Josh Allen’s Elbow Injury

“The sky is falling, the sky is falling!”- Chicken Little

At least this is how it can feel on social media when Josh Allen, arguably the best quarterback in the NFL, is dealing with an elbow injury that could affect what could be a Super Bowl season. 

Mass hysteria breaks out as rumors swirl and reports are released giving minimal details regarding the elbow injury from Sunday’s loss to the New York Jets.

Josh Allen’s injury went from slight pain to potentially significant injury overnight, putting everyone on edge about his status. 

Per Ian Rapoport, this injury is something to monitor as the team gathers more information. 

As for Chris Mortensen, the fear is for a UCL injury along with associated nerves.

So there is some confirmation in the tweet above with the first two possibilities being realistic in the UCL sprain and ulnar nerve involvement.

In this article, you will understand the anatomy, the timeline, performance, and any concerns moving forward as you read below.

Anatomy

The elbow is made up of 3 bones: the ulna, radius, and humerus. The elbow is primarily comprised of the capitulum on the humerus fitting inside the semilunar notch which is part of the olecranon process on the ulna to make a hinge joint. 

Surrounding the joint are ligaments that provide support to the joint to provide support. These ligaments are the lateral collateral ligament, the ulnar collateral ligament, and the annular ligament. The lateral collateral sits on the outside portion of the elbow, mostly injured due to fracture or dislocation. The annular ligament holds the head of the radius in place along the elbow joint, and the ulnar collateral ligament sits on the inside of the elbow. 

This is similar to the MCL of the knee in its function. It is more of a stabilizing ligament due to the throwing motion required in the human body. This ligament is made up of 3 bundles that spread out like a fan to cover the entire inside portion of the elbow. The elbow is a rather stable joint as compared to the shoulder or ankle, but as with any joint, can be injured with the proper forces.

The ulnar collateral ligament helps to provide medial support to the elbow so that the ulna does not shift off the humerus during elbow flexion/extension. This ligament also provides support during the throwing motion seen in many sporting activities. 

Injuries occur to this area as the result of acute hyperextension, excessive external rotation of the shoulder leading to chronic issues such as pitching, or a sudden forceful valgus or lateral stress to the joint during elbow extension. The sudden forceful valgus stress with the elbow bent was the case with Allen. 

As for the Mortensen report that is looking at a possible nerve injury, the team is likely looking at ulnar nerve involvement in this case. The ulnar nerve runs along the same area where the UCL is and the area you feel when you hit your funny bone. This nerve innervates a lot of the muscles of the hand and forearm responsible for movement at the fingers and wrist. This means this can impact grip strength as well. 

When Allen’s forearm was pulled backward, the position of the arm in 90 degrees of shoulder abduction and elbow flexion, places stress on the ulnar nerve. Bringing the hand back further and then placing it into radial deviation further stresses the nerve and is a rehab intervention in certain cases to work on neural tension. However, this was more traumatic and the sudden overstretching to the area likens more to the moves you saw in pro wrestling as a kid making their opponent tap out by putting a body part in a compromising position. 

To understand what that stretch looks like, check out this video here.

The team is likely performing a nerve conduction velocity test which is s test that essentially assesses the quality of the nerve to ensure that it carries the signal from the brain to the muscle properly. Any latency issues can show up there and give them a plan of action on how to address the issue. 

Issues with gripping the football would be equally, if not more problematic than the UCL sprain in itself. Allen would lose power to his throws, the touch throws would be off, and generally, ball security would be a huge concern. While not to scare anyone, this is what the team is looking for when they mention nerve involvement. If there is an injury to the area, I expect it to have more of a short-term impact than long-term implications.

Concerns and timeline

What does this mean though for a timeline moving forward?

Fortunately, we do have some context on these types of injuries as Allen injured the same ligament in 2018. His hit was the result of a forced hyperextension when a helmet came up and under, striking his elbow. He attempted to continue playing before the pain was too significant to continue. 

To recall, Allen ultimately missed four games and had the bye week on top of that too, giving him five weeks to recover. Injured reserve rules were different back then, only having the ability to bring back two players from IR and having to stay out a minimum of eight weeks. 

Now, the team has the ability to return a player after four weeks but they have seven return from IR designations, originally eight. They used one on Xavier Rhodes despite his practice squad status. Don’t worry, the Bills would save a spot for Josh Allen in any case.

Looking at the research, it hasn’t changed much since Allen injured the elbow last time. Most quarterbacks who suffer a UCL tear are managed non-operatively. In 2018, Allen missed 42 days but had the benefit of a bye week, and the team not wanting to rush him back during a 6-10 season in his rookie year.

Now that Allen is a perennial MVP candidate and is the engine that drives the Bills’ offense, timelines can change. Looking at the schedule and opponents, the Bills have the Minnesota Vikings in Week 10, the Cleveland Browns in Week 11, the Detroit Lions in Week 12 on a short week, and then the New England Patriots in Week 13.

Assuming this injury is at least Grade 1, very likely a Grade 2, Allen is looking at missing at least two games, knocking him out of Week 10 and 11. The short week complicates things, especially with an inferior opponent in the Detroit Lions, giving him three missed games. 

However, giving Allen a month off to rest and missing Week 13 against the Patriots could be problematic when you’re 0-2 in the division.

Missing four games then brings up the discussion of placing him on injured reserve. I believe from a pure roster management standpoint, you keep him active to force teams to game plan against him in the event that he could play. In the event he is doing better, you can return him to play sooner.

Knowing that Allen has rehabbed from this injury in the past, has worn a brace to throw during games before, and has played through other injuries, this makes me believe that he will avoid injured reserve. I also believe since the rehab team has worked through this prior, they can shave some time off of his rehab timeline without risking his long-term health.

I project Josh Allen to miss at least three games as he rehabs from this injury. 

This would give him 24 days from the date of injury which is on par with the research showing 26.4 days to return. The fact that he could still throw a football 70 yards in the air with a sprained UCL strongly suggests the injury is not as severe as in 2018.

Possible surgery?

Those that are concerned about surgery have valid thoughts. However, throwing a football has different throwing mechanics, less velocity, and overall less volume than that of a baseball pitcher. His 2018 injury healed without surgery and I expect this one to do the same. 

Even if he did need surgery in the offseason, the procedures for UCL repair with internal bracing are improving and have minimal long-term issues. Athletes can return as quickly as five months, though I do not think the Bills would be that aggressive with QB1 if he were to have surgery. Based on what we know at this time, there is zero concern that he will require surgery.

Performance and re-injury risk

When he does return, I expect that his game will rely more on touch throws and the short to the intermediate passing game. Despite the long bomb, he tossed Sunday, this may overstress the elbow if he does this frequently. I do expect him to take some speed off his throws to limit the pain through the elbow when throwing as well. Once the team knows everything is structurally sound, then pain during throwing may be the primary limitation. Grip strength due to the ulnar nerve involvement will have to be adequate as well.

I do expect teams to pressure him often when he does return and look to hit his arm at every opportunity. Relying on his legs and the rushing game will help alleviate these concerns. The addition of Nyhiem Hines in the passing game may be a very well-timed trade.

He will have a brace for when he does return and will slowly work with more speed and distance into his throws as he recovers. In the interim, the Bills’ offense will be predicated on death by 1,000 paper cuts and not atomic bombs like we have seen earlier in the season. 

Can he re-injure the elbow? Absolutely. He can also injure any other body part at any other time. As long as he gives his elbow enough time to rest and rehab, then I am not concerned. He may have to rely on his running abilities more if the plays break down, but we know that the risk of injury is more significant in the pocket. Keep in mind, both elbow injuries happened in the pocket and not on the run. 

Overall impressions

I am an eternal optimist in most cases which is why I was considering the possibility that the injury wasn’t as bad as it seemed. Now that we have more information, realistic expectations begin to set in. 

If this is the stretch of games for the Buffalo Bills to miss Allen, it’s these next three games. This is why Case Keenum was brought in to help keep the team afloat in the event Josh Allen is out for any amount of time. 

The Buffalo Bills have an excellent training staff and medical facility for these exact issues. It can’t prevent injuries, but it can help cut down on the time missed. I wish Josh Allen the best in his rehab and look forward to the Bills marching toward the playoffs in December and January.

Top Photo Credit: AP Photo/Adrian Kraus