal seat belt for the knee. Just like it is possible to drive a car with the seat belt broken, one can function without the ACL. However, when racing NASCAR, your seat belt better be working, just like your ACL is needed for the aggressive running/jumping/cutting of football. Without an ACL it is playing “Russian roulette” with your knee as there can be permanent cartilage damage if the knee gives out.. Rodgers was able to play through with a brace at lower levels of competition. Rightfully, his ACL surgery was done before exiting college and advancing to the NFL.

Is cadaver the best ACL graft like Rodgers recommends?

Certainly, the cadaver ACL worked for Rodgers. However, that would not be my (or most NFL physicians’) first recommendation. Fortunately, disease transmission risk with cadaver grafts is small. Even so, autograft (own tissue) patellar tendon with bone on each end is the most popular graft choice in the NFL. Bone-tendon-bone (BTB) graft is the strongest and most likely to succeed. Cadaver can work but has the higher re-tear rate over hamstring and BTB autografts. Using cadaver leads to less post-operative soreness and makes for a quicker recovery but may not be worth the significant (up to 30% per the ACL Study Group) re-tear rate. The cadaver failure rates are highest for younger and more active patients. Remember, missing a second consecutive season likely means the end of an athlete’s career.

Why is cadaver a potentially weaker graft choice?

All ACL grafts are scaffolds for one’s own tissue to grow into. Logic would tell you that your own tissue grows best into your own tissue versus someone else’s. A graft that does not incorporate and ligamentize is doomed to failure. There is no true rejection, as that is an immunologic response and cadaver patients don’t need to take special medications like organ transplant patients. Perhaps when technology arrives to tissue type and match to donor to recipient, cadaver failure rates will improve.

Can the ACL be stronger after surgery?

After one year of recovery, my patients are twice as likely to tear the other knee ACL versus re-tearing the reconstructed ACL. This is why I recommend bracing during the first year with early return to sport. The new ACL is not truly stronger, just lower re-tear risk. No, I would not recommend prophylactic ACL surgery.

Has ACL recovery gotten faster?

It sure seems that way. Rehab techniques have improved but there is no way to speed up biology. The media with Adrian Peterson’s nine-month return to rush for 2000 yards makes it seem like early return is something new but ACL recovery has been getting faster for over a decade. Shannon McMillian returned to play international soccer 102 days after her ACL surgery and at four months played in the 2003 Women’s World Cup for USA.

What is best thing to do for an ACL tear?

Pick a surgeon you trust and not the specific technique or graft choice. There are many ACL techniques (open, double incision, single incision, medial portal technique, all-inside) and many autograft (BTB, hamstring, quad tendon, contralateral) or allograft (BTB, Achilles, posterior tib) options. Let the chef tell you what he cooks well and the best meal to order. Let the surgeon tell you the procedure he is most comfortable with and what is best for you. Don’t make a surgeon who recommends cadaver harvest a hamstring graft. In other words, when you go to Morton’s get the steak. If you want fish, go to Oceanaire. Trust the recommendation or choose a different restaurant or surgeon.

Overall the joke is on us to take Rodgers comments so literally. It is very nice of Rodgers to thank and credit his ACL donor. At least this gave us a chance to discuss some of the fact and fiction about ACL surgery and recovery.

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Monday Morning MD: Giving out pain medicine “like candy”

Calvin Johnson created a stir with his in-depth interview this week. The recently retired Detroit Lions wide receiver spoke candidly about a wide range of topics. At one point the likely future hall of famer compared giving out pain meds to handing out candy.

The way Johnson’s interview was promoted, it seemed like the nine-year

Calvin Johnson created a stir with his in-depth interview this week. The recently retired Detroit Lions wide receiver spoke candidly about a wide range of topics. At one point the likely future hall of famer compared giving out pain meds to handing out candy.

The way Johnson’s interview was promoted, it seemed like the nine-year veteran was going to slam the NFL and the Lions medical staff. In reality, after watching the interview in its entirety, I don’t feel that is the case at all and agree with a majority of what Megatron said. Let’s analyze the top five highlight quotes.

“Team doctors and trainers were giving them (pain medications) out like candy.”

If Johnson was referring to the accessibility of pain medication, where players could obtain pain medication thru the team doctors, that is indeed true. NFL players do not have to go to the local retail pharmacy like the rest of the world. However, that hardly means that pain medication wasn’t controlled and medically indicated.

No formal prescriptions are written, because scripts are only needed if one is to the pharmacy. That doesn’t mean there wasn’t appropriate documentation and control. Doctors manually record each pill administered or dispensed. Team physicians chart or dictate every encounter to document medical examinations and use of medications. Players use to make fun of me for “talking to myself” into my dictaphone on game day.

Most people are not aware that each medication, narcotic or otherwise, is tracked. Teams have a mandatory quarterly drug audit where every pill is accounted for. When news of the painkiller lawsuits came out, several players jokingly asked me how come I never “hooked them up” and why pain pills were not more plentiful to them.

Johnson acknowledges that medication availability became more difficult in the later half of his career. Toradol for prophylactic use was discouraged and team doctors were no longer allowed to travel with any narcotic medication for road games. It was typical for a team athletic trainer to walk up and down an airplane aisle after a road game to pass out Advil or Tylenol, which can be considered painkillers.

“The team doctor, the team trainers, they work for the team”

This is certainly true. Keep in mind, team doctors only work for the NFL as a side job. They all have university or private practices and only a minor portion of their income is related to the team. To think that physicians would jeopardize their personal careers by knowingly mistreating players defies logic.

Johnson added “and I love ’em, you know”. “They’re some good people, you know. They want to see you do good.” I agree that a medical staff wants to return a player to the field and that goal is in alignment with players’ desires to stay in the line up.

“You can’t take Toradol and pain medicine every day”

I certainly agree with this statement. During my 17-year tenure as team physician, we never used medication on a daily basis or to get thru a practice. Toradol, a strong anti-inflammatory with pain relieving properties which is in the same category as Advil, was used sparingly. Ketorolac, the generic name, is typically limited to 20 doses over a five-day period. Players received no more than 20 doses across an entire season. Our club even performed a Toradol study that showed it was safe to be used this way and presented it at the NFL Physicians Society meetings.

On game days there may have been a line for Toradol, but players just didn’t jump into line. The use of medication was predetermined and consented. No one was forced or encouraged to take Toradol or pain pills to play. In fact, players were the ones asking for the medications. We rarely used Vicodin or other narcotics as we felt that might interfere with the mental aspects of football.

“Concussions happen”

There is no question that concussions are unavoidable in football. Johnson didn’t come out and blame the league for knowingly putting players at risk, but he described a culture that demands that players play. There is no question the culture has changed but it is far from perfect as the Case Keenum situations still occur.

Megatron missed only nine games in nine seasons and was listed on the injury reports for his ankle, knee, Achilles, shoulder, thumb, quadriceps, groin, thigh, hand, foot and back. Interestingly, Johnson was never listed for head injury, although he acknowledged he had his “fair share” of concussions. Note the second half of Johnson’s career was played with a spotter in the sky, sideline video injury review and independent neurotrauma specialists on the sideline.

“Catching the ball hurt”

I don’t doubt that Megatron played thru pain. He described getting his knee drained 12 times during one season. I have witnessed the everyday pain he spoke about.

There is no question that catching a pass with his deformed finger with a boutonniere injury would be painful. He waited until retirement to have surgery, as the long recovery would have cost him game time.

Fortunately, Johnson made over $100 million in his career, another few million wouldn’t change his life and he chose health. It does seem he had some gas left in the tank and there were other factors. He hinted at the Lions lack of winning. “If we would have been a contender, it would have been hard to let go. If the Lions could get out of their own way…”

Johnson has the most receiving yards and touchdowns for any player to never win a playoff game. His 2008 team was the only team ever to go 0-16.

For the most part, I agree with what Johnson said and I hope he makes the Hall of Fame. He harbored no grudges, made no accusations, nor pointed any fingers. There was honest dialogue from his point of view. This type of frank discussion from a players perspective only helps football and helps fans understand the game behind the scenes. Thanks for letting me share some of my reaction to his comments.

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Monday Morning MD: Ready or not?

With just under a month to go before training camp, much attention is paid to whether an injured player will be ready to go. Typically, this is the time of year for optimism. Players, coaches and management signal mostly confidence of good recoveries. Players are not going to doubt themselves and “coach speak” abounds.


With just under a month to go before training camp, much attention is paid to whether an injured player will be ready to go. Typically, this is the time of year for optimism. Players, coaches and management signal mostly confidence of good recoveries. Players are not going to doubt themselves and “coach speak” abounds.

Joe Flacco declared himself ready for training camp and his coach said he was “ahead of schedule” coming off his ACL tear. Tony Romo (clavicle, Mumford) has been full go at practice. Jordy Nelson (ACL) is reportedly raring to go. Jamaal Charles is on pace for another quick ACL comeback. Pete Carroll expects Jimmy Graham and Thomas Rawls to be ready. Arian Foster (Achilles) is purportedly ready for camp. Even top-five rookie pick Jalen Ramsey who had recent knee surgery says he is 100% for camp. Despite this optimism, often teams will start a player on PUP, if even for a day, to provide insurance for a set back.

When optimism is not rampant, it leads one to worry. The news has not been universally positive for Le’Veon Bell. First, he injured two ligaments (PCL and MCL) which makes recovery harder than if he had an isolated ACL tear. Bell hopes to be able to cut by training camp. He is not sure his knee is fine right now. It’s possible Bell will be just fine this coming season, but we are not hearing the usual early optimism.

Hopefully, Bell can overcome this lack of usual optimism. For now, the Steelers have not extended his rookie contract which expires later this year.

MMMD 1: Happy and safe Fourth of July

Last year’s Independence Day news was dominated by the injury to Jason Pierre-Paul. This year, JPP has a public service announcement cautioning fireworks safety. He shows the significant damage to his hand (CAUTION: Graphic picture attached to link) during the PSA. Unfortunately, most of the 10 things to know about JPP fireworks injury that I wrote last July came true. Fortunately, he is still playing football as expected.

Buccaneers cornerback C. J. Wilson also injured his hand with fireworks last year. He unfortunately retired from the NFL as a result of his injuries.

Hopefully, history will not repeat itself this July 4th.

MMMD 2: Players and guns

I don’t know what the statistics are for men average age 25 and gun violence but it just seems like three recent incidents seem like too many.

Aqib Talib was shot (or shot himself) in Dallas where details are still sketchy. Thankfully, he avoided major nerve, artery or structural injury. A Buccaneers rookie was shot up to three times. Ex-Colts Zurlon Tipton is tragically dead at age 26 from an accidental self-inflicted gunshot wound. He also had a December 2015 gun incident.

With gun control a national topic, I don’t know what the answer is. It just seems to me enough players are injured during football that these gun related injuries seem senseless.

MMMD 3: Players worth the pay?

This week there was plenty of discussion if players were worth the extravagant pay. The bottom line is that some owner was willing to pay it, so that is the value. After all, the value of an oceanfront home is what someone is willing to pay for it.

Before people hate on players for their high salaries, consider that top athletes make a fraction of what top Wall Street executives make. In addition, NFL salaries are not guaranteed for injury and corporate executives have much longer careers.

MMMD 4: Al Jazeera HGH investigation

Even though the main informant has recanted, the NFL plans to interview all players implicated by the report. I have no idea if Peyton Manning did or didn’t use HGH, but I do know that HGH would not have helped his nerve issues as some have claimed. If and when players are exonerated, I hope that generates the same publicity as the accusations have.

MMMD 5: “Billionaire A–hole”

Jake Plummer ripped the NFL’s marijuana stance and Jerry Jones for saying it was “absurd” to say there is a link between football and CTE. It may be ridiculous for Jones to say there is no CTE link, but it is also unproven for Plummer to say marijuana prevents brain damage. While it may be true that marijuana by-products may ease head injury symptoms, that is a long way from proof of preventing brain damage from concussions. Seems to me the owners and players need to listen to scientists and conduct more studies. Otherwise, it is just more concussion politics.

MMMD 6: New medical lawsuit

Just when we thought the health and safety litigation was finally ending with the concussion settlement and the dismissal of the painkiller lawsuit, now comes more litigation. The painkiller lawsuit has been reformatted into 32 individual cases against the team as opposed the league in general.

If this legal challenge goes to court, I am sure the teams will claim that they do not practice medicine and that pain medicine decisions were made by the medical staff. I find it interesting that no individual team physician has been named over this issue yet.

MMMD 7: ProFootballDoc scorecard

Last week I showed a picture of Jaylon Smith continued use of an ankle foor orthosis (AFO) and how that means his peroneal nerve really has not improved. Ed Werder has now confirmed that there was no significant improvement in the injured nerve so far. As I first indicated before the Combine, Smith is unlikely to play in 2016. The question is now becoming if he will make 2017. I hope he can beat the odds.

This makes the current 2016 record 10-0 from the previous 9-0.

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Monday Morning MD: Video is the history

Lesson number one in medical school is history is the most important part of a physical examination. Before touching the patient a detailed history is required. History for a traumatic injury is a description of the mechanism. What better description is there than actual video of the injury? Every day, I have at least one

Lesson number one in medical school is history is the most important part of a physical examination. Before touching the patient a detailed history is required. History for a traumatic injury is a description of the mechanism. What better description is there than actual video of the injury? Every day, I have at least one patient that shows me how they were hurt by showing me team, cellphone or GoPro video.

This is the basis of my video injury analysis which was honed with 17 years of Monday morning visits to the video department to reverse engineer injuries I saw and examined from the day before.

When I ran onto the field to tend to a player, my assistant physicians were trained to watch the video board for replays to see the mechanism of injury. Late in my career, sideline injury video was introduced for concussion but found to be more helpful for other injuries as it is difficult to judge head injuries by video.

The English Premiere League has now introduced video to the field. Liverpool medical staff now have the injured player on the pitch in front of them, yet still rely on video. This further validates my use of video to assess injuries. ipaddr

Of course, I would be more accurate examining a player than just looking at video. Although I am flattered by some who say I never miss, that is hardly the case. During the 2015 season, I publicly documented 94.3% accuracy. Ten times my video assessment was not accurate, but it was correct on 165 occasions. Some injuries had inadequate visual evidence and I could not opine at all.

When Jaylon Smith injured his knee on New Year’s Day, I tweeted my immediate worry about nerve injury. Later, video Smith posted of himself walking confirmed the peroneal nerve injury despite the player’s denials. In the offseason there is limited video so I rely on other methods of deduction. A recent photo had Smith still with an ankle foot orthosis (AFO), indicating his nerve is still not functional. ClfYaxdWYAAJWRM

I am not diagnosing players on twitter. If I had any role in treatment or access to X-rays or MRIs, I would not be able to comment due to HIPAA privacy laws. I deal in insider knowledge, not insider information. I know the vast majority of medical personnel in the NFL but I never contact them for information, nor would they violate player’s privacy and tell me.

When I am treating or have treated a player, I skip commenting specifically. For example, I did not comment on Drew Brees’ shoulder issue last year. On occasions when a team physician colleague discusses an injury with me, I no longer voice a public opinion. I also examined some players in preparation for the Combine and of course I did not comment on their collegiate injuries since I had the insider information. When I do speak about a player that I have treated, I have permission from the athlete or limit my discussion to publicly available knowledge.

There is no substitute for an examination, but there is growing use of video on the field to help with diagnosis. The use of video in injury assessments is here to stay.

MMMD 1: “Wide receiver” fracture revisited

With all the prominent pass catchers who have suffered a Jones fifth metatarsal fracture, I proposed to rename the injury. Bears WR Marquess Wilson re-broke his foot and was announced to likely start on PUP.

A second surgery is needed up to 20% of the time as has happened to Dez Bryant and Julian Edelman recently. Bryant has been recently cleared as his second procedure was in January. Edelman’s timeline is tight as his second screw insertion was reported in May. Sammy Watkins had April first-time surgery and may not be ready until the first game.

Remember, this fracture happens due to a “watershed area” in the bone where there is limited blood supply. This fact also makes healing more tricky.

MMMD 2: ACL mental hurdle

Anterior cruciate ligament reconstruction presents physical and mental hurdles. I wrote about this in my MMMD extra: ACL surgery series weekly during the 2014 offseason as I chronicled what the recovery for Von Miller and Rob Gronkowski might be like.

Joe Flacco’s admits his biggest remaining hurdle is mental. Until a player gets hit on the knee and momentarily thinks he re-tore the ACL, but gets up to realize his knee is ok, he will always have doubt.

Despite many early returns to sport, the mental hurdle to feel the knee is 100% as well as the biology of ACL graft incorporation makes the second year back the better year. The scary thought is that Todd Gurley should be even better this season.

MMMD 3: Doctors held to higher standard than lawyers

Johnny Manziel’s attorney mistakenly texted an AP reporter violating attorney/client privilege. If a medical professional breached doctor/patient confidentiality, there would be stiff potential penalties. Even if the medical information was leaked accidentally and inadvertently, there are HIPAA penalties up to 50k per single occurrence. Although just as damaging to Manziel, there are no such fines for a legal transgression of this type like there would be for medical leaks of information. In both cases the aggrieved party can take their own legal action, but only medical has built-in penalties.

MMMD 4: Offseason program over, injuries still coming

Players and coaches are essentially off for a month before training camp begins. The medical work continues as well as the injury announcements. This year just under half of teams lost a significant player to injury this offseason. Add Saints CB Kyle Wilson to the list who has been placed on Injured Reserve with a shoulder labral injury.

MMMD 5: Cautionary tale for stem cells

All stem cell treatment is not the same. Most stem cell treatments are illegal in the United States due to safety concerns. Unregulated stem cell treatments can have disastrous consequences including developing tumors in your body.

Only one’s own un-manipulated stem cells are legal in the US. Any other form is either not truly stem cells or is being performed illegally. There are some legitimate cutting edge clinics outside the US, but many more are dangerous shams than the real deal.

MMMD 6: Be true to yourself

One of the lucky things from my almost two decades in the NFL is to have met many great people and worked for many great coaches. What I learned is that one needs to be true to one’s self to be successful. I worked under hard line leaders and nice guy players’ coaches. Both styles work if you are real, as players will see thru any false pretenses.

Mike Riley was a genuinely nice guy and the players loved him for it. Riley recently made news when he met up with a rape victim who harbored hatred for the coach and instead became a “friend and ally” by genuinely caring.

Riley is just a really good human being. Being genuine and true to yourself is the key. Hip hip hooray! (Those who have played for Riley will know what I am referring to.)

MMMD 7: ProFootballDoc scorecard

When Calvin Johnson posted gruesome pictures of finger surgery, speculation arose of his potentially coming out of retirement. I wrote last week that having the procedure meant the absolute end of Megatron’s football career. Contrary to the thoughts, that type of finger surgery is only done when a player retires due to the long recovery. Johnson indeed has now emphatically confirmed that he is not coming back.

The previous 2016 record of 8-0 now increases to 9-0. I will continue to publicly keep track of right and wrong analysis this entire season.

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Monday Morning MD: Female firsts

There have been a series of female firsts in the NFL this past year. First a woman was named an official, then the first training camp coach, followed by full-time coach. Now a woman is head team physician for the first time.

Sarah Thomas was named the first female official last season and she performed

There have been a series of female firsts in the NFL this past year. First a woman was named an official, then the first training camp coach, followed by full-time coach. Now a woman is head team physician for the first time.

Sarah Thomas was named the first female official last season and she performed well. Jen Welter was hired by the Cardinals as the first female coach when Bruce Arians appointed her to coach inside linebackers during the preseason. The Bills then made history by hiring Kathryn Smith as the first female full-time coach as Rex Ryan made her a special teams quality control coach.

Now the Redskins have hired Dr. Robin West as the NFL’s first female head team physician. She certainly deserves the position as I know her as a top quality orthopedist from her time as an assistant team physician for the Steelers.

It comes as no surprise that women can do any of these NFL jobs. Amy Trask was the CEO of the Raiders for 16 years.  The Ravens have had Dr. Leigh Ann Curl as their lead orthopedist for over a decade. I know both to be well respected across the league circles.

To me, the hiring of Dr. West is really a non-story, as women have held prominent places in medicine forever. The bigger sign of changing times in the NFL is not that a female was named to be a head team physician but that there was a news conference to make the announcement.

Back when I was named head team physician, there wasn’t even an announcement despite being the youngest ever and younger than some players. Recently, it became common for teams to issue a press release to announce physician staff changes. A press conference is unprecedented and a sign of things to come with the increasing roles of team physicians. In my 17 years in the NFL, I am glad I never had to hold a press conference.

Times are a changing in many ways for the NFL. Congrats to all the female trailblazers.

MMMD 1: #1 priority of minicamp

I wrote a month ago how the main priority was to get out of the offseason healthy. Typically, 50% of teams lose a significant player by end of minicamp.

The Chargers ended minicamp practice early and even skipped the final day after and injury scare to Danny Woodhead. An ankle injury to the third down specialist in 2014 sent the previously playoff bound Bolts into a tailspin. Fortunately, injury was avoided, but the team also ended practice early.

This follows the trend where the Jaguars changed their practice regimen this year after losing their first-round pick Dante Fowler, Jr. to an ACL tear last offseason. Expect the offseason safety trend to continue next year.

MMMD 2: New “Injury” described

After almost two decades as a NFL team physician, I thought I had seen every injury imaginable. This week, I learned about a new “injury”.

The Bills held Karlos Williams out of minicamp practice because he was overweight. The Buffalo RB self-described it as an “injury of pregnancy” where he gained sympathetic weight with his expectant fiancée.

Just when I thought I had seen it all…

MMMD 3: Every club has a team dentist

The Redskins announced Josh Doctson missed practice to get a tooth pulled.  It is common to have dental issues and players get quick access.

Players get top medical care and that includes dentistry. Every team has a team dentist that will take part in physicals with a dental check station. Also players don’t wait weeks to get in to see the dentist. The appointments are usually streamlined by a call from the team athletic trainer and often planned to not miss practice time.

MMMD 4: Maurkice Pouncey had seven surgeries

When the Steelers center was first injured, I knew he would need surgery and his season was in jeopardy. What I didn’t know is that Pouncey’s ankle would become infected and that he would require seven surgeries and a skin graft.

Infections are nasty and can happen with any surgery as in this case when the wound does not heal properly. This revelation explains why Mike Tomlin was mum about Pouncey’s potential return during last season and why the Steelers wasted their only IR/dfr designation on Pouncey,

MMMD 5: Concussion politics continue

Two weeks ago, I wrote about the significant politics of concussions. This week, competing concussion researchers were at it again.

Boston University was to present its highest public health award to the primary subject of the Concussion movie. Instead the award was rescinded and the former honoree claimed there was a “vendetta”.

I don’t know who is right or wrong (or if both are wrong) in this situation, but this is another example of unbecoming behavior for researchers and universities. Certainly it would have been interesting to see the university of one competing concussion research group honor a hated competitor. However, once the honor was set to be bestowed, I am not sure what forces come to play to make a university change its mind. I also don’t know why the researcher would claim a “vendetta” against him. Last time I checked, it was a privilege, not a right, to receive an award.

The bottom line is that in science, researchers collaborate and share information. This is true unless you are talking about concussion researchers and that needs to change. It is about finding a solution and not claiming credit or assigning blame.

MMMD 6: 10 person practice squad renewed

Practice squads are traditionally fixed at eight players. Two years ago the NFL and NFLPA agreed to a two-year experiment to expand to 10. That has expired but word comes that new rule has been extended. This certainly makes sense as the NFL no longer has a developmental league with NFL Europe’s demise.

MMMD 7: Dolphins bullying scandal fallout

Almost three years later, three of the four major figures in “bullygate” are still out of the NFL. The target, Jonathan Martin, has retired from the NFL. The two fired Miami staffers have not found jobs in the league. The main accused bully, Richie Incognito, missed 2014 but has been with the Bills since 2015.

Offensive line coach Jim Turner has not found another NFL job and is with Texas A&M. Head athletic trainer Kevin O’Neil was made a scapegoat and despite being called “the best I ever worked with” by Jimmy Johnson, could not land another job until now. Only this week, O’Neil has found a job as athletic trainer at Florida International University.

Congrats and I hope he can put the false accusations behind him as there is always more to the story.

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Monday Morning MD: Lightning strikes again

Baltimore 2015 first-round draft pick Breshad Perriman never played a down in his rookie season. History is likely to repeat itself as the Ravens wide receiver may miss his sophomore campaign as well. Perriman reportedly “partially” tore his ACL in offseason workouts on Thursday.

Medically, partial ACL tears are rare. The knee is either

Baltimore 2015 first-round draft pick Breshad Perriman never played a down in his rookie season. History is likely to repeat itself as the Ravens wide receiver may miss his sophomore campaign as well. Perriman reportedly “partially” tore his ACL in offseason workouts on Thursday.

Medically, partial ACL tears are rare. The knee is either stable or it is not. The term “partial” is overused when it comes to describing ACL injury. The vast majority of time, a partial tear leads to the same ACL reconstruction surgery as a “complete” tear.

MRIs often properly call it a partial tear because typically the injury is not seen on all images but that doesn’t mean the ACL is not completely torn. Imagine if a rope frays and breaks, there are still normal looking portions of the rope but the rope no longer holds. In the same way, a MRI can show normal parts of an ACL, yet it is not in continuity. This is why I say a good orthopedic exam can be more accurate than imaging.

The other reason teams use the term “partial ACL” is to give hope until the diagnosis of full tear is confirmed by second opinion. This is the same reason why teams say “MRI pending” when the team typically knows before the MRI that the ACL is torn. The same optimism was applied last season when the team remained hopeful of a Perriman return after in-season PCL surgery and stem cells, where I was more realistic.

Perriman’s second opinion is coming today. I hope he beats the odds and it is found that his ACL is not completely torn. Apparently the wide receiver did finish practice after the non-contact injury before reporting with swelling the following day. This also favors an isolated tear without associated cartilage injury. His main chance is to hope the finding is a spurious MRI diagnosis and that his knee is stable. Unfortunately, I think that possibility is less than 5%, as in my 17 years as an NFL team physician I’ve never encountered a true partial ACL tear.

The likelihood is that Perriman will need formal ACL reconstruction which would mean missing his second straight season. Sometimes compensation plays a role but there is no direct indication that there is any relationship to his PCL injury on his other knee.

Raven’s fans can keep hope that last season Kiko Alonso returned to play for the Eagles with a partial ACL tear; however, he was largely ineffective. It would be great news and a big surprise if Perriman’s second season was not unfortunately over now.

MMMD 1: Offseason injuries piling up

I previously indicated that approximately half of NFL teams will suffer a significant/season-ending injury before OTAs and minicamps are done. Add three ACL tears to the list of teams already suffering injury. Besides Perriman, Saints pass-rusher Hau’oli Kikaha (3rd time) and Patriots TE Michael Williams both tore ACLs. We are shy of 50% of teams losing players (and I hope it stays that way) but with another week and many minicamps to go, it seems inevitable that history will repeat itself.

MMMD 2: Jamaal Charles ready for minicamp?

Reports surfaced that the Chiefs running back might participate in minicamp. When Charles tore his ACL eight months ago, I wrote how I expected a good comeback for 2016 despite his age. As well as he is doing, I sincerely doubt that Charles will be a minicamp participant.

Things may be progressing smoothly, but there needs to be full medical clearance before participation in any practice. This is not to say Charles won’t be doing drills on the side.

Charles made a great comeback last time from ACL surgery to have a career high 1500 yards rushing but was overshadowed by Adrian Peterson’s 2000 yards. He will be back for 2016, just not yet.

MMMD 3: Megatron not coming back

Calvin Johnson posted gruesome pictures of his finger surgery. Some speculated that perhaps fixing his finger which may have interfered with his ability to catch passes signaled a potential comeback.

I think it indicates just the opposite and that Johnson will remain retired. In my experience, such extensive surgery and long recovery for a boutonniere finger correction is only done at the end of one’s career. To me, having the finger surgery ends any speculation about thoughts of returning to play.

MMMD 4: Jalen Ramsey video

Many Jaguars fans were overjoyed to see their top-five pick running after knee surgery. The video indicates good progress but he is still a long way from returning. Just look at how he limps when slowing down and one can see he is not ready to cut or change directions yet. Ramsey will be ready for training camp, but he is not there yet.

MMMD 5: Oakland safety incidents

In this health and safety era, one major reason for the Raiders needing a new place to play is injury concerns. Oakland is the only NFL city remaining that shares the field with a Major League Baseball club. Early season home games are played on a partial dirt field and this leads to additional injures.

This weekend on SiriusXM NFL radio, I heard first-time host Brian Costello tell a story about Antonio Cromartie breaking ribs and having to be carted in a circuitous route outside the stadium through heckling fans to get to medical attention. I can corroborate that dangerous situation as it happened to me as I cared for NFL players as well. The locker room is up two flights of stairs from the field and the x-ray room is up an additional three flights of stairs and down a long corridor. Not to mention the locker rooms are so small that there is inadequate treatment areas where it forces players to be taped, examined and treated in the hallways and shower areas.

MMMD 6: Real Football Network

I am pleased to announce that I am joining Real Football Network. The number one SiriusXMNFL duo of Pat Kirwan and Jim Miller leads the effort to provide insider video and audio for the serious football fanatic or fantasy player. I will provide similar in-depth medical analysis as I have here, but in video and audio form.

MMMD 7: ProFootballDoc scorecard

I wrote last week that Broncos knew about Aqib Talib’s injury immediately, even while details of the shooting were sketchy. Although the Broncos CB was lucky the bullet avoided major nerves and arteries, there is still muscle damage and he will indeed miss the rest of the offseason program.

Will count this group of assessments into one correct tally for 2016. This improves the previous 7-0 record to 8-0.

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Monday Morning MD: Stop with the concussion politics

Everyone needs to stop taking sides and protecting their own interests. The NFL, team owners, Congress, NIH, concussion researchers, movie makers, medicine in general, players, coaches and media are all at fault here. Controversy was re-ignited and politics further injected recently when a congressional report criticized the NFL and their doctors. The goal should be

Everyone needs to stop taking sides and protecting their own interests. The NFL, team owners, Congress, NIH, concussion researchers, movie makers, medicine in general, players, coaches and media are all at fault here. Controversy was re-ignited and politics further injected recently when a congressional report criticized the NFL and their doctors. The goal should be to prevent concussions and find a cure for chronic traumatic encephalopathy (CTE), not playing politics of the blame/credit game.

The NFL is wrong to play politics and deny funding for a $16 million Boston University study that was selected on merit by the National Institute of Health (NIH). Obviously the league has not yet learned from its past mistakes and being slow to react to the concussion issue.

Team owners are wrong for continuing to shoot from the hip and deny links to CTE. Jerry Jones calls it “absurd” and Jim Irsay compares the risk of football to that of taking aspirin.

Congress is wrong for making it a Democratic committee issue. CTE is not a partisan disease. What impartiality does a report have that harshly criticizes and singles out a “NFL doctor” when it never attempted to reach out to or speak to that physician before publishing findings?

The National Institute of Health (NIH) is wrong to allow the NFL to call their $30 million grant unrestricted with “no strings attached”. In reality, the league retained “veto power”. The prestigious NIH should have never allowed itself to be manipulated that way or accept conditional monies.

Concussion researchers are wrong for taking sides by becoming paid experts in concussion litigation. The different camps are wrong in pressuring families to donate to one group over another and for not sharing the brain tissue to verify findings.

Movie makers are wrong for perpetuating the lies of the self-serving claims of one man that he discovered CTE. The reality is the degenerative brain disorder was first described in the 1920’s. I do applaud the awareness the Concussion movie brought to the issue but the truth would have done the same trick.

The medical community in general is wrong for being slow to provide definitive care for head injury. Diagnosis is inexact and there is no proven medication or treatment. There is even disagreement on cognitive rest versus controlled brain stimulation after concussion.

Players are wrong for not taking care of their own. In the much publicized Case Keenum incident, watching the film shows two of his offensive lineman clearly see their QB stagger and fall down as they try to help him up, yet neither directs him to the sideline or calls for medical attention.

Coaches are wrong for downplaying concussions as mild or blaming the media. The “back when I played” philosophy just doesn’t work.

Media is wrong for feeding the hysteria. Labeling members of the Head, Neck and Spine Committee as “NFL” doctors is an exaggeration. They should always point out most are tenured professors at prestigious universities that receive no pay from the league for their committee service. Also the media mantra of “a concussion is a concussion” is a disservice as medicine will indeed categorize severity and type one day.

We need answers, not politics or self-serving stances. Let’s all work to a concussion solution and not worry about who gets the blame or the credit.

MMMD 1: CTE happens outside of football

This is not a political item. This is stating fact about an issue that is very personal to me. BMX legend Dave Mirra died four months ago and has been independently diagnosed by multiple centers to have CTE, the first action sports athlete to have the confirmed diagnosis.

Clearly CTE is a societal problem that extends beyond football. It is an issue that affects me deeply as Dave is the fourth former professional athlete friend to have committed suicide. I attended and spoke at his celebration of life and hope to never have to do that again for anyone else.

MMMD 2: Aqib Talib shot

While details are still sketchy about the circumstances of the Dallas nightclub shooting, the medical information is clear that the Broncos cornerback will make a full recovery. The gunshot wound did not damage any major arteries (presumably no nerves) or ligaments. However, it was significant enough to warrant an overnight stay at the hospital but no surgery was required. Do not expect Talib to participate in minicamp or the rest of the offseason program, but he should be good to go for the start of training camp.

How do clubs get their medical information so quickly when it is not even known how he was shot? The team medical staff is usually asked to get involved early and speak to treating physicians. During my 17-year Charger career, I was asked to immediately intervene and obtain medical information on two shootings of players, Terrence Kiel and Steve Foley. This is just one of many circumstances where the team physician’s job is not what the public thinks it is.

MMMD 3: First round rookie injury ups and downs

Jalen Ramsey received double good news. His meniscus tear did not require a repair with longer recovery and was not related to his previous reported microfracture surgery.

Josh Doctson has an Achilles issue and minor foot injury and will be held out of practice for now. Hopefully this is all precautionary for the Redskins.

Technically, Dante Fowler, Jr. (ACL), Kevin White (tibial stress fracture) and Breshad Perriman (PCL) are not rookies but all three missed their inaugural season. These three first round “rookies” are all on track to make a strong 2016 debut.

MMMD 4: Offseason injury survival

All 32 teams have injuries already. In my experience, half of teams will have a significant loss that affects the season. This offseason is not proving to be any different.

Titans OL Byron Bell (ankle fracture/dislocation), Lions TE Tim Wright (ACL), Ravens CB Jumal Rolle (Achilles) and Jaguars DE Jonathon Woodward (Achilles) are among the few that are out for the season. Bengals TE Tyler Eifert (ankle), Bills DE Shaq Lawson (shoulder) and Cowboys DT Maliek Collins (fifth metatarsal) and among the many that have had surgery that could effect the upcoming season.

Despite the current CBA with limited offseason work, the injuries will continue to pile up this summer.

MMMD 5: Happy National Cancer Survivor Day

Certainly Eric Berry and his family celebrated the occasion this Sunday. The Chiefs safety beat Hodgkin’s lymphoma and has returned to play football.

Another less famous NFL player, David Quessenberry, has not been so lucky yet. The Texans offensive tackle has battled non-Hodgkin’s lymphoma since 2014. He was declared in remission last year and had regained the 30 pounds he lost. This week he was placed on the non-football injury list (NFI) and will not play this season. He missed the last two season to cancer and now will miss a third. If he returns, it would be unprecedented, as he will have missed four NFL seasons (first one due to ankle injury). The bigger hope is the NFI status doesn’t mean there is recurrence of cancer.

MMMD 6: Stolen laptop is a big deal

We are not talking team espionage here. This is not Spygate, but it is a much bigger deal. The theft of a Redskins athletic trainer’s laptop occurred during Combine medical rechecks. This surely meant that the medical records of over 300 potential draft picks were exposed. Also potentially at risk were previous Combine and team medical records as well as potentially thousands of NFL players as the league has moved to electronic medical records.

The good news is that there is no indication that any medical records were accessed. The bad news is the laptop was password protected but not encrypted as required by federal HIPAA law. The Redskins could face significant fines and punishment. There is also a requirement to notify all players whose records were potentially compromised.

I am sure the league has circulated a memo reminding all clubs that encryption is mandatory to avoid the risk of hefty federal fines.

MMMD 7: ProFootballDoc scorecard

When news of Jalen Ramsey’s meniscus tear broke, I surmised that the procedure would be a simple menisectomy (trimming) and not a repair that affects his coming season. This opinion was not based on video (as there was none), but simply my orthopedic and NFL team physician background of knowing common injury patterns. Fortunately for the Jaguars, the simpler arthroscopic surgery will have Ramsey back well before training camp. The better long-term news is the meniscus tear was in a different area of the knee than the previous high school surgery, meaning there shouldn’t be recurring problems.

This takes the previous 2016 6-0 record to 7-0.

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Monday Morning MD: When your examination room is the 50-yardline

I have faithfully written a weekly column (plus other features) without a break since October 14, 2013 when I started my post team physician media adventure. After a total of 153 thousand-plus word articles, I am taking my first break this Memorial Day weekend. Last week at the Marshall Faulk charity fundraiser, I ran into

I have faithfully written a weekly column (plus other features) without a break since October 14, 2013 when I started my post team physician media adventure. After a total of 153 thousand-plus word articles, I am taking my first break this Memorial Day weekend. Last week at the Marshall Faulk charity fundraiser, I ran into the author of this Physician Magazine piece written 15 years ago who has graciously allowed me to reprint it. The feature was unusual as the Chargers allowed unprecedented game day access in a time that was well before the first HBO Hard Knocks. I hope you enjoy it.

When Your Examination Room Is the 50-Yardline

Every professional sports franchise has them—team doctors. In this special Physician report, we follow an NFL team doctor on Game Day.

by Mike Yorkey

December 15, 2001: 12:07 p.m.

It’s two hours before kickoff against the Oakland Raiders, and San Diego Chargers’ All-Pro linebacker Junior Seau is all over Dr. David Chao.

“Hey, everybody, a reporter is here to do a story on Chao!” hollers out an animated Seau, who’s obviously enjoying seeing the tables turned for a change. “Doc’s going to be famous. C’mon and see this everybody!”

I’ve just arrived in Dr. Chao’s cubbyhole office, which adjoins the Charger training room and locker room underneath the west grandstands of Qualcomm Stadium. In this quiet, windowless environment, it’s difficult to believe that the Chargers and Raiders will square off in a noisy nationally televised game two hours from now.

Several half-dressed players—some of the biggest human beings I’ve ever seen up close—pop in their heads to see what the commotion is all about. Meanwhile, Junior continues to tease Dr. Chao. “This is what you gotta write,” he says. “You gotta tell everyone that he’s the best doctor in the whole wide world! You don’t have enough paper to print everything I’m going to tell you about him.”

I shoot a glance toward Dr. Chao, whose grinning smile is a mixture of pride and embarrassment. “Now, Junior . . .”

“Take a look at my fingers and hands,” says Junior, as he fans out his massive, battle-scarred extremities. I peer at his supersized fingers, which resemble long, gnarled tree branches. The digit and middle fingers on the left hand make several intriguing zigzags, but what’s especially interesting is the double-sized knuckle on the middle finger. How did that happen? Junior, however, wants to show off Dr. Chao’s handiwork on his right hand.

“See this scar?” he says, pointing to a nasty gash below the padded thumb area. “Chao was trying to write my initial, so gave me this S.”

Junior is right. I have never seen a set of simple interrupted sutures come out in the shape of an S, but that is how his brutish scar healed. “I got sewn up during a game, but it doesn’t matter,” says Junior, as he turns serious for the first time. “Chao is a good man. He’s done a lot for the kids in my foundation,” he says.

As a native San Diegan, I am well aware of Junior’s foundation and his remarkable story. The son of American Samoa immigrants, Junior grew up in nearby Oceanside, where he made good on the gridiron and starred at USC. He was a first-round pick of the Chargers in 1990, and when riches and glory came his way for becoming one of the best linebackers in NFL football, he formed the Seau Foundation, a non-profit charitable organization.

“How does Dr. Chao help?” I ask Junior.

“Let’s say a kid on the Oceanside High football team goes down with a serious knee injury and comes to us for help,” replies Junior. “The boy doesn’t have medical insurance. We cover the cost of the surgery bay and materials, which are given to us at cost, while Chao donates his surgical skills. I would say that Doc’s done ten kids for me,” says Junior. “He’s a good man.”

Dr. Chao is still smiling like a Cheshire cat.

12:45 p.m.

For the last ten minutes, I’ve been playing straight man to Dr. Jerry Hizon, a Charger team doctor who must have moonlighted at the Comedy Store during residency.

“You know where David went to high school?”

“No, I’m afraid not,” I reply.

“Think 90210.”

“You mean Beverly Hills High?”

“You got it. And did you know that David thought Harvard was too easy?”

“He went to Harvard?”

“Sure, but you probably want to write about David’s water polo days at Northwestern. He was All Big-10 while he was in med school.”

I look at Dr. Chao, and he’s rolling his eyes again. Now, I’m really confused, which causes Dr. Hizon and the rest of the doctors in the room to crack up. I feel like I’m part of a freshman hazing.

Welcome to the sports medicine world of NFL football, a fraternity that David Chao has belonged to since 1997, when he joined the Chargers. The 37-year doctor is affiliated with Oasis Sports Medical Group, the official team physicians for the Chargers. As the lead doctor, David is on-call 24/7 throughout the season, which lasts six to seven months. He also flies with the team on all road trips, which often start with a Friday morning flight to points east and doesn’t end until the team plane returns to San Diego on Sunday evening. During the week, David maintains his practice with Oasis, seeing patients, performing surgery (usually knee, shoulder, and hip repair) and making “house calls” at the Chargers’ practice facility near Qualcomm Stadium.

For today’s game against the Raiders, David is quarterbacking the medical coverage. Dr. Hizon, a family practitioner, and another Oasis doctor, Dr. Paul Murphy, an orthopedist, will assist him. This trio works all games, home and away. Dr. Bob Speer, a pediatric anesthesiologist, Dr. Calvin Wong, a family practitioner, and Dr. Stan Sherman, a trauma anesthesiologist, will handle back-up roles. Finally, an orthopedic fellow, Dr. Chris Pallia, is on hand to observe the action. With seven doctors on the field, you could say that the Chargers are ready for anything, but experience has been a stern teacher in the violent world of NFL football.

We are ninety minutes before game time. A dozen players drop by David’s office to have their sore joints and muscles checked—ankles, knees, hips, ribs and shoulders. Many are linemen and all are gargantuan: the typical size appears to 6-foot, 5-inches tall and 300 pounds. These players will be slamming their bodies in the trenches with devastating impacts. When an irresistible force meets an immovable object, something has to give, and it’s usually a joint, a bone or a ligament.

“The guys are big and the size is good, but I think what you have in the NFL is the last of the warriors,” says David. “Injuries are a big part of the game, however. Out of 53 guys on the team, I would say that I operate on 15 to 20 during and after the season, and I’ve operated on more than half the players on this team at one time or another.” No wonder why Dr. Hizon told me that the NFL stands for the Not For Long league. The players have incredibly short careers.

The talk turns to what Dr. Chao does during the game. “What’s it like running out on the field with a capacity crowd and all those people on TV watching you treat a player for an injury?” I ask.

“What I’ve found about sports medicine is that you have to keep a little perspective,” says David. “I’m here as a doctor and a physician, and my job is to see the players, and that’s it. The fans are here to see the players play, not the doctors. If I’m not noticed in a game, then I’m happy. In fact, I’m the only guy on Sunday that team owner Dean Spanos wants to do nothing. My goal is to stay out of the way and in the background.”

“But don’t you have to make quick judgment calls?” I ask.

“The easiest part about sports medicine is the medicine itself, if that’s where you keep your focus. I remember when I was working at the X Games in San Francisco. There was a doctor who was helping me, and we had a freestyle motocross rider go down with a lunate dislocation. I evaluated and treated him, and then I sent him off with another X Games doctor to the hospital with instructions to get X-rays and call me back with the results. About an hour later, I received a call on my cell phone from the other doctor, and he said, `It’s a non-displaced radial fracture. I’m going to put him in a cast and bring him back.’ ”

“I asked whether he was sure, and he said yes, but I asked him to bring me a copy of the X-rays when he returned. When I got a look at them, he said that it’s the only fracture, the radial head, but I immediately noticed that his lunate was dislocated. It’s a common error to make, but an error that I am 100 percent sure that he would not have made if he was back in his own office. With everything else going on at the X Games, his focus was off, which was a reminder to me to take care of the medicine first.”

2:07 p.m.

We run out onto the field with the Charger players, and the wall-to-wall noise of the capacity crowd creates intense energy. Everywhere I look, everyone has his game face on. We are minutes away from kickoff against the first-place Raiders, the evil-dreaded Silver and Black who have been the Chargers’ bitterest rivals for forty years. This late-season matchup has drawn the third-largest home crowd in franchise history—67,349—and filled Qualcomm Stadium to the brim. Unfortunately for the Chargers, two-thirds of the fans appear to wearing black Raider jerseys.

David stands amongst the coaches and players on the Charger sideline. As soon as the opening kicking sails through the air, he doesn’t take his eye off the action. He must concentrate on the players because a career-ending—or life-threatening—injury is just a snap of the ball away. It’s also not a good idea to direct your gaze away from the action if you value keeping your body in one piece.

“I’ve covered high school, junior college and college football, but NFL games are different,” says David. “At the high school level, if there is a pitch coming toward me, I will wait until the players are right on top before stepping back. In the college game, I start to think about moving when I see a sweep coming my way. But NFL `game speed’ is so fast that if quarterback Doug Flutie even looks my way, I’m backing up because they are coming hard. As you see on TV, the players will fly 10, 12 yards out of bounds sometimes. They are on top of you in a split-second because their speed and quickness are so unbelievable.”

2:25 p.m.

Injured player!

The game is only a few minutes old when the Chargers’ rookie cornerback Davis Sanchez is slumped on the grass, writhing in pain. David and team trainers James Collins and Scott Trulock sprint out to midfield, where they take several minutes tending to the young player. After they gingerly assist him to his feet, Sanchez nearly collapses from back spasms. They half-carry him to an examination table behind the bench for a further look, but Sanchez is grimacing with each step. He looks done for the day.

Before the game, David told me that decisions about whether an injured player can return to the game are made as a team. James Collins, as the head trainer, is the first to make an evaluation. If it’s an orthopedic question—a tender back, an injured knee, or a deranged shoulder—then Dr. Chao takes the lead. If it’s a possible concussion or something internal, then Dr. Hizon is the go-to guy.

Earlier in the season, quarterback Doug Flutie was knocked silly in a game against the Kansas City Chiefs. Dr. Hizon proceeded to ask him several standard memory questions:

  • “What’s the date?”
  • “Who are we playing?”
  • “What’s the score?”
  • “Who did we play last week?”

When Flutie didn’t have the answers, he was through.

“Football players are proud,” said David. “They do not like to be carried off the field. If they can get up, then they will walk off as best as they can. I’ve had players with dislocated shoulders, with ACL tears, even with ankle fractures, refuse to be carried off the field. Then there are some players you just can’t keep from playing. I’ve seen James Collins carry their helmets so they couldn’t go back in.

“The best story I can tell you happened in Oakland. Late in the first half, Junior Seau hurt his leg, and when I ran out onto the field, I was worried about a fractured tibia. He continued to limp and play, but during halftime, we accompanied him to a special room and took some X-rays. Afterward, I told him to wait until we could determine whether there was a fracture. We didn’t want him to hurt himself anymore.

“The X-ray developer took forever, but when I finally got a look, I could see that his tibia was negative. I ran as fast as I could to the field to tell Junior that he was okay to play, but just as I arrived, I heard the public address announcer say, `TACKLE MADE BY JUNIOR SEAU.’ That pretty much sums up Junior and all the players—they will play with pain.”

3:20 p.m.

Already, David has made four “field visits” as the first half winds down toward the two-minute warning. No major injuries; just the usual bang-ups.

Suddenly, Carl Robbins, a 70-year-old member of the chain crew, collapses like a sackful of football helmets and hits the ground with a thud. At first blush, it doesn’t look good.

Dr. Chao is first on the scene since the older man toppled within a few yards of him. Heart attack? Stroke? Dr. Chao works to clear the breathing passage and stabilize him as EMTs rush to the scene. Technically speaking, Carl Robbins is not David’s medical responsibility since the chain gang member is working for the NFL, but those technicalities are naturally brushed aside as moments like this.

An EMT places an oxygen mask on the man while they wait for a sled to arrive. Play cannot resume, however, since the chain-crew member collapsed just a few yards from the sideline. It will take 20 minutes before Robbins can be driven off in a cart and taken to nearby Kaiser Medical Center. (Later, it was learned that Robbins passed out in reaction to some blood pressure medicine he had taken. “I’ve gotten calls from Florida and Philadelphia, people who thought I was dead,” he said, adding that he was grateful for the quick medical attention.)

4:59 p.m.

We’re deep into the second half, and for the eighth time, David runs out onto the field to help an injured player. Normally, David is out on the field two or three times, but today’s game seems to be an exception. One injury looks career threatening: Charger receiver Curtis Conway’s legs twisted around like a pretzel while trying to make a catch. Instead of a fibular fracture or torn ACL, however, Conway was able to shake off the pain and even return to the game.

5:12 p.m.

Drats! The Chargers have just lost another tight game in the last minute, 13-6. Dr. Chao runs to the middle of the field for his post-game handshake with his Oakland counterparts—the Raider team doctors. Then we hustle off the field and into the locker room with the disappointed players.

Dr. Chao beckons me to follow him. Charger team chaplain Shawn Mitchell is about to lead the team in its post-game prayer. David bends one knee, bows his head, and places his hand on the shoulder of a Charger player; I do the same with Dr. Chao.

“Thank you, Lord, for Your protection today, and we ask that you help any weary and injured players on our team and on the Raiders,” says the Charger chaplain. “Please heal anyone that’s hurt, and we give You all the glory, amen.”

Dr. Chao and several doctors return to their cubbyhole office, where they will be available for the next 90 minutes or so. Sometimes after a game, it takes the players some time for the adrenaline to wear off—and that’s when the body starts sending signals to the brain that something hurts.

When that happens, they need to see a doctor who understands what they’ve been through. Fortunately for the players, they will be evaluated by an all-star team of sports medicine physicians led by Dr. Chao.


Up Close and Personal

Dr. David Chao

Age: 37

Marital status: single

Education background: After graduating from Beverly Hills High with honors, David attended Harvard University, where he majored in psychobiology. He then attended the Northwestern University School of Medicine (where he was a standout water polo player), served his residency at Northwestern Memorial Hospital in Chicago, and a fellowship with the Minnesota Vikings, Timberwolves and Twins.

Current team physician duties with: San Diego Chargers, Point Loma Nazarene University, United States International University, X Games (Winter and Summer), and various San Diego high schools.

Notables: He is considered a worldwide expert in hip replacement surgical techniques.


What Are You Doing Friday Night—or Monday Afternoon?

Dr. David Chao says that you don’t have to work in the NFL to work the sidelines. In fact, there are probably high schools in your hometown that could use your expertise during the game and afterward in the surgical bay.

In addition to taking care of the Chargers’ medical needs, Dr. Chao says doctors around the country can make it a ministry to help injured high school players without insurance or the ability to pay. “I just started my own foundation to help high school players in San Diego who need surgical care,” said Dr. Chao, who added that he probably does 20 plus free operations on injured high school football players during the year.

“A foundation can pay for the hard costs—the screws, the equipment, and hospital—so all the professional costs are free,” said David.

If you would like more information on setting up a foundation in your hometown, contact San Diego Sports Medicine Foundtation.

I hope the readers enjoyed this guest column with a small peak behind the curtain. Thanks to the author, Mike Yorkey, for allowing me to re-publish it.

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Monday Morning MD: Two consecutive top-5 overall picks injured

The Jacksonville Jaguars now have the dubious distinction of having two consecutive top-5 overall picks injured early in the offseason program. Last year, Dante Fowler, Jr. tore his ACL in the first rookie minicamp practice. Now Jalen Ramsey has suffered a “small” meniscus tear.

Last week I wrote how half of teams will

The Jacksonville Jaguars now have the dubious distinction of having two consecutive top-5 overall picks injured early in the offseason program. Last year, Dante Fowler, Jr. tore his ACL in the first rookie minicamp practice. Now Jalen Ramsey has suffered a “small” meniscus tear.

Last week I wrote how half of teams will suffer a significant injury program. With Ramsey for the Jaguars, Shaq Lawson (shoulder) with Bills and Jumal Rolle (Achilles) of the Ravens, that makes three of the potential 16 teams already.

The size of Ramsey’s meniscus tear is not the biggest factor for a quick return. The type of tear and location (peripheral vs inner rim) determines the type of arthroscopic surgery needed: menisectomy (trimming) versus meniscus repair (sewing). A typical return from menisectomy is 4-6 weeks. A meniscus repair would mean 4-6 months out.

Statistically, there is over a 90% chance that Ramsey’s tear will not be amenable to repair, thus dictating the trimming surgery with quicker recovery. Interestingly, a previous poll of NFL players showed they would overwhelmingly choose the menisectomy (earlier return) over a repair (less long term arthritis, longer recovery) even if their tear was a candidate for repair.

Myles Jack’s knee situation with the osteochondral lesion is much different. He was another top-5 talent that fell to the Jaguars early in round 2 due to reports of needing future microfracture surgery. Jacksonville fans are understandably worried, but the two situations bear little resemblance medically.

Concern for Ramsey’s knee in Jacksonville is high as it came to light that he had a microfracture surgery as a Sophomore in high school. A report surfaced that Jaguars may contradict that he ever had that procedure. Even if Ramsey did have microfracture surgery, at age of 15, the results are much better.

I was not aware of Ramsey’s microfracture history, but I assure you the Jaguars medical staff knew the facts. For almost two decades I was in the same Combine medical room as Jacksonville and have worked with their current head athletic trainer. Yes, draftees conveniently “fib or forget” about their injury history, but team doctors know this and factor that in. Even without the operative report of the high school surgery, with portal scars on his knee, likely a MRI was obtained that would show any previous microfracture surgery. With Fowler and now Ramsey, the consecutive year injuries appear to be bad luck, not something missed by the Jaguars medical staff.

The Jacksonville GM, now knows his team doctor very well given the three knee issues of Fowler, Jack and Ramsey. If all three work out, the Jaguars could have a formidable defense and make the biggest improvement of any team in 2016. If the three knee issues do not perform well, the GM could be looking for another job.

MMMD 1: Shaq Lawson needs shoulder surgery after all

Before the draft, I indicated that the team that drafted Lawson would either do surgery immediately or hope to get through the first season with a shoulder harness and then have surgery in the offseason. Despite the player’s previous denials of any need for surgery, a labral repair surgery was performed this week. Unfortunately, the procedure means Lawson will start the year on PUP and undoubtedly miss Week 1. If rehab is smooth, Lawson could return 4-6 months after surgery, which means he could miss half of his rookie campaign.

This is not to say the Buffalo made a bad draft pick. There is no doubt the Bills medical staff was aware of the issue and the Lawson first-round selection was a calculated risk. The good news is that once healed, there should be no long-term issues.

Lawson played three years with a shoulder brace. It is not unusual that as a player steps up to a higher level of competition, injuries they could play with before, now get unmasked. Reports say Lawson re-injured the shoulder doing a bag drill. Even though it was likely that he was not wearing brace when the shoulder re-dislocated, the Bills are making the right decision to get their prized rookie fixed now.

MMMD 2: Wide receiver fracture

The Jones 5th metatarsal fracture should be renamed the WR fracture. Sammy Watkins joined a long list of recent WRs to have a screw placed in his foot. Julian Edelman, Dez Bryant, Julio Jones and DeVante Parker all had a second screw in the same foot. Others to undergo surgery for Jones fracture include Hakeeem Nicks, Michael Crabtree, Marvin Jones, Demaryius Thomas and Quinton Patton.

Other positions get the injury too: 49ers RB Carlos Hyde and teammate S Jimmy Ward among others. However, fifth metatarsal fractures are more common in wide receivers than any other position group due to the hard cuts they have to make. No one knows who Sir Robert Jones, the namesake for the Jones fracture is anymore. I propose we just call this injury a “wide receiver” fracture.

MMMD 3: Another reason for Laremy Tunsil draft tumble?

A report surfaced that Tunsil’s draft day fall may not have been exclusively related to the gas mask video. A “pre-arthritic” ankle may have contributed to the slide. Don’t forget that Tunsil had an ankle fracture/dislocation in the bowl game at the end of his junior season, but returned to play well. This injury could indeed lead to future arthritis but that typically takes decades.

College teammate Laquon Treadwell had a similar injury and was a fellow first-round pick. Then again, Darren Sproles had a similar injury and surgery early in his NFL career and is beginning his 10th season since that ankle injury.

MMMD 4: Cardinals with confidence in Tyrann Mathieu

Teams are usually hesitant about a defensive back coming off an ACL tear (see Darrelle Revis and the Jets 2012). Arizona has no such fears and is rumored to be extending the contract of the “honey badger”.

It typically takes longer for a DB to be fully effective after ACL surgery due to the demands to react to the offensive players moves. However, Mathieu already showed he could recover from a potentially career threatening ACL/LCL injury in 2013. This ACL recovery is easy compared to the last one.

MMMD 5: James Harrison’s suspicions about NFL drug test unfounded

The often-fined Steelers linebacker wondered why he wasn’t allowed to film his recent drug test. This was not a case of Harrison being singled out but it is against league policy for anyone to record the testing procedures.

Recording a test would make it easier to study the process and circumvent future testing. In a recent Olympics cheating scandal, Russia was accused of substituting clean urine samples in look-a-like bottles. Filming what the bottles look like might help in this counterfeiting process.

The NFL is often accused of acting suspiciously (see Deflategate), but this does not seem to be the case here.

MMMD 6: Crazy stories

We have gotten numb to off field stories from Aaron Hernandez to Johnny Manziel. Add two more unbelievable stories that involve two players I know, respect and wish the best for. Erik Kramer survived a suicide attempt where he shot himself in the head. Reche Caldwell landed in jail after casually ordering drugs over the internet.

There are many positive stories about former players, we just don’t hear about them as often. This weekend was the Marshall Faulk Celebrity Championship that has raised hundreds of thousands of dollars for charity. What is unique is that Faulk primarily raises money not for his own charity, but for the Junior Seau Foundation. After the 2012 death, the NFL MVP of 2000 voluntarily stepped up to take the lead to continue to raise money in Junior’s absence. Faulk just wants to pay Seau back for his encouragement when the young running back starred at San Diego State.

I would rather hear more about these great charitable acts from players than hear more crazy stories about former players.

MMMD 7: ProFootballDoc Scorecard

The 2016 record was 5-0 even though injury predictions/assessments are sparse this time of year.

Prior to the draft, I indicated Shaq Lawson would need shoulder surgery, which he denied even after the draft. With his recent labral repair, that increases this seasons total to 6-0.

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Monday Morning MD: #1 priority of minicamps

‘Tis the season for rookie and team minicamps. The intent is to indoctrinate rookies, provide a primer on new terminology and get an early talent evaluation. However, teams have an underlying more important goal.

Everyone’s main objective is to finish minicamps injury free. In my 17 years as a NFL team physician, it seemed that

‘Tis the season for rookie and team minicamps. The intent is to indoctrinate rookies, provide a primer on new terminology and get an early talent evaluation. However, teams have an underlying more important goal.

Everyone’s main objective is to finish minicamps injury free. In my 17 years as a NFL team physician, it seemed that every other year my team suffered a significant season altering injury to one of our main contributors. Lead pass rusher Melvin Ingram tore his ACL in the 2013 Chargers mini-camp. Last season, Jaguars #3 overall pick Dante Fowler Jr. ruptured his ACL on the first day of minicamp and missed his entire rookie season. The Broncos suffered the same fate last year with tight end Jeff Heuerman.

Clubs have a focus on trying to stay healthy. After last year’s loss, Jacksonville has made it a bigger priority to stay injury free and have changed their rookie minicamp.

Statistically, over 50% of teams will have a season-ending injury during offseason activities. Last week, Ravens cornerback Jumal Rolle tore his Achilles tendon and will miss 2016.

The most common offseason injuries are muscles strains including the hamstring, groin, quad and calf, which usually recover in plenty of time. ACL and Achilles tears are the feared ones that will lead to a loss of the upcoming season. These injuries are commonly high-speed non-contact injuries. Thus, even with limited contact practices, the new CBA has not resulted in lower numbers of these injuries. Achilles have become the new ACL with increased numbers and both are dreaded season-enders.

The main priority has become staying healthy while accomplishing offseason goals.

MMMD 1: Julian Edelman with a second foot surgery

Early reports called the procedure minor and that he would be back for training camp. Edelman had revision surgery where a screw was reinserted into the same left fifth metatarsal bone. Also called a Jones fracture, this is a problem fracture due to its poor blood supply. Returning to play early increases the chance of needing a second procedure, which often is accompanied by bone graft.

Needing a second surgery for a Jones fracture is not unusual and does not indicate mismanagement by the surgeon or Patriots medical staff. When hurrying back to play, this happens up to 20% of the time. Recent examples of needing redo surgery include Dez Bryant, Julio Jones and the NBA’s Kevin Durant.

Healing after revision surgery typically takes 3-4 months. It is possible that Edelman will be ready for the start of training camp but is it more likely he begins on PUP and targets a return before the first real game. If the Patriots are unlucky, it is possible they could play early season meaningful games without Tom Brady and their #1 wide receiver.

MMMD 2: Dez Bryant recovery from second Jones fracture surgery

The Cowboys wide receiver returned six weeks from his initial fifth metatarsal screw placement but never really excelled, posting a maximum of five catches in a game and totaling three touchdowns in 2015. After revision surgery, he is reported to be recovering well and on target to participate in some of OTAs and the June minicamp.

The key here is Bryant had his 2nd foot surgery in January and “isn’t fully cleared yet”.  If Julian Edelman follows this timetable, his May surgery will have him back in October. The take home message is to be careful with fifth metatarsal fractures.

MMMD 3: Melvin Gordon microfracture surgery

When the word “microfracture” is used, many jump to the conclusion that a player is doomed. I agree with Chargers GM Tom Telesco. Not all microfracture surgery is the same and the key is the size and location of the lost articular cartilage.

I have not treated Gordon and do not know the circumstances of his surgery, but given the optimistic return guideline of 4-6 months and the reports of his workout progress, the running back should be on course for a much better 2016 than rookie year. The team knows the details of the January surgery, yet they did not draft a running back or add one in free agency. That likely speaks loudly to the Chargers’ confidence in their starting running back’s rebound for a strong year.

MMMD 4: BFR and Le’Veon Bell

The Steelers RB is among the latest new believers of blood flow restriction (BFR) training. I have written about this new game-changing rehabilitation technique.

The question is will BFR be enough to get Bell back for next season. The Steelers have set no timeline. In general, MCL/PCL surgery is harder to recover from than an isolated ACL tear. Simply put, recovering from two torn ligaments is harder than returning from one. There is no guarantee that Bell will be 100% or even ready to play Week 1, but if he is, BFR will share in the credit for his return.

MMMD 5: Ricardo Lockette didn’t have a choice

Big news of the week was the Seahawks WR/ST retiring from football. Congrats to Lockette on his decision to walk away healthy.

The reality is that the injury and subsequent surgery caused him to lose significant rotation in his neck motion. A spine fusion from C1-C4 leaves him with well under 50% of his ability to turn his head to the right and left. It would be unprecedented to return to football from a three-level fusion.

Lockette made the right choice to retire, but the medical reality is that he didn’t really have a choice.

MMMD 6: Kudos to NFL player engagement

I personally know of dozens of players who have taken advantage of programs. From broadcast boot camp, finance workshops to coaching or scouting internships, there are many programs aimed at giving former players direction. I am not saying the NFL is perfect in all aspects related to former players but I see an honest effort to help players with life after football careers.

MMMD 7: ProFootballDoc scorecard

In the offseason, I have not updated the running 2016 scorecard each week as activity is sparse. I will still keep tabs this season and see if it is possible to continue the slight improvement from 92.6% in 2014 to the 94.3% in 2015.

In early March, the Byron Maxwell and Kiko Alonso trade to the Dolphins was rumored to be off due to Maxwell’s physical, which noted sternoclavicular (SC) joint problems. I tweeted at the time it was likely the deal would still go through and it did. Despite worry about Tony Romo’s offseason surgery to decrease the chance of recurrent clavicle fracture, I correctly indicated that the Dallas QB would be fine and indeed he is already cleared and throwing 100%. Prior to Jaylon Smith’s Combine medical evaluation, he was universally thought to be a top pick. Seeing video posted by the player, I concluded nerve issues and indicated that unfortunately he would fall out of the first-round.  I even got lucky and predicted the Cowboys would draft him. Myles Jack is able to play football today, but an OCD lesion would drop him out of being a top 10 pick.

Adding these four correct assessments to the 1-0 2016 record leaves us with a 5-0 start for this coming season.

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Monday Morning MD: Youth movement in pro sports

The NFL has always valued youth, and with the current CBA it really seems like any player approaching 30 becomes expendable. Fueled by analytics, the youth movement has reached coaches and management across all sports leagues.

This week, the NHL’s Arizona Coyotes hired a 26 year-old analytics expert as their general manager. Examining the current

The NFL has always valued youth, and with the current CBA it really seems like any player approaching 30 becomes expendable. Fueled by analytics, the youth movement has reached coaches and management across all sports leagues.

This week, the NHL’s Arizona Coyotes hired a 26 year-old analytics expert as their general manager. Examining the current roster, the new GM is younger than over half of his players.

In MLB, Theo Epstein was 28 when the Red Sox hired him. His success may have encouraged other owners and leagues to hire young Ivy League brainiacs. The Browns have gone that route with young Harvard educated executives Sashi Brown and Paul DePodesta who then in turn hired 28 year-old fellow Crimson Andrew Berry for the top personnel job.

The NFL has long embraced the youth movement. Howie Roseman was 36 when he became the Eagles GM. The Bears Ryan Pace was 37. At 31, Lane Kiffin was the youngest NFL head coach. Bill Cowher and Mike Tomlin were both only 34 years old when they each started their long Steelers tenures.

I am not against this youth movement. In fact, I was part of it. There is no official record keeping of age for medical personnel, but I was likely the youngest head NFL team physician ever. Being 32 when I first started as a team doc, the first 8 years I was younger than at least one active player on the roster. William Fuller was older and when he retired, we acquired Jim Harbaugh who was three months older. When Jim moved on, I thought my streak was over; however, Doug Flutie joined the roster and he was two years older.

There was nothing significant about being younger than a player except it made me feel more part of a peer group all trying to achieve the goal of a championship. I related and cared personally about the guys off the field, which made it easy to do the best thing possible for them to keep them healthy and on the field.

The last nine years of my 17-year NFL tenure, players were all considerably younger than me but many felt like my little brothers. This camaraderie made it easy to spend time on the road and enjoy going the extra mile to help out my teammates.

The youth movement eventually caught up to me too. When my GM and head coach became younger than me, it was a sign of how the times have changed. I will always feel lucky to have been in a position to have these special friendships that extended beyond the traditional doctor/patient relationships.

It meant a lot to me when players accepted me into the special fraternity made possible by age. My biggest compliment was when Philip Rivers called me a teammate saying I “wasn’t a doctor that also happened to be a team doctor. He was a Charger all the way. He’ll be missed.”

Time marches on. Many say the NFL stands for “not for long” and that has never been more truthful. The only seemingly constant is the owners.

MMMD 1: Unprecedented suspension reversal

The NFL has long enforced the policy that a player is responsible for what is found in his own body, no matter what. The league seems to have shown some compassion when Duane Brown proved his positive test was related to eating meat in Mexico.

Brown’s Texans teammate once claimed “over trained athlete” syndrome for his positive test, but Roger Goodell did not buy that excuse. The league has never accepted tainted supplement arguments either. In an unusual but positive step, the NFL overturned Brown’s suspension. As a result, warnings about eating too much meat in Mexico and China was issued to players by the league. My guess is this will be a one-time exception to the hardline policy of being responsible for what is in your body regardless of the circumstances.

MMMD 2: Will Jaylon Smith play?

Owner/GM Jerry Jones said Smith will not start the season on injured reserve (IR) for 2016. Some interpreted that as optimism for the knee and nerve recovery. In reality it is just wordplay as Smith undoubtedly will start the 2016 season on the non-football injury (NFI) list. NFI refers to any injury not happening in a NFL season, so collegiate injuries qualify.

The Cowboys were in a unique position to draft Smith as the GM is the owner and the trusted team physician (and Smith’s surgeon) has enough political capital with the team where his job will not depend on his being right about nerve recovery. The Patriots were reported to covet Smith late in the 2nd round but I would be surprised if that were the case. Certainly Bill Belichick doesn’t worry about answering to the owner; however, New England has a new team physician this season. I find it hard to believe that any new doctor would put his job on the line to clear a player with a nerve injury with unpredictable recovery.

Smith has a multi-ligament knee injury plus a nerve issue. Ifo Ekpre-Olamu was a projected early pick last year and fell to the seventh round after dislocating his knee. The Browns released him without playing a down and he is now with the Dolphins. Marcus Lattimore had two years of rehab with the 49ers but retired without ever being activated. Navarro Bowman had an ACL/MCL injury, missed an entire season and returned to play last year, but his knee is far from normal. Willis Magahee did return after his severe injury to have a productive career.

Not all of these severe knee injuries are similar. The point is a multi-ligament injury without nerve issues already is career threatening. Adding nerve recovery makes it even more daunting. Here is hoping Smith beats the odds to make it back. With some luck and lots of hard work, he could be a quality player, but it would be unprecedented to have 100% recovery and reach all of his pre-injury potential.

MMMD 3: Medical analytics

Much has been written about Myles Jack. Some argue he needlessly dropped. Other say his knee is a time bomb. I think he was drafted in the expected spot. Jack can play football today but the question is for how long.

The general manager makes the final decision but he relies on his team physician’s input. Many thought the Packers should have selected Jack with the 27th pick. An inside look at how draft decisions are made show why he wasn’t. Analytics may be new to the NFL, but medical analytics is exactly what team physicians have been doing at draft time for decades.

MMMD 4: Sports science seems to work for soccer

Coincidence or cause and effect? Leicester City has been transformed from bottom feeder to Premier League champions. They certainly aren’t the only European team that embraces sports science but they are among the leaders in integrating its use.

Chip Kelly, now with the 49ers, aggressively brought sports science to the Eagles with modest success. Other teams have adopted some new age medicine techniques. I don’t think just sports science is solely responsible for Leicester City’s championship, but it certainly was a factor as they were among the leaders is lowest injuries. The question now is how might this translate to football.

MMMD 5: Cold weather games cause more injuries?

In my 17 years in the NFL, I often noted that wet or snowy games made for poor footing and made for less traumatic injuries. Now a study comes out that claims cold weather leads to more concussions and ankle injuries.

Although I applaud the authors for their work, calling a warm weather game 70 degrees Fahrenheit and marking a cold weather game at 50 degrees Fahrenheit, may skew the data. 50 is probably the average temperature of an NFL game. The increased injuries seen might simply correlate with games played later in the season as the weather happens to be colder. Much more research needs to be done and this is a good start.

MMMD 6: BFR at NFL course

Last week the NFL had its bi-annual course with the American Orthopedic Society for Sports Medicine. I have been fortunate enough to be invited to lecture several times as team physicians present the latest breakthroughs to other sports medicine practitioners. Being asked to speak at this meeting is an honor and means the topic is being endorsed by NFL physicians.

The latest on blood flow restriction (BFR) was presented. This is another indication that this new rehab and workout technique is reaching the mainstream. KAATSU is the world-wide leader in BFR and I have meet with the inventor in Japan over five years ago. As I predicted, BFR is catching on as shown by its inclusion in the NFL course. Over half of pro teams now incorporate BFR techniques.

MMMD 7: Genetics matter

The QB lineage of the Mannings is well documented. Both Peyton and Eli have successfully followed in father Archie’s footsteps. There are plenty of other famous football families.

Three recent examples involve the city of San Diego. Third overall pick Joey Bosa’s dad played in the NFL. Fullback Derek Watt was drafted and will face brother J.J. Watt this season. Ian Seau was signed by the Rams and will always face comparisons to his Hall of Fame uncle Junior Seau.

I hope all of these legacy players can make their own names in the NFL.

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Monday Morning MD: 2016 NFL draft dominated by medical

Medical always plays some role in the NFL draft; however, the 2016 version would have a completely different look without two “red light” knee issues on two top players. If linebackers Jaylon Smith and Myles Jack were healthy, they would have been selected at the beginning of the first round, instead both fell out of

Medical always plays some role in the NFL draft; however, the 2016 version would have a completely different look without two “red light” knee issues on two top players. If linebackers Jaylon Smith and Myles Jack were healthy, they would have been selected at the beginning of the first round, instead both fell out of the first day into the top of the second and the “dominos” fell differently as a result.

The Cowboys gambled on Jaylon Smith out of Notre Dame who has been described as a generational linebacker. If he fully recovers from the multi-ligament knee injury and his peroneal nerve wakes up, he could be the steal of the draft. On the other hand, if he becomes the next Marcus Lattimore and doesn’t play a down, Dallas fans will surely lament the pick.

It is hard not to root for Smith, who has done everything right, except have a bad luck horrific knee injury during the Fiesta Bowl game. He couldn’t have found a better landing spot as the Cowboys team doctor performed his surgery and he will be reunited with his older brother who is a running back on the team.

Smith is still using an ankle foot orthosis (AFO) due to his persistent foot drop. It would be unprecedented to have someone play his career with an AFO, much less make a Pro Bowl while wearing one. His surgeon has shown great optimism for a full nerve recovery going against others who were more pessimistic. The Cowboys exhibited a lot of faith in their team physician by selecting Smith so high.

His doctor knows best if the nerve will wake up, but no one knows for sure as nerve recovery is unpredictable. Even if the nerve recovers, the chance is small that it will return to 100% function. Without the nerve issue, an ACL, PCL and posterolateral corner injury is still career threatening. With the nerve issue, the odds are stacked against Smith.

It takes three things to recover from any major injury. First, the injury has to be amenable to recovery. Second, one needs good surgery. Third the player needs to be motivated and have good rehabilitation. I compare it to needing a good snap, hold and kick to make any field goal. Smith certainly had good surgery as his doctor is tops. No one can question his work ethic in rehab. The remaining issue of the nerve is really out of Smith’s or his surgeon’s hands.

Smith remains optimistic saying he “absolutely” could play in 2016, but there is no guarantee he will ever play at all, much less perform to his potential. The best hold and kick may not be able to overcome a bad snap.

Myles Jack is the other top linebacker with medical issues and his situation is the opposite of Smith. Jack is healthy and able to play today, but the question is for how long? The Jaguars were rumored to be interested in selecting Jack with their number one pick and overall 5th selection. With the medical issues, they nabbed him at the top of round two.

Jack reportedly has an osteochondral defect (osteochondritis dissecans – OCD) lesion involving his knee articular cartilage and the underlying bone. This is essentially a separate issue from his meniscus tear and is likely congenital. The irony is the OCD may never have been discovered by teams absent the meniscus issue. There would have been no reason to X-ray or MRI the knee if there was no knee injury history.

No one knows how long Jack will play. If, or some say when, the OCD lesion breaks off, microfracture type surgery with up to a one year recovery is needed. Regrowing articular cartilage is the “holy grail” of orthopedics as typically the new cartilage is not as strong as the original.

If healthy, these two linebackers would be the stars of this draft. Jaylon Smith is the proverbial “start up company” with huge potential that may never get off the ground, Myles Jack is the “newspaper” that is popular today but needs to retool to the internet age to stay relevant. Best of luck to both.

Here are some more draft medical observations:

MMMD 1: No false medical info leaked

There was suspicion that teams were leaking false information to drive down the values of Jaylon Smith and Myles Jack. Many teams leak false information about their interest in a player, but I have never seen a team tell lies about a player’s medicals. It just would be unethical. As it turns out, both of these players have real knee issues.

MMMD 2: Jaguars defense to add three top-five players

Dante Fowler, last year’s first round pick, tore his ACL at the first mini-camp and missed the season. Myles Jack is a first round talent who dropped to the second due to medical issues discussed above. No one questions the top-five talent of Jalen Ramsey.

Fowler, Jack and Ramsey could turn Jacksonville’s defense into a force. When is the last time a team added three top-five level players at one time?

MMMD 3: Shaq Lawson still says no surgery

Despite my analysis, and a report from Adam Schefter that surgery is needed, Lawson still denies it. No one is panning the pick or saying he can’t play this year, but he will need a brace.

In the end, the Bills are likely to recommend labral repair surgery after this season to give more time for recovery. If Lawson plays well with his shoulder brace, stabilizing the shoulder should make him an even better player as the harness keeps the shoulder in the socket but limits his range of motion.

MMMD 4: Raiders top two picks with medical questions

First pick Karl Joseph is coming off ACL surgery. Second pick Jihad Ward is said to need a knee scope.

Joseph appears to be recovering well from October ligament reconstruction but don’t be surprised if he is not activated with the start of training camp. He will contribute this season but may not be in full form until the middle of the season.

Ward has denied the need for surgery but his potential knee surgery should not prove to be a big deal. Anticipated recovery should not be more than four to six weeks and look for that to happen after mini-camp breaks.

MMMD 5: Top 2 picks overcame throwing side injury

An injury to anywhere on the throwing upper extremity of a quarterback is a cause for concern. This year the first and second overall picks beat their injuries.

Jared Goff had shoulder surgery on his AC joint after his freshman year and has done well since. Carson Wentz missed the second half of last season with a scaphoid fracture. Both should be healthy. In the end, this is football. Players will get injured. What type of injury determines if there are any potential future problems. No issues with that on these two top picks.

MMMD 6: 49ers follow recent tradition

In the Trent Baalke era, there has been a penchant to get value by drafting players coming off ACL injuries. This year was no exception when the 49ers selected cornerback Will Redmond who tore his ACL in October. That makes a seventh player since 2013, which is essentially a normal full draft class.

MMMD 7: End of the magnet era.

There is no official count, but the day of draft magnets is ending. The small custom player magnets loaded with info were ubiquitous in war rooms for decades. Now most teams are in a hybrid system or switched entirely to an all-electronic draft board.


The picture was from Mike Silver’s 2014 war room visit with the then St. Louis Rams. Images shared from this year’s Los Angeles Rams show a much different 100% electronic video board system. Things do change in the NFL

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Top 2016 NFL Draft Medical Issues

As draft day approaches, there is a plethora of information and mock drafts which are all affected by medical grades. I will take this opportunity to analyze the top medical issues for the 2016 draft. It is widely acknowledged that medical evaluations are an important factor in the decision making process.

All team physicians

As draft day approaches, there is a plethora of information and mock drafts which are all affected by medical grades. I will take this opportunity to analyze the top medical issues for the 2016 draft. It is widely acknowledged that medical evaluations are an important factor in the decision making process.

All team physicians won’t agree on a player’s medical grade, just like scouts won’t necessarily agree on a player’s talent. Even though each team acts independently, a consensus on medical grade is typically reached. It is not uncommon for team medical staffs to trade information and consult with each other.

Below are my top medical issues for a few key NFL draftees. Using the format of last year’s top NFL draft medical issues column, the assessments are categorized into red, yellow and green light ratings. This is for simplicity as teams certainly utilize more sophisticated grading systems.

I have not examined any of the following players or seen their medical records. If I had, I would not be allowed to comment based on federal privacy laws (HIPAA). For these evaluations, I utilize public reports combined with my knowledge as a practicing orthopedic surgeon/sports medicine specialist, my almost two decades of experience as a head team physician and my insight from having attended 19 NFL Scouting Combines. Injured players also now commonly post video of workouts and I take that information into consideration as well. Like a traffic light, the ratings are subject to change as more facts become known with a physical examination.

RED Light issues:

Indicates a serious medical issue that should cause a team to stop and reassess. These players aren’t undraftable, but their draft position will likely be affected by the evaluation of team doctors. When a player is red flagged, it doesn’t mean he can’t play football. It just means there is an issue to cause a team to stop and pause. Usually a “red M” goes on the players draft board magnet as a reminder.  A general manager will have a long discussion with his medical staff prior to a final decision. They may need surgery, be recovering from surgery or have significant longevity issues. One or more teams will likely have taken these players off their draft boards due to medical risk while others will be willing to take a risk based on need or value.

Jaylon Smith, LB Notre Dame:

This is the tragedy of this draft. I worried about nerve injury as soon as I saw the unfortunate New Year’s Day injury. When I later saw video of Smith wearing the ankle foot orthosis (AFO) that indicated a peroneal nerve palsy existed, I predicted a “medical redshirt” year for 2016 and a tumble from top pick to a Day 3 late round flyer before his Combine medical exam. His injury is much more than an ACL tear. It also includes his lateral collateral ligament (LCL) and the posterolateral corner (PLC), which is confirmed for the first time by recent comments from his surgeon indicating “all the structures on the lateral side of his knee” were damaged. Even without the foot drop issue, this is a daunting recovery. To my knowledge, no NFL linebacker has ever played wearing an AFO. Is Smith talented enough to beat the odds and do so? Maybe, but that doesn’t mean he would still be the “generational” linebacker that he was projected to be. While it is possible the nerve could wake up, it would be beating the odds to think there would be 100% recovery. Smith has longer odds than Marcus Lattimore (not reported to have a nerve issue) who retired after two years of rehabilitation with the 49ers and never played a down. I give Smith a lot of credit for working hard and having a great attitude. The workout videos, while impressive, still show the affects of the foot drop on the left side. The use of the bungee cord dampens explosiveness and helps hide the nerve palsy, but it is still evident. I hope I am wrong and Smith beats the odds to return. He has an excellent surgeon who is optimistic of a full recovery. His doctor also happens to be the Cowboys head team physician. We will see if this gives Dallas enough confidence to select Smith before Day Three.

Myles Jack, LB University of California Los Angeles:

The worry here is not the meniscus but the articular cartilage. Putting together various reports, Jack has an osteochondral defect (osteochondritis dissecans-OCD) which involves a lack of blood to the underlying bone, thus putting the overlying cartilage at risk. This condition is congenital and not directly related to the meniscus issue. There is no question that Jack can play NFL football today. How long his knee will hold up is the question. If this piece breaks off, there is no simple surgical fix as there is a divot left in the bone surface. Results depend on the size and location of the OCD lesion. Ultimately, re-growing articular cartilage is the ‘holy grail” of orthopedics. All 32 NFL head team physicians will form their own opinions but any OCD lesion has to worry a team. Just like all scouts don’t universally agree on player evaluations, doctors each will have their own take on medical risk. Unlike Jaylon Smith, Myles Jack will still be drafted high but his knee will affect his draft stock.

Brad Sylve, CB Alabama:

Torn Achilles the day before his Pro Day and had repair surgery. Despite great speed, he still might not have been drafted pre-injury. However, now he is definitely a free agent. Sylve is unlikely to be ready for training camp, which is where he would get his reps to make a squad. He likely will have the equivalent of a medical redshirt year and try to catch on next season.

YELLOW Light issues:

Indicates a significant medical issue that needs to be taken into account. As the color indicates, a general manger needs to slow down and factor in his team’s medical assessment. As a reminder, typically a “yellow M” is placed on the players draft magnet. If two players are rated the same, it might be less risky to select the non-yellow light player.

Shaq Lawson, DE Clemson:

Was called back to medical rechecks for a shoulder issue. Lawson finally acknowledged his shoulder injury by saying it is now finally ready by sending video to all 32 teams this weekend. He claims he hurt it his freshman season where it “popped out”. Lawson played three years with a brace and claims there is no issue with it. When a shoulder dislocates and requires reduction, there is a very high chance of a labral tear. It is something he can play with in a brace. The NFL team that drafts him may have him undergo immediate surgery or choose to have him play with a brace and have surgery next offseason. I don’t believe this will completely deter suitors from drafting him but it does warrant a closer look and may affect his draft position.

Devontae Booker, RB Utah:

Suffered a torn meniscus and bone bruise. Booker said he was 70% at his Pro Day. The concern is the bone bruise as it would be unusual for the meniscus to still bother him at four plus months from surgery. Teams will have to take a closer look at the bone contusion issue before making a final decision on Booker.

Karl Joseph, Safety West Virginia:

Tore his ACL in October 2015. Seems on track for a good recovery but likely will not be ready to practice day one of training camp. Joseph may not return to full form until the middle of this coming season. Teams will have to consider his rehab progress before selecting him.

Laquon Treadwell, WR Ole Miss:

Fractured fibula and dislocated right ankle in 2014. The injuries are all healed now and he played well in 2015. Treadwell ran a somewhat slow 4.63 in the 40-yard dash which opened up questions on the ankle. It could be because he is a big physical receiver but teams will want to make sure it is not due to sequela of the ankle fracture/dislocation causing the loss of speed where perhaps there is early ankle degenerative changes.

GREEN Light issues:

Indicates a definite medical issue, but one that has healed or should have minimal long term effect. These player injuries have been evaluated by the medical staff and are a “go” as the color indicates. These players have known injuries that shouldn’t scare away a general manager.

Carson Wentz, QB North Dakota State University:

Missed second half of season with a right throwing wrist injury. By reports of the surrounding circumstances and his post-operative cast, he appears to have had a scaphoid fracture. Because it is his throwing hand, teams will have cause to take a good look. Scaphoid fractures can be problem fractures, but when diagnosed and treated quickly, they usually heal well. Assuming x-rays show the bone is healed, there should be little risk here.

Jared Goff, QB California:

Had right shoulder surgery after his freshman year. As a likely #1 pick and franchise QB, any throwing shoulder issue is always a potential concern. Goff played three more years after the surgery. The procedure was to fix a separated (not dislocated) shoulder. Technically, the procedure was to his AC joint and not his ball and socket true shoulder joint so there should be no worries here.

Scooby Wright, LB Arizona:

Had lateral meniscus tear and was scoped at the beginning of season and returned to play within a month. Subsequently suffered a foot sprain. His injury issues should be minimal at this point.

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Monday Morning MD: Biggest deal for schedule release is the bye week

Why is the schedule release even a big deal? After all, opponents and home/away locations are already known. Much is made of strength of schedule but only two games are variable based on position of finish. Six within division, four vs rotated AFC division and four vs rotated NFC division are fixed for years to

Why is the schedule release even a big deal? After all, opponents and home/away locations are already known. Much is made of strength of schedule but only two games are variable based on position of finish. Six within division, four vs rotated AFC division and four vs rotated NFC division are fixed for years to come. Just two in-conference opponents in another division with same place finish are variable. Besides divisional rivals, the Cowboys have long known they were playing the NFC North and the AFC North in 2016. Only their 4th place division finish has them matched with 4th place 49ers and Buccaneers.

Despite already knowing opponents, everyone eagerly looks at the NFL schedule as soon as it is released. Fans get excited, circle big matchups, note night games and perhaps schedule a road trip. Media pundits start picking wins and losses and prognosticate season records.

Schedule release is also a big deal for everyone employed by the NFL. What do medical staffs and those who work for clubs look at?

General managers, coaches, staffers, players and wives all look for different things, but the common thread is that everyone, including doctors, looks for the bye week. In the regularity of the NFL, any schedule alteration is looked at first.

Chargers GM Tom Telesco said the bye week “is the only thing I look at right away”.  It is the extra week to work with when it comes to pre-existing or new injuries.

As a former NFL team physician, I would agree. The bye is the first thing I looked at. Not because it was my only free weekend during the season, but it was important to know when the bye is to use the off week to your advantage. Often we might ask a player who needed an in-season procedure to hold on until the bye week to have surgery in order to not miss any games. It also provides the extra week to rest/rehab injuries.

A team never wants its bye week too early or too late. In 1999, my team essentially did not have a bye as it was the first week of the season. Currently, the bye weeks are between weeks 4-13. The Packers and Eagles have to feel their Week 4 bye is too early for their liking. They finish with 13 straight games without a break.

The next thing team doctors look at is how the schedule affects their medical practice. Friday departures, weekday games, and late returns impact patient schedules. Yes, team physicians have “day jobs” and the travel affects them. Contrary to popular belief, no NFL doctor solely works for the club. In fact, typically less than 5% of their income is derived from the team. The weekday disruption is a major factor. A Thursday night game meant I had to clear my Thursday afternoon to be at the stadium at least three hours before the game and then move my Friday morning surgeries to be available for the routine day after game player injury check. A Sunday night game makes for a very late return home and could wipe out the Monday workday.

Head coaches make their team’s daily schedules and they too look for aberrations to the regularity of the NFL. Bye week, Monday/Thursday games, Sunday night games, London and coast to coast travel with late night/early morning returns all disrupt the routine that is the NFL. When a team plays Monday, the Friday practice is called a Thursday schedule. West coast teams have to decide on when to make it a three-day road trip and depart on Friday. East coast teams have to deal with getting home at 4am from a routine Sunday day game on the west coast. For example, the Patriots are known for staying on the west coast for the week if they have back-to-back cross-country travel.

Players peek at the bye week to see when they can get home to visit family. However, in their “one game at a time world” the opener is the first thing that comes to mind. Then perhaps they peek at contests with special meaning: primetime, rivalry, hometown return, former club, etc.

The wives look at the bye week as well but then go straight to the holiday schedule. Is daddy home for Christmas? How will the family adapt Thanksgiving plans?

Equipment guys look forward to seeing the bye week as they work with expanded rosters throughout training camp and the bye is their first and only break. Their attention then turns to which games will be in cold weather as they make their special preparations.

The bye week is the common thread that everyone looks at when the schedule is released. Team medical personnel is no exception.

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Monday Morning MD: Game changing rehab/workout technique

Athletes have long searched for a shortcut to success. Blood flow restriction (BFR) training may be that answer. Yesterday, ESPN featured BFR training on Outside the Lines and how it is catching on in professional leagues.

BFR training involves light workouts with tourniquet bands to control blood flow to the extremities. It can be overly

Athletes have long searched for a shortcut to success. Blood flow restriction (BFR) training may be that answer. Yesterday, ESPN featured BFR training on Outside the Lines and how it is catching on in professional leagues.

BFR training involves light workouts with tourniquet bands to control blood flow to the extremities. It can be overly simplistically described as a convenient way to altitude train in a lower oxygen state, but that would be short-changing the muscle hypertrophy and potential systemic benefits.

Modifying circulation to the extremities allows the body to use up the oxygen carried in blood. This creates an environment where light activity can reproduce the gains of heavier workouts. BFR is the recent American term that is catching on. The Japanese were the first to popularize it decades ago. BFR

I first learned of and reviewed this cutting-edge technology over 10 years ago in the form of KAATSU training. While traveling to Tokyo with the USA Rugby Sevens team five years ago, I sought out Dr. Sato and spent a day with the inventor of this specific form of BFR training. He refers to it as blood flow modification (as opposed to restriction). This blood pooling technique has been popular in Japan for over two decades.

Decreased blood flow equals less oxygen available to limb muscles allowing light resistance exercises to equal that of heavier workouts. There is local effect of lactic acid buildup but there is a claimed systemic effect as well.

Where BFR training has taken off is in the rehabilitation world. In the United States, its roots began with use in the military in treating severe limb injuries. Among the first NFL users was Jadeveon Clowney as he “looked spectacular” in his recovery from 2014 microfracture knee surgery. ESPN injury analyst Stephania Bell has been a proponent of BFR training and reported that 20 NFL teams were now using the technique. It has been presented at the NFL Physicians Society meetings during the Combines.

I have believed in this technique for years and currently am using it on three USA Rugby players as they recover from surgery (2 ACL tears and a tibia fracture) and hope to make the short timeline of the Rio Olympics this August. Athletes lose muscle girth when not able to workout in the post-operative period. BFR training allows one to keep muscle mass and fitness when you are limited in workout abilities.

Muscle gain at lower loads has many implications beyond making middle-aged Americans looking for a workout shortcut happy. If one can put less stress on the body to maintain fitness, that potentially leads to career longevity for a professional athlete. It may even lead to reduced late season injury and breakdown from cumulative stress. An NFL player with articular cartilage wear essentially has limited “tread on his tires”. Imagine if he could workout at lower loads and still stay in shape while not “burning more rubber”.

The potential systemic benefits of BFR type training is even more exciting. In theory, BFR training also stimulates the pituitary gland to produce natural and legal human growth hormone (HGH). In addition, this type of HGH is more effective than the synthetically produced kinds. Also VO2 max (oxygen usage or a measure of aerobic fitness) is said to be improved with even light bike riding.

Safety is a natural concern when limiting blood flow. However, BFR training has been proven over time to have few complications. KAATSU, the most vetted type of BFR training, has shown an excellent safety profile over more than two decades. When used with proper medical supervision or training, there has not been reports of nerve or vascular injury. After all, in surgery, we routinely will use tourniquet for up to two hours, whereas this total training here is targeted for under 30 minutes.

BFR training/rehab makes intuitive sense. Athletes feel the burn with light exercise and early results are encouraging. With more and more NFL, MBA and MLB teams jumping aboard, this type of training has definite potential to be revolutionary. Who wouldn’t be excited to train at lower loads with less stress and get the same benefit?

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Monday Morning MD: How 2016 NFL rules changes will affect safety

At the recent NFL owners meetings, a total of 10 new rules were announced for the 2016 season. The league often touts its health and safety improvements. Four of the new rules were enacted with player welfare in mind; however, did the league go far enough?

Four rules changes for safety

  1. All chop

At the recent NFL owners meetings, a total of 10 new rules were announced for the 2016 season. The league often touts its health and safety improvements. Four of the new rules were enacted with player welfare in mind; however, did the league go far enough?

Four rules changes for safety

  1. All chop blocks are now illegal

In my opinion this is long overdue rule change helps prevent ankle and knee injuries. The old rulebook with some chop blocks being legal was confusing. In addition, whether a player is engaged or not, diving at a player’s planted leg increases the chance of high ankle sprain/fracture, medial collateral ligament (MCL) knee injury and sometimes even anterior cruciate ligament (ACL) tear. As a team physician in 2002, I witnessed Jamal Williams suffer a season ending ankle fracture from a legal chop block and felt that play should have been outlawed for over a decade. Many defenders and coaches have complained about it as well. Thankfully, all forms of the chop block have now been eliminated.

  1. Horse collar tackle expanded to include the area “at the nameplate and above

This is another good rule, but does it go far enough? Horse collar tackles from behind were outlawed over 10 years ago due to the propensity to cause eversion ankle fractures and other knee/leg injuries when a runner is folded back onto his leg. This rule expands the definition of “collar” to the nameplate area and jersey up high. However, tackling by a player’s long hair that often covers the nameplate and collar is still legal. Hair is considered part of the body. Pulling a player to the ground from behind by his dreads is still legal, but that maneuver is just as dangerous as a true horse collar or tackling by grasping the nameplate area. I understand that some will say the player should cut his hair, but my point is that dangerous type of tackle from behind is still legal.

  1. Retroactively designate IR player as “designated to return”

I think this is another great rule change that may not go far enough. A team no longer needs to designate a player for return off injured reserve (IR) with the initial roster move. The club can move players to IR as before and then wait to see which player recovers quickly enough or perhaps becomes more valuable to the team to return. The same eight weeks absence is required as before, but this solves several issues. Teams have sometimes used the old IR/dfr designation on a player that subsequently has a setback in recovery and the player never makes it back. Other times, clubs wish they had saved the spot or used the spot as their roster situation changes as the season progresses. This way all IR players can stay “alive”. Only one can practice as early as six weeks and return to play in eight. This rule is still limited to a one-time use and perhaps the NFL should think about adding more short term IR slots since players are getting paid anyways and many want to return.

  1. Moving the touchback on kickoffs to the 25-yard line

The theory behind the rule is to entice more touchbacks and thus decrease collisions on kickoff returns. In reality, this may have the opposite effect. Strategically, kickers may now add elevation to the kickoff and attempt to pin a returner into a corner of the playing field forcing a return. The unintended consequence may be that we see more kick returns. Thankfully, this is just a one-year trial and the league will re-evaluate before it becomes permanent.

The other six rule changes were adopted outside of a safety focus. Players are now ejected for a second unsportsmanlike conduct penalty, the extra point conversion is permanently at the 15, offensive/defensive play callers can use headsets form the field or the booth, no more 5-yard penalty for illegal touching when out of bounds (just loss of down) and multiple spots of enforcement for double fouls after change of possession are eliminated.

The final rule change adds a delay of game penalty for calling a timeout when not allowed. The rule is fine but I feel the NFL should never penalize a team for a medical timeout. If a doctor or athletic trainer feels there is a chance their player has a head injury, they should be allowed to go onto the field and stop play without waiting for the referee or “eye-in-the-sky”. When someone is acting for safety, there should be no risk to being penalized or being charged a timeout. If this rule were in place, the Case Keenum situation with the Rams last year might have been avoided.

The league is making an earnest effort to make the game safer. Perhaps it would be even better if the NFL would add a medical person to the competition committee where the vast majority of the rules change proposals come from. Another option is to start a separate player welfare rules committee that would be specifically charged with coming up with new safety rules. This group would be made up of mostly medical personnel. Since almost half the rule changes have to do with health and safety issues, why not involve medical personnel. This new medical rules committee might have been more expeditious in suggesting to outlaw all chop blocks, adding hair as part of the dangerous horse collar tackle or coming up with the next good player safety rule.

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.

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Monday Morning MD: The NFL should “Let it go”

I never thought I would relate the theme of the children’s movie "Frozen" to sports. Then again, Disney does own ESPN.

“Let it go” should be the mantra for the NFL as it should stop trying to defend its defunct Mild Traumatic Brain Injury (MTBI) committee. The media and concussion critics should also “let it

I never thought I would relate the theme of the children’s movie “Frozen” to sports. Then again, Disney does own ESPN.

“Let it go” should be the mantra for the NFL as it should stop trying to defend its defunct Mild Traumatic Brain Injury (MTBI) committee. The media and concussion critics should also “let it go” and stop looking backwards to critique the league’s decade plus old research.

We all know the NFL attitudes toward concussion are historically far from idea. The league has essentially admitted the errors of the MTBI committee by disbanding the group years ago. There is a new Head, Neck and Spine committee in its place. The new committee is no longer run by the NFL’s often criticized medical advisor. It was a bad look to have a rheumatologist who is a league employee head the MTBI group and the league has seen the error of its ways. The chair of the MTBI committee being the lead author on head injury studies invited criticism based on qualifications and conflicts of interest.

Even thought the MTBI papers have already been discredited, the recent New York Times article rightfully points out specific study errors. Publishing data with one team not reporting any concussions for six years clearly makes no sense. Add that during that time period, the team’s star QB Troy Aikman was publicly reported to have four concussions and was thought to retire because of head injuries makes the research look even worse.

I have participated in NFL research as a team physician. Yes, it is hard sometimes to get busy team doctors to respond to questionnaires and surveys. However, this was a study performed on behalf of the league. The NFL has required all head team physicians and athletic trainers attend certain concussion symposiums in person and there are frequent directives for conference calls. It would have been simple to mandate that all teams carefully report concussions for the MTBI studies.


Lead Author on the field tending to Wayne Chrebet after concussion

Undoubtedly, there is recollection bias and it is difficult for a team physician to remember every concussion across a six-year span. However, the authors should have at least gotten their own team’s head injury data correct. Not reporting at least two concussions on the team for which the lead author worked seems inexcusable. Jets receiver Wayne Cherbet’s career ultimately ended over head injuries, yet his two concussions during the research period were not listed in the study by the authors which included Chrebet’s team physician.

The MTBI committee said it analyzed all concussions diagnosed by team medical staffs during 1996-2001. All players were said to be included as well as all concussions, no matter how minor. That clearly was not the case as at least 100 additional concussions were identified by cross-referencing public reports. It is embarrassing that the NFL’s own injury reports were used to contradict and prove the underreporting in the NFL studies.

The research was at best sloppy or at worst fraudulent. One member of the MTBI committee indicated he was unaware of the omissions but agreed: “If somebody made a human error or somebody assumed the data was absolutely correct and didn’t question it, well, we screwed up. If we found it wasn’t accurate and still used it, that’s not a screw-up; that’s a lie.”

The NFL looks silly when trying to defend the research of the long ago disbanded MTBI committee when one of the authors has called the omissions a mistake. The excuse that the research was “necessarily preliminary” rings hollow. The paper is based on data up to 20 years old, the scientific community doesn’t put much stock into it and it is pointless to defend it.

The NFL justifying the shoddy research perpetuates the criticism of its attitudes towards head injury. However, linking the NFL to big tobacco seems quite a stretch. Yes, some attorneys and lobbyists overlapped the two industries, but that hardly warrants the headlines of “ties to tobacco industry”. More accurately, the NFL had ties to some people who in turn had ties to the tobacco industry. If the New York Times is going to hold the NFL researchers to the highest scrutiny, the paper should do the same for its headline writers. The league official statement on the concussion research correctly refutes the ties.

Media and critics should move on. We all know the NFL mishandled and underestimated concussions. Overall, the medical community has been slow to point out concussion dangers. However, it’s time to stop beating a dead horse. The best team doesn’t win every game. The best player misses a tackle now and again. Peyton Manning started his Hall of Fame career with 28 interceptions his first season. The NFL has made some early mistakes but has since done better; however, Jerry Jones calling any concussion link “absurd” doesn’t help the situation.

The NFL should let it go and stop defending the research of a defunct MTBI committee. They already admit the new Head, Neck and Spine committee doesn’t rely on that previous research. Media should let it go and stop sensationalizing the story by bringing big tobacco into the headlines. I want to let it go and no longer write columns about the finger pointing and defensive posturing. Lets all let it go and work forward to find solutions.

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.

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Monday Morning MD: Did the NFL flip-flop on a link between football and CTE?


If you believe the headlines, the NFL has reversed field and finally pulled its head out of the sand. If you listen to critics, this is the “smoking gun” plaintiff attorneys have been searching for. While it is true that the NFL has acknowledged a link between football and chronic traumatic encephalopathy (CTE), this


If you believe the headlines, the NFL has reversed field and finally pulled its head out of the sand. If you listen to critics, this is the “smoking gun” plaintiff attorneys have been searching for. While it is true that the NFL has acknowledged a link between football and chronic traumatic encephalopathy (CTE), this is hardly equivalent to big tobacco’s late admission in 1997 that smoking causes cancer and heart disease.

In reality, this was another round of politics and semantics. My hope is the NFL and its critics both stop the gamesmanship and get to some real answers. What happened in Congress last week did not get us closer to prevention, treatment, cure or a living diagnosis of CTE.

This week, a senior NFL official did seem to contradict what the league’s own appointed medical personnel recently said during Super Bowl week. In fact, this league vice president was sitting on the same stage when the neurosurgeon denied a link between football and CTE just a month ago.

Although the refutation and now admission of a link appear at odds, I do not think they really are. The recent acknowledgement of a link does not signal a big NFL policy shift. This is not the “gotcha” moment that some have made it out to be. Let’s examine the context of both statements to see why.

Just before Super Bowl 50, Dr. Mitch Berger, the head of the NFL medical subcommittee on long-term brain trauma, denied any definitive link between football and CTE. Having attended that health and safety press conference where he said this, it was my impression that the neurosurgeon was answering the question as a medical professional using strict scientific guidelines of proof. He was indicating that there is no medically proven link of “cause and effect” for football and CTE.

When Jeffery Miller, NFL senior vice president of health and safety policy, answered affirmatively that there was a link between football and CTE, he gave the obvious answer as a lay, non-medical person. If you watch the House of Representatives roundtable discussion, it seems clear that Miller is using the word “link” in the vernacular, acknowledging there is an association. Given the autopsy findings in former football players, colloquially no one can doubt there is some sort of relationship between football-related head trauma and CTE. Miller even tries to clarify his answer to that effect. The key is to find what that link truly is.

This news was incorrectly heralded as the first time the NFL acknowledged a link. In 2009, an NFL spokesman told the New York Times that it is “quite obvious from the medical research that’s been done that concussions can lead to long-term problems.”

To me, Miller’s opinion does not seem at odds with Berger’s earlier statement. This is not an axis shift coming out of the NFL. Medically speaking there is currently not conclusive scientific evidence of a direct link between football and CTE. On the other hand, common sense tells us that there has to be some associative relationship that links football related head trauma and CTE.

The latest statements are not surprising at all. I don’t believe the NFL is flip-flopping or even has changed its stance. Of course, I don’t know how attorneys may use the latest statements and how it might impact the legal proceedings of the concussion lawsuit settlement.

I have said many times, there is so much more we don’t know about concussions than what we do know. We are in our absolute infancy of knowledge and medicine needs to catch up. Lumping together all head injury as concussion is like diagnosing every knee injury as a sprain with no distinction for ACL, MCL, meniscus, articular cartilage, tendon, muscle or dozens of other specific structures. It would be silly to group all knee injuries as the same, yet that is where we are at with head injury. We know less about concussions today than we knew about treating ACL tears in the 1960’s

Conventional thinking is that cognitive rest in a dark quiet room was the best treatment for a concussion and now some scientists say using your brain after a head injury is the better way to go. Not only is there no treatment for CTE, there is no way to conclusively diagnose it except by autopsy. We have come a long way in the last decade but we are just starting the quest for knowledge.

The NFL has been the lightening rod for criticism from concussion and CTE advocates. They may have been slow to the party or let down by their medical advisors back in the day. Currently, the league is no longer in denial.

The many rules changes have produced a new safer game. Just look at the recent ESPN 30 for 30 film: The ’85 Bears. The vast majority of the plays shown highlighting their defense would be penalized, fined and/or suspensions today. However, this protection does not apply to running plays or limit the routine head contact on every play. Why did Dave Duerson, who killed himself, have CTE and why does Jim McMahon have brain injury symptoms? Meanwhile, teammates Mike Singletary and Ron Rivera seem to be fine.

New York Giants owner John Mara said Sunday that the long-term effect of concussions on players and the link between football and CTE represent the most serious issues confronting NFL owners at the league meetings which start today, “and I don’t think anything else comes close.”

Let’s stop the rhetoric and focus on a solution. It doesn’t matter who first found or said there is a link between football and CTE. The focus should be on finding ways to diagnosis, treat, cure and prevent progressive brain disorders.

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Monday Morning MD: The new trend


There is a new injury rehabilitation trend and it has nothing to do with actual medicine. As social media continues to blossom, posting video of one’s recovery workouts has become the norm.

Le’Veon Bell, Jason Pierre-Paul and Jamaal Charles are just a few examples of NFL players who recently have joined the injury update


There is a new injury rehabilitation trend and it has nothing to do with actual medicine. As social media continues to blossom, posting video of one’s recovery workouts has become the norm.

Le’Veon Bell, Jason Pierre-Paul and Jamaal Charles are just a few examples of NFL players who recently have joined the injury update by social media movement. Draft eligible players, like Butkus Award winner Jaylon Smith, have also participated in the “check out how well I am doing” posting craze.

Athletes who share these updates typically are trying to make the point of how hard they are working or how great the rehab is going. What is usually highlighted is the best snippet of their recovery, which may not be reflective of their actual status.

When news is leaked to the media, the information needs context and interpretation. Rarely is the message taken at face value. The same should be said about the injury updates. The videos need analyzing to determine their true meaning as well.

Self-released Vines should be looked at with a critical eye. I am not saying the postings are staged or faked, just that they need context and interpretation.

Le’Veon Bell, coming off MCL and PCL surgery, tweeted “clear to run” with a video link to prove it; however, what it showed wasn’t exactly running. Medically, it is more accurately described as jogging on an anti-gravity treadmill. Yes he was performing the running motion, but it was partial weight-bearing as the machine unloads body weight. In reality, it was a good sign of progress for Bell, but hardly as advertised.

JPP has used social media to post his own hand X-rays from last year’s unfortunate July 4th fireworks accident. Yesterday, he tweeted “they said I wouldn’t be able to grip the bar and lift weights anymore” with a video of him bench pressing. Others may have questioned his ability to bench press, but I never did. Power grip is mostly provided by the 4th and 5th fingers, therefore it is no surprise that he can bench, but that doesn’t mean he will be the same dominant player.

Jamaal Charles took to Twitter to counter naysayers that claim he is too old and can’t come back from a second ACL surgery. His assertion of quick recovery seems to be accurate as Charles looked good to me with his agility on jump rope and balance board. I never doubted that he would make a successful comeback as Charles has done it before on the other side.

Jaylon Smith has released several videos after ACL and LCL surgery. His pre-Combine post that was meant to show off his knee progress unintentionally alerted the world of his nerve issue. He continues to post rehab video, this time doing squats. I applaud his dedication and wish him the best; however, peroneal nerve function is not required when performing squats. The key for Smith will be his nerve status at the Combine medical rechecks two weeks before the draft.

The previous trend was to have personal physicians make statements or write letters espousing support for an athlete’s recovery. Those letters had very little influence and were understandably taken as biased. Due to HIPAA confidentiality laws, a physician can’t reveal medical information without permission from the patient. What player will allow a negative report to be released? What doctor would publically claim the outcome of their surgical work wasn’t positive? With social media, the workout videos seem to have replaced those physician letters.

“Selfie” rehab videos are not just limited to football. Even Tiger Woods posted a video of hitting into a virtual golf machine in response to articles that said his career was over.

The new trend of rehab video is interesting and can be informative. It provides a small window into the recovery process. Like all data, there needs to be context and interpretation before extracting great meaning from the posts.

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Monday Morning MD: Peyton Manning’s greatest feat

MMMD 3.7.16

Peyton Manning’s greatest feat


In a career of great accomplishments, it is not the two Super Bowl victories, five league MVPs, 200 victories or the single season and career record for passing touchdowns that stand out to me. In a first ballot Hall of Fame career, Peyton Manning beating Mother Nature in

MMMD 3.7.16

Peyton Manning’s greatest feat


In a career of great accomplishments, it is not the two Super Bowl victories, five league MVPs, 200 victories or the single season and career record for passing touchdowns that stand out to me. In a first ballot Hall of Fame career, Peyton Manning beating Mother Nature in his recovery from four neck surgeries is his greatest feat. Having success playing with a grandma-like triceps muscle is what is most unbelievable to me.

Peyton ManningA

How does anyone play quarterback in the NFL with an arm that looks like this? With nerve issues leading to multiple neck surgeries, his arm was significantly atrophied as he joined the Broncos. His triceps waggle resembled that of an octogenarian. There were also reports of his fingertips being numb. If a sure-fire top college quarterback prospect showed up at Combine with similar neck and arm findings, he would not be drafted at all based on his medical exam.

Manning not only had a successful post-Colts career, he passed for an NFL record 55 touchdowns and 5,477 yards in 2013. His triceps strength seemed to improve but there was no question that his entire Denver tenure was played at less than 100%. Manning proved a quarterback’s most important attribute is intelligence, not arm strength.

During his time with the Broncos, his throwing was so limited that any lower extremity injury unmasked his arm strength issues. We all saw that with the 2015 plantar fasciitis; however, also recall last season’s poor performance during a home divisional round loss to the Colts when he had a quad tear and resulting in the firing of John Fox.

Having examined the neck and the arm, the Colts knew the bleak medical situation with the nerve issue. Owner Jim Irsay took the percentage play by bidding farewell to Manning and drafting Andrew Luck in 2013. In the end, Manning was able to beat the injury and Father Time to play four more years and gain that second ring.

Atrophy and strength loss from nerve compression typically never returns. Through Manning’s hard work, the triceps atrophy seemed to improve some.

Peyton Manning

While it may be true that Manning’s wife was shipped HGH, it is a medical fact that human growth hormone does not help with nerve issues, thus it would have made little medical sense to use it.

To me, Manning’s greatest accomplishment was to play well returning from the neck and arm issues. A close second is how he was the consummate professional.

Before I had the fortune to meet Peyton, I was not particularly a fan. After all, as the Chargers head team physician, the Colts were our rivals in the mid-2000s. After meeting Manning and serving as his team doctor at the Pro Bowl, I was proven wrong. There was absolutely nothing not to like about Manning on or off the field. I came to have the utmost respect for him.

Manning took his Pro Bowl selections as an honor and duty. He felt obliged to accept every invitation and never bowed out due to injury. At our first AFC team meeting, Manning took charge of the room and showed off his sense of humor and leadership. On the sidelines, he was the leader of the pranks. Loosening tops off water bottles and handing them to first time Pro Bowlers saying to stay hydrated due to the Hawaii sun. My now wife became a life long fan when three days after briefly meeting Peyton, he made a point to say hello remembering her name as they crossed paths on the way to the hotel pool. I have previously chronicled how while Manning was making time for a Make-A-Wish visit, he was still concerned about the athletic trainers and doctors being able to enjoy our time in Hawaii.

Manning is famous for hand writing letters to players on their retirement. He is known for touching lives away from the camera or media. I witnessed Manning (and GM John Elway) quietly attending the “celebration of life” for Junior Seau while turning down media photo and interview requests saying they were just here for the family.

As Manning makes his retirement announcement, this is his time. Yet, he took the effort to personally text former and current teammates and coaches to thank them and let them personally know about his impending retirement.

Whatever happened in the Tennessee training room two decades ago was regrettable. Mooning (or more than that) was an unacceptable act even for a college student. Judging Manning on his body of work has to have him in the plus column even with that blemish.

I was lucky our paths crossed. I only wish they had crossed sooner. The Chargers unfortunately had the second pick as Manning and Ryan Leaf were coming out of college and the Colts made the right decision.

To me Manning’s greatest feat is giving us four more successful years with a terribly weakened arm. The NFL is better for having him for 18 years. The league would be even better if all players acted more like Peyton. There is no better ambassador for the game.

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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


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.



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