Shocking news out of One Bills Drive Wednesday with the news that Von Miller would be out for the remainder of the season with a torn right ACL suffered on Thanksgiving.
This news comes as a major surprise following initial reports that the injury was a knee sprain followed by a more specific diagnosis of a lateral meniscus tear. At the time of the latest information, I had detailed his possible interventions and timelines here.
On Tuesday, Miller underwent exploratory arthroscopic knee surgery to clean up the knee to allow for maximal healing. Regrettably, the doctor found that the posterior meniscus was flipped, there was cartilage damage, and there was a torn ACL, ending his season.
Below is an outline of the anatomy, imaging issues, surgery, potential concerns, and a timeline for him to return.
ACL 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.
Meniscus anatomy
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.
The play
Below is the play where Miller ultimately tore his ACL and meniscus. The knee went into a classic valgus angle with knee flexion and hip internal rotation with a planted foot commonly seen with ACL tears.
The initial fears were the ACL was torn, but initial reports stated it was a knee sprain and later, that he had torn only the lateral meniscus.
Looking at the play again, we now know that he suffered at least a partial ACL tear, a lateral meniscus tear, and cartilage damage. To have the MCL sprained as well would not be surprising but was not reported and those rarely require surgery.
ACL surgery
Miller had an ACL reconstruction, the gold standard of choice when it comes to returning to play. With this being one of the most studied injuries in the literature it seems, outcomes have been improving over the years. Return to play can vary by position but is generally a 9-to-12-month recovery with additional damage potentially pushing that timeline longer.
According to ESPN, there was a “looseness” in Miller’s knee and an MRI did not show the initial tear. Regrettably, exploratory surgery found the ACL tear. The doctor found that the ligament would not hold and that corrective surgery was required. Miller himself said that he knew the ligament may have been compromised.
It was also mentioned he had a flipped meniscus which is a type of bucket handle tear. What this means is that the tear was suffered on the lateral meniscus on the posterior or back horn. The portion of the meniscus that tore flipped up over and sat on the anterior or front portion of the meniscus. This presents as a thickened anterior meniscus on MRI.
The original plan was to flip the meniscus back over to the correct position to allow for normal knee movement and clean out any cartilage damage. This would have likely required a repair in the offseason, but since the doctor was already in there, they almost certainly repaired the meniscus knowing that the ACL also needed to be corrected.
Imaging issues
This may also explain why the medical team did not see the ACL tear on imaging if the meniscus was blocking the view somehow. The ACL tear also may have been partial which means that it wasn’t readily apparent on imaging but more easily observed under direct assessment during surgery.
I am far from an expert when it comes to imaging with regard to reading and diagnosing. However, reading this page regarding meniscus special cases provides a wonderful overview of the considerations when reading imaging and how the meniscus presents when torn on imaging.
Professionally, I hear from patients all the time how the surgeon tells the patient that their knee or hip was “the worst they’ve ever seen”. Or the doctor “found more damage once they got inside”. A physical exam and imaging can tell the provider a lot, but sometimes performing surgery helps clarify any remaining questions. This was likely the rationale for the exploratory surgery.
I recall one instance where an athlete was thought to have torn his ACL and when the surgeon went in for surgery, the ACL was intact despite the MRI saying otherwise. Both good and bad things can be found when undergoing surgery.
Re-injury risks and rehab
As with any other ACL injury, he is at increased risk of 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. 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.
Nine years after an ACL tear though, I don’t think anyone could have predicted that.
Looking at the NFL, upon returning to play, 12.3 percent of players are more likely to re-injure the same knee versus 7.3 percent of the opposite knee. The NFL at least shows a lower rate, but still, there is a risk to suffer another injury.
The presence of meniscus damage does increase the risk for osteoarthritis, but repairing the meniscus can cut down on that risk versus trimming/removing the meniscus.
The meniscus repair won’t really lengthen his rehab timeline as the meniscus repair will run concurrently with the ACL rehab. But having multiple healing structures at once won’t make things quicker either.
The cartilage damage was secondary to the trauma of the ACL and meniscus and is somewhat expected after these injuries. It’s also possible he had cartilage damage from the years of stress placed through his knee following the original ACL injury.
Miller did have a patellar tendon autograft according to his appearance on the Pat McAfee show on Thursday. In 2013, he had a portion of the patellar tendon taken from the right knee and used that as the graft. This time, they used the other side which according to the research, is superior in returning strength compared to the same side graft. They also have the lowest re-injury rate at four percent when compared to other grafts.
Von himself said he should return in six-to-seven months which would place him to be ready for training camp.
Performance upon returning
While we did see Tre’Davious White take just under a year to return with an expected decline in function, we may see similarities for Von Miller.
This study looked specifically at offensive and defensive linemen in the NFL with regard to their outcomes. Addressing defensive linemen, 88.9 percent return to play with no in-game performance drop-off when matched with controls. Keep in mind, this includes defensive tackles and defensive ends in this group. However. those that returned did play fewer overall seasons (7.2) than matched controls (9.2).
To note, when he returned in 2014 from his first ACL, he still put up 14 sacks and was a second-team All-Pro. It’s been a few years since his last Pro Bowl or All-Pro nod, but Miller has shown he’s still an elite player in his position. I expect there to be some level of acclimation required when returning even with his level of experience.
When he returns, he will likely line up on the left side to play against the right tackle to push off his left leg when bending the edge. He appears to be rather comfortable playing on the left side so his usage or snap counts would likely not change.
Timeline to return
This is where things can get interesting.
The average time for a player to return from an ACL reconstruction is 12.4 +/- 2.5 months across all positions. Those returning from an ACL revision take 12.6 months to return which is what Von Miller had.
In 2013, Miller tore his right ACL in Week 16 and was able to return to play in Week 1 of the 2014 season. It’s worth highlighting he had surgery with Dr. James Andrews’s group.
The article went on to state that there was no significant damage to the surrounding ligaments and that he would have a six-to-nine-month recovery. He was able to return in 34 weeks which is just shy of nine months.
Von himself said he’ll be back in six-to-seven months. While his attitude is positive, you still can’t speed up the healing process that much, especially at his age. He does have the benefit of having done this rehab before, but experience only helps so much.
This time, he had surgery with Dr. Daniel Cooper, based out of Dallas. He is the head team physician for the Dallas Cowboys for a while and has been affiliated with them in some capacity since 1992.
Cooper has performed a number of ACL repairs and based on several recent examples, he has shown a willingness to be more aggressive.
The first example is Cowboys WR Michael Gallup tearing his ACL on January 3rd and having surgery on February 10th of this year. He eventually returned to playing on October 2, a mere 34 weeks after his surgery. Keep in mind, he is 26 years old.
Cowboys LB Jabril Cox suffered a torn ACL in Week 8 last year against the Minnesota Vikings. He had surgery several weeks later, putting his surgery date in roughly mid-November. He was able to return to play in Week 3 but didn’t have to spend any time on the PUP list. This meant that he was able to pass a physical, taking him 36 weeks to return. He is only 24 years old.
Cooper has also performed surgery on former first-round pick QB Teddy Bridgewater following his traumatic knee injury in 2016. He also performed ACL surgery on Cowboys LB Jaylon Smith whose rehab was complicated by nerve damage that cost him his entire rookie season in 2016 but returned and is still playing with the New York Giants.
Cooper’s track record speaks for itself when it comes to the quality of his outcomes. There are many others that have undergone ACL reconstruction with the doctor, but these are some of the more recent and higher-profile athletes.
While all this seems positive, there are downsides and not-so-successful stories. Most recently, we saw Washington Commanders DE Chase Young have an extended absence in his return from his right ACL tear in Week 10 last year. As of publication, he has been removed from the PUP list but still has not played this year. Young underwent surgery with Dr. James Andrews per reports.
Former Bills DE Trent Murphy tore his ACL in 2017, missing the entire season with Washington before signing with the Bills in 2018. He said he needed duct tape to get through that first season following his injury and never regained his form following his nine-sack season in 2016. He also slow-played his ramp-up during OTA’s in 2018 and still dealt with soft tissue injuries in camp. The current medical staff we have in place was there when Murphy was there.
We also saw former Bills DT Harrison Phillips return from his ACL tear and struggle in his first season back from the original injury in 2019. He eventually did return to somewhat of his normal self, cashing in on a free-agent deal with the Minnesota Vikings this past offseason.
The Buffalo Bills have been fortunate to have mostly avoided ACL tears since Sean McDermott took over in 2017. The ACL tears are as follows: P Cory Carter, DT Harrison Phillips, CB Tre’Davious White, OT Tommy Doyle, DT Justin Zimmer. Of those, we have only really gotten to see how they have managed a late-season ACL tear in White and that timeline extended to nearly a year.
To note, Justin Zimmer tore his ACL on November 11, 2021 in practice and was then released following the season. This year, he had a workout with the Bills in late September, signing the first week of October, putting him between 10.5-11 months out from the surgery when he signed on October 4. That tells me that they have some wiggle room on timelines to return.
While Miller and White had the same injury on the same date in different years, Miller had surgery roughly a week sooner than White did when looking at the calendar. We know that the Bills are going to be more conservative with ACL rehab looking at Tre’Davious White, but there were believed to be some mental aspects that White had to work through in trusting his leg again. Those are variables to consider in rehab, but can’t always be predicted. That also likely extended his return-to-play timeline.
Looking back at the above-mentioned study with defensive linemen specifically, the average time for a lineman to return was 11.3 months +/-2.9 months. So that means Miller could return at 8.5 months or at 14.2 months based on the research. You can make the argument that a defensive end does have to react to what the offense does, but they dictate far more of the action than a cornerback as we saw with Tre’Davious White.
So boiling it down: Miller is a future Hall of Fame defensive end who tore his ACL and meniscus in Week 12 and will be working with a relatively conservative training staff. He also went to a surgeon who appears to be willing to be more aggressive in his return to play criteria based on his past work. The average time for a defensive lineman to return is 11.3 months, give or take nearly three months. To add the final cherry on top, Miller himself returned from the same injury in just under 9 months nine years ago.
He is 33 now, he was 25 when he had the surgery in 2014 following the 2013 season. Do I expect him to have the same outcomes as he did last time?
No.
For those worried about his age, offensive tackle Jason Peters tore his ACL and MCL in late October 2017 with the Philadelphia Eagles at age 35. He was able to return in Week 1 and play all 16 games the following season. As of today, he is still playing with the Dallas Cowboys. Age is a consideration but not the only factor.
Week 1 of the 2023 season is roughly 10 months from the date of surgery on December 6. Miller is a highly motivated athlete who has been through his share of major injuries and appears to have the right mindset. However, I don’t expect the team to be overly aggressive with an older player who has five years left on his expensive contract. Brandon Beane himself said they expect him back for most of 2023, implying that his recovery may stretch into the season.
Looking at his return date, a reasonable expectation is that he starts training camp on PUP and then works his way back. Miller will be 33 weeks out from surgery at that point when training camp starts.
Realistically, he will miss the first four games of the season while on PUP and then return sometime in late October/early November after a ramp-up period. This is the same idea we saw with Tre’Davious White. He would also need that callusing that training camp gives a player as Brandon Beane has said previously. He wouldn’t get that as much in practice as we have seen.
This is the approach that I believe they will take, barring setbacks.
This seems to fall in line with what the Bills are comfortable with based on past history and the timelines. That would also fit what the literature says.
I can’t discount the possibility that he does try to return sooner and gets activated from PUP prior to the ten-month mark at roster cutdowns if everything looks fantastic. There is the concern of hamstring, groin, calf, or even quad injuries if he returns too soon, slowing down his participation during camp. But he would still need that practice time with live reps, which would be hard to get early in the season after training camp breaks.
It’d be really aggressive from Miller and the surgeon and I’m not certain the Bills would be on board. But returning anytime sooner than late October/early November would be a huge benefit to the Bills.
I wish Von Miller the best in his rehab and recovery and looking forward to his return in 2023.
Top Photo Credit: Getty Images
