The Buffalo Bills‘ worst fears on Thanksgiving were confirmed on Black Friday when it was announced that All-Pro CB Tre’Davious White suffered a left ACL and meniscus tear and was ruled out for the season.
There was heavy speculation that this was the injury from myself and others within the medical football community as soon as TV replays showed the left knee buckle. White’s reaction on the sideline along with his game status as doubtful later ruled out further cemented the fear.
While he is out for the season, there is concern regarding the rehab process along with his availability and performance heading into the 2022 season.
The Anatomy
The ACL is a ligament that connects the tibia to the femur and runs medial to lateral — or inside to outside — acting as a stabilizer in the knee to prevent the femur from shifting too far forward over the tibia during movement. It also assists in preventing hyperextension in the knee. When the knee is loaded during activity such as cutting and sudden stops, the ACL is designed to keep the knee stable, but in the presence of injury, the ligament is overloaded which either stretches and partially tears or fully tears based on the activity. It is possible to live a normal lifestyle with an ACL-deficient knee, but nearly impossible to resume a high level of play post ACL tear without reconstruction as an adult.
Activities that cause the ACL to tear are direct blows such as a low block or a blow to the knee while the foot is planted. Non-contact typically occurs when a player doesn’t land properly after jumping in the air, when they perform a sudden change in direction at a high speed, or when they attempt to quickly decelerate. Roughly 70-to-75 percent of ACL tears are non-contact in nature in the general population.
Tears also occur with hyperflexion or hyperextension of the knee. In the event of ACL rupture, the knee buckles and there is usually immediate swelling, tenderness, loss of ROM, and pain. Risk factors include but are not limited to: gender, age, playing surface, level of play, biomechanical variances, previous injuries to the knee, equipment, and environmental conditions.
The Injury
The injury occurred with 6:21 left in the 2nd quarter while White was covering New Orleans Saints WR Marquez Callaway. When Callaway turned to his right looking to show he was open, White stayed with him step-for-step, planting his left foot into the turf to change direction quickly.
Due to suddenly changing direction, this put the foot planted into the ground, hip into internal rotation, and abduction to pivot, placing a valgus stress on the knee. This position is unfortunately a common mechanism for the ACL to rupture.
The alignment of the joint placed stress so great through the knee that it tore the ACL and meniscus, with the familiar pop heard when a ligament ruptures. Had his foot not stuck in the turf and continued sliding left while he went right, he may have escaped the tear.
Trainers and doctors quickly rushed out to White to assess, performing an orthopedic special test on the knee known as the Lachman test. The femur is stabilized with the knee in slight flexion with the tibia then moved anteriorly or forward to determine the laxity of the joint. Depending on the give of the tibia in relation to the femur determines whether there is an ACL injury.
After leaving the field, the team performed x-rays to rule out any additional damage and then had an MRI done upon returning home to Buffalo Friday to confirm the diagnosis.
White will have surgery to repair the damaged ligament and meniscus shortly to begin his rehab afterward as he prepares for the 2022 season. It’s worth noting the meniscus damage will not have any effect on the recovery timeline.
It’s worth noting that he did not have any prior ACL tears or have any other injuries that would have predisposed him to this injury. He was playing on turf which has been shown to increase ACL tears, but the mechanism of injury was the same and still could have happened on natural grass.
Rehab
Rehabilitation and recovery for an ACL tear can take anywhere from 9-to-12 months with more complex tears taking even longer. Restoring full range of motion followed by strength slowly will be the main focus to regain function of the knee. Biking, walking, running, jumping, cutting, and pivoting will all be slowly introduced as healing occurs through various stages.
Here is an example of an ACL reconstruction rehab protocol detailing the steps during each phase.
Based on this timeline, White could return as soon as training camp, though there is a distinct possibility he starts on the PUP list until he is cleared. Depending on how his recovery goes, there’s a fairly decent chance he could be ready for Week 1 of the 2022 NFL season. By that point, he would be roughly 10 months out which isn’t uncommon to return to play. I don’t believe the Bills need to rush him back, but White may feel ready and want to be aggressive in returning that quickly.
Update: White had ACL reconstruction on December 15th, starting his rehab timeline which makes starting on PUP a certainty. Week 1 is still in play but highly unlikely with this updated news.
Considering what they have invested in him, there would not be a need to rush him back any sooner in training camp. Athletes returning prior to 9 months increase their risk to suffer another ACL injury by 7-fold rather than those who delay their return to sport.
Re-injury risks
As with any other ACL injury, he is at increased risk to re-tear the surgically repaired side but he is also at an even higher risk to tear the contralateral side, upwards of 20-to-30 percent within the next two years, based on the various sources within the literature within the general population. He is over the age threshold of 25 that we see an increased risk for ACL tears which does help him in avoiding, but not fully eliminating future tears.
Looking at the NFL, 72 percent of ACL tears are non-contact and 12.3 percent are more likely to re-injure the same knee versus 7.3 percent of the opposite knee. The mean time for a player to return from an ACL reconstruction is 12.6 months across all positions. This study is worth noting as the Bills’ orthopedic surgeon, Dr. Leslie Bisson, contributed to this article.
Performance upon returning
There is concern that Tre’Davious White may not be the same player upon returning to the field. Despite all the structures healing by the time the season starts, the knee will initially be lacking the awareness necessary to perform the fluid movements that made him an All-Pro.
The natural ACL contains mechanoreceptors that provide the body the ability to detect tension, acceleration, the direction of movement, and position of the knee joint, generally known as proprioception. These mechanoreceptors are found in all ligaments and provide the body feedback with all movements in our lives.
With decreased feedback from the knee during movement, can lead to a player being a step slower and not being able to adjust to what’s in front of him as easily. Add in the defensive demands of the position where he has to react, his lockdown play may be exposed at times. However, the mechanoreceptors can reinnervate over time, indicating the body can restore this function through healing.
Based on the research available, ACL injuries can affect defensive players adversely. Addressing this paper from 2017, there were several metrics that suffered a decline upon returning successfully from an ACL tear. This study looked at all defensive positions but broke down metrics for each defensive group specifically. There were statically significant declines in production for defensive backs for games started, solo tackles, and interceptions over the 3 years following injury.
What isn’t clear is whether the production goes down because of the decreased availability or whether the performance is affected solely by the ACL injury. I’m going to lean towards the lack of availability over true talent level.
The final sentence of the article goes on to state that those who were above-average players before the injury returns relatively average following the injury. Take that how you will.
What White does have working in his favor is that he was a former high draft pick that has already signed his lucrative contract extension. This means that the team has invested considerable resources into him, he has consistently shown the ability to perform at an extremely high level, and stay healthy otherwise. The team will continue to commit to ensuring that he will return to the level of play they are accustomed to prior to the injury.
For further confidence in White’s return to form, there are comparable players who have suffered an ACL tear in the NFL and came back to make a 1st or 2nd All-Pro team in at least either the Associated Press, Pro Football Writers of America, or Sporting News. This is not a fully comprehensive list, but players I found over the last 25 years that have received All-Pro honors. They are below:
CB Rod Woodson: tore ACL in 1995, returned the same season. Was 2nd Team All-Pro in 1996 (Steelers), 1st Team All-Pro at safety 2002 (Ravens).
CB Bobby Taylor: tore ACL in 1997. Was 1st Team All-Pro in 2002 (Eagles).
CB Carlos Rogers: tore ACL, MCL in 2007. Was 2nd Team All-Pro in 2011 (49ers).
CB Darrelle Revis: tore ACL in 2012. Was 1st Team All-Pro in 2014 (Patriots).
CB Chris Harris Jr.: tore ACL in 2013. Was 2nd Team All-Pro 2014, 2015. 1st Team All-Pro in 2016 (Broncos).
Collegiate ACL tears, later All-Pro
CB Antonio Cromartie: tore ACL in 2005. Was 1st Team All-Pro in 2007 (Jets).
CB AJ Bouye: tore ACL in 2012. Was 2nd Team All-Pro in 2017 (Jaguars).
CB Eddie Jackson: tore ACL in 2014. Was 1st Team All-Pro 2018 (Bears).
Safeties who tore their ACL, later All-Pro
S Eric Berry: tore ACL in 2011. Was 1st Team All-Pro in 2013, 2015, 2016 (Chiefs).
S Tyrann Mathieu: tore ACL in 2013, 2015. Was 1st Team All-Pro in 2015, 2019, 2020 (Chiefs).
This is an example of players who were mostly elite talents before their injury and were able to regain the form necessary to return to the very top of their profession. Some had never even made All-Pro prior to their injury.
So while the article regarding defensive players does imply that this ACL tear will negatively impact White’s career trajectory, these players are exceptions and fairly decent sample size to combat that fear.
Outlook
What this boils down to is that White may be delayed in starting training camp on the active roster. He may be ready to play Week 1, but he will likely not be at 100 percent. His production may be close to the level of an average player at his position for 2022.
This was an unfortunate injury that significantly harms the cornerback depth for the Bills for the remainder of the 2021 season. I believe he will have a slow start to the season in 2022 and may not really regain his elite form until 2023. Once he is able to fully recover, I fully believe he could return to a Pro Bowl and even All-Pro level eventually as he gets farther away from his ACL tear.
The Denver Broncos Chris Harris Jr. and Pittsburgh Steelers Rod Woodson may be the best examples above of outliers to return to form immediately.
Injuries are a part of football, they are what helps create parity in each and every game. These players work incredibly hard to get to the NFL; all have the ability to rehab and continue playing at a high level. I wish Tre’Davious White the best of luck in his rehab as he prepares for the 2022 NFL season.
Top Photo Credit: Rich Barnes-AP
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