Von Miller’s Knee Injury

Von Miller must have had a lucky horseshoe hidden somewhere from all his years as a Denver Bronco. If he did, it came in handy Thursday night when he went down with a right knee injury with 2:44 left in the second quarter. 

The video of the play below had all of social media worrying for the worst in an already tough season due to injuries. 

Fortunately, positive news came out Friday morning with an update that Miller tore his lateral meniscus in his right knee. He is out for at least 7-to-10 days while he seeks out the best solution for his knee.

Despite it being a meniscus tear, there are a bunch of possibilities for management which makes determining a timeline as of publication very difficult. 

The Anatomy

To understand proper management of the meniscus after injury, the structure must be understood. The meniscus is two concave structures that are c-shaped and lie over the tibia in each knee. The meniscus is comprised of a medial and lateral meniscus and acts as a shock absorber during activity. These menisci also help deepen the joint so that the femur can articulate with the tibia, providing stability. During meniscus tears, a rotational force is applied to the area while the knee is bent and causes a shearing motion, causing a portion of the meniscus to tear.

There are various types of tears which include but are not limited to: complete or partial, horizontal or vertical, longitudinal or transverse. Acute tears are more likely to present as longitudinal/bucket-handle and radial tears most likely seen in football players. 

Symptoms

Symptoms of a meniscal tear typically consist of pain, tenderness, swelling, locking or clicking during knee movement, and initial difficulty in placing weight through the knee. Meniscal tears are typically seen in conjunction with MCL sprains/tears and ACL tears due to the rotational forces through the knee during impact.

Overall, these types of injuries can slow up a player but not entirely derail their season. Several tests to identify meniscal tears including Apley’s, McMurray’s, joint line tenderness, and Thessaly’s test all assist in identifying whether a meniscal tear is present. 

However, these tests are not always reliable or specific which means they may identify pain and restrictions but will not be able to identify the type or severity of the tear. These tests replicate the mechanism that would cause the meniscal tear. This typically warrants further imaging such as MRI to identify specific lesions which will determine the appropriate interventions.

Types of tears

Once a tear has been identified, the type of tear can affect healing rates: longitudinal tears heal better than radial; simple tears heal better than complex; traumatic and acute tears heal better than degenerative. 

Based on location and length of the tear will determine proper management. The meniscus has several “zones of vascularity” which include: red-red zone, red-white zone, and white-white zone. 

The red-red zone has the highest blood supply and lies on the outermost portion of the meniscus. The red-white zone is the area that connects the red-red and white-white zone and contains some blood supply. 

The white-white zone has a poor blood supply and demonstrates the poorest area for healing. If the tear is small, conservative management or a meniscectomy may be performed to remove the offending piece. If the tear is larger, then a suture repair of the meniscus is warranted and an extended rehab is required.

If the tear is large enough, surgery may be necessary to fix the tear and allow it to heal properly. 

Possible interventions

The medical team and Miller are looking at all possibilities as to how he will manage the knee injury. They are buying some time, already ruling him out for the Week 13 contest against the New England Patriots. 

There are likely currently three options on the table as to how to manage this issue. 

• Rest and rehab
• Meniscectomy 
• Meniscal repair

Since Sean McDermott has been here in 2017, they have taken a different approach to each meniscal injury as seen below.

Rest and rehab approach

This would be the simple approach and could allow the quickest return to play. What will happen is a course of physical therapy along with modalities to restore function and reduce swelling. There really wouldn’t be much of a specialized approach toward this option, but there are some drawbacks.

If the tear is large enough or what is considered a bucket-handle tear, this could impede the function of the knee, causing locking and loss of function. Despite the best rehab, if a flap of the meniscus keeps getting in the way, this could limit Miller at the wrong time. As of this time, reports are that he tore the lateral meniscus, but not the type of tear and size. 

If the tear is small and not impeding function, he could rehab it, but if the knee isn’t responding well, then this could lead to inevitable surgery. This would essentially waste time and extend the timeline to return. However, surgery could still be recommended in the offseason.

If they do the rehab and rest approach with the idea the tear can be conservatively managed without setbacks, I could see him miss two, potentially three games. We saw this approach with Kelvin Benjamin in 2017, missing two games, though at times he was limited after he returned. He could also return with a brace to protect the area and limit any unnecessary associated movement. Snap counts could change, and which side he lines up on could be affected, he could be a step slower; he would be limited in some way working through the injury.

Meniscectomy

This is a surgical approach that trims out the torn portion of the meniscus and smooths down the area to restore function. These are quite common and fairly straightforward. The surgeon goes in with a camera and a small tool to trim out the offending piece. 

Return-to-play timelines can vary but players can return several weeks after rehab. We saw Charles Clay return after three games missed plus the bye for four weeks total and I am not opposed to this approach, but it also has several drawbacks. 

Cutting into someone does bring the possibility of infection which could significantly complicate a return to play. While no one expects to get a post-surgical infection, it has to be a consideration. 

Sometimes, going in for surgery may rile up an already irritated knee. Trying to fix one problem may only add to the inflammation already present in the knee. This could delay healing and return to play. Even with the best rehab and treatments, setbacks could still occur and may require more of a more nuanced approach. Personally, I have dealt with this in a professional setting where someone goes in to get their meniscus trimmed and they have more problems after the surgery than they did before.

There is research that shows that meniscectomies are no better for outcomes than rehab with non-obstructive meniscus tears. This is over a 24-month period, but still, it shows that surgery doesn’t always lead to a better outcome. Trimming out the meniscus may allow for a quicker return, but that could lead to degenerative changes down the road. 

Research shows that trimming out the meniscus can lead to a greater chance of arthritis within the knee joint. We have seen this play out with Charles Clay when he was here and there have been countless others over the years. Maintaining thigh strength can help minimize the effects of the arthritis setting in according to the research, but degeneration can still occur despite the best intentions. 

Von Miller is 33 years old and has a lot of miles on his body. He recently signed a six-year, $120 million contract that he expects to play through to the end. The veteran suffered an ACL tear in his right knee in 2013 that already opened him up for degenerative changes commonly seen after an ACL reconstruction. He is already at greater risk to suffer osteoarthritis within the knee due to the ACL surgery alone. Adding in the meniscectomy, that increases his OA risks down the line.

“But he’s a football player, he’s going to have arthritis.” Yes, very likely, but does he want to have symptomatic arthritis two years from now and require a lot of effort to get up and ready for a game every week? He would also struggle to potentially play out his contract if the knee degenerates further. What this comes down to, does the short-term benefit of the surgery benefit him long-term? That’s why he is taking 7-to-10 days to figure out his options.

If he goes this route, he could miss three or four weeks as he rehabs leading to two to four games missed, depending on how rehab goes and when he has the surgery.

Meniscus repair

A meniscus repair would end his season. This is where the surgeon goes in and sutures down the torn piece of the meniscus to allow it to heal properly. This technique has been preferred and has far better outcomes for long-term management. We saw them do this with Cody Ford back in 2020, ending his season.

Upwards 80 percent of individuals undergoing a repair showed no osteoarthritic changes after 8.8 years. This is compared to 40 percent of no OA changes after a meniscectomy. Return to pre-injury level of sport is 96.2 percent with repair compared to 50 percent after meniscectomy. 

Miller could undergo this now to extend his career or if it’s significant enough, but he could also delay the surgery and get it done in the offseason. It would be expected if he has this surgery that he would be fully ready for the beginning of the season next year.

What will the Bills do?

The simple answer is, I don’t know.

I would want to see how the knee responds to the initial rehab, I would want to know the type of tear, and how the knee was looking prior to surgery. I would also want to know if there was any associated damage as a result of the knee injury such as an MCL sprain or cartilage damage that wasn’t reported. 

I don’t believe that he will undergo a repair now unless it was absolutely necessary. That would be heartbreaking and add a final nail into the coffin of an already tough season when it comes to injuries. However, he could still do this in the offseason.

What it may come down to is the type of tear and how Miller responds to the initial treatment. I would personally prefer the rest and rehab approach, working back into shape, and returning to playing with a knee brace. I would also expect to see him limited to playing on the right side of the line, but we have seen him do that already lately. This would at least reduce stress through the right knee as he bends the edge, not having to push off as much.

The meniscectomy may be beneficial, but at what cost? It would take care of the issue now but to return now only to have issues later is something the team has to seriously consider. 

If he doesn’t have surgery because the tear is small or non-obstructive, I could see him returning after missing two to three games. If he has a meniscectomy, that could push into two to four games missed based on how the schedule lays out.

So a timeline between two to four games is what could be considered realistic. 

Injured reserve could also be a possibility, but that rules him out until a return in Week 17 against the Cincinnati Bengals. There are a lot of variables in play which makes nailing down the timeline so difficult. The risk of re-injure the area or flaring it up during rehab or in games could also significantly alter this timeline. There aren’t exact percentages to say his risk to re-injure, but the already damaged area could worsen with more trauma.

While this doesn’t give a concrete answer as to his timeline, the Buffalo Bills also don’t know what things are looking like right now either. I outlined the pros and cons of each intervention and based on their decision that will help dictate when he returns. 

I wish Von Miller the best in making his decision and eventual rehab in addressing the injury.

Top Photo Credit: Von Miller Instagram