Midway through the first quarter of Sunday’s game against the Jacksonville Jaguars, All-Pro LB Matt Milano ran toward QB Trevor Lawrence attempting to bat down the pass.
Following the play, Milano stayed down on the field as trainers tended to the latest injury in what became an injury-marred day for the Bills. Milano required the assistance of the staff to get off the field before a cart came out and an aircast was initially placed on his right leg.
He was quickly ruled out of the game and reports later indicated that Matt Milano suffered a fracture and other possible soft tissue damage with possibly an ACL tear. He possibly stayed in England to undergo surgery to stabilize the fracture.
While there is not an official timeline for Milano to return, it is likely that he is done for 2023 and another key cog of the Bills defense is no longer able to contribute.
Below are the details of the injury, rehab outlook, and timelines as we look towards 2024.
The Injury
With 7:55 left in the first quarter, Matt Milano began running toward Jaguars QB Trevor Lawrence with his hands up, trying to block his throwing lanes. Lawrence got the ball off just as he was getting tackled by Tim Settle and Leonard Floyd.
Milano attempted to stop by planting his right foot in the ground to stop his momentum, but his forward momentum along with Leonard Floyd’s body hitting him below the knee, caused Milano to turn his body as he was hit.
He required the assistance of training staff to get off the field followed by the cart with reports of an aircast to get to the locker room. He was later seen with a knee immobilizer on the cart as seen in the picture below.
The likely injury is a right tibial plateau fracture and MCL sprain. There was a concern for ACL damage, but reports did not specify that the ACL was torn which is ideal looking at long-term concerns.
The Anatomy
The tibial plateau is the top of the tibia or shin bone. The meniscus sits on top of the tibial plateau and this along with the femoral condyles and patella make up the knee joint.
A tibial plateau fracture is usually the result of high-energy trauma and direct impact on the proximal knee. Below in the short video are the types of tibial plateau fractures, the last three occurring more with high-energy impacts.
These injuries are also associated with meniscal, ACL, MCL, and PCL injuries due to the forces placed through the knee either varus or valgus. Fortunately, Milano likely suffered an MCL sprain that is high grade, but the only other associated soft tissue damage as the ACL was not reported to be damaged.
Surgery & Rehab
Surgery is indicated to stabilize the fracture with an open reduction, internal fixation (ORIF) technique with screw placement to fix the fracture. The video below shows how this is done in a non-bloody or gory way.
Rehab for these types of injuries can take upwards of 6-12 months as indicated in this rehab protocol. As this is a major area for weight bearing in the body, this is not something that can be rushed greatly, and non-weight bearing is indicated for at least the first eight weeks. Aggressive timelines can be indicated if healing is going well, but even then, weight-bearing increases progress 25 percent/week.
As for the expected MCL sprain, it can heal up by itself and can have an internal brace placed to assist with stability. There are no differences between surgical and non-surgical outcomes for MCL injuries implying that the MCL will not be a concern moving forward.
NFL Outcomes
We know that Milano required surgery and possibly already underwent surgery in England to stabilize the fracture before he flew.
Tibial fractures that required surgery have a median lost days of 232 days (mean 220 +/- 97.5 days.) which equates to nearly eight months. Based on this information, this all but rules out Milano for the remainder of the 2023 season.
However, there are two cases that I found that showed a possible return to play within three months. The first case is Kansas City Chiefs S Daniel Sorensen who suffered a left tibial plateau fracture with lateral meniscus tear in the preseason in 2018. He underwent surgery in mid-August and was able to miss the first nine games of the season on injured reserve before returning to play in Week 10 to play in seven regular-season games and two playoff games.
The other instance is a case report from PFATS, the Professional Football Athletic Trainers Society. This was done by Andrew DePietropaolo PT, DPT who is an Assistant AT for the Green Bay Packers. He highlighted a case where the player suffered a similar injury to what Matt Milano suffered and they were able to return to practice in 10 weeks and played half a game later that week. It’s also worth highlighting that this case involved an MCL internal bracing to address ligament laxity from the initial injury.
This player was OL Josh Myers who returned to play at 10.5 weeks and played in a full playoff game at 12 weeks. Different duties with offensive line vs linebacker, but still some positive news.
This could potentially happen for Milano if indicated. Otherwise, the MCL would heal naturally while he healed from the fracture.
So it’s possible, but this is two cases out of what is available from a surgical perspective. The linked article above noted that they had 64 tibial fractures over a seven-year period with 21 requiring surgery, though not all for the tibial plateau.
Of the other two surgical cases that I found for a tibial plateau fracture, JJ Watt suffered the same injury in 2017 in Week 5, though his mechanism was more similar to that of an ACL tear. He underwent surgery and missed the remainder of the 4-12 season for the Houston Texans. When Watt did return, he posted an All-Pro season with 16 sacks, seven forced fumbles, and 61 total tackles.
The other instance is former WR Nate Burleson who suffered a tibial plateau fracture in Week 7 during the 2012 season while playing for the Detroit Lions. He was able to return to play the following season, his last in the league. He played in nine games securing 39 receptions for 461 yards and 1 TD. He did suffer a broken arm in a car accident halfway through the season which obviously impacted his stats.
Furthermore, the author of the SB Nation Arrowhead Pride article, Aaron Borgmann, is a former AT/PT for the Kansas City Chiefs and Philadephia Eagles. He indicated in the article that there is no performance drop-off upon return or long-term concerns. I have followed his work for a long time and I highly value his professional opinion.
Final Thoughts
There is a small, small, small, small, small chance Matt Milano could return late in the playoffs, but that’s assuming a lot of things at this point. I would place my money on a 2024 return for Matt Milano along with a prior level of play expected. It’s a fracture that cost him the rest of the season, but there are minimal long-term concerns moving forward.
If the Bills made another deep playoff run, then maybe the drum will beat loud for a Matt Milano return, even at less than 100 percent. But it’s unfortunate that the Bills will be without one of their most impactful defensive players for the rest of the season.
I wish Matt Milano the best in his rehab as he prepares for the 2024 NFL season.
