After a brutal loss to the Patriots on Monday, the press conference got even worse with the news that Dawson Knox would undergo right wrist surgery and be out indefinitely. This was a surprise announcement as detailed with timestamps in the tweet from News 8 AJ Feldman below.
The fan base knew that Knox was working through a wrist injury since suffering the injury back in Week 5 against the Jacksonville Jaguars. But the severity of the injury had been obviously downplayed due to competitive advantages. Over the past two weeks, Knox required the wrist to be taped up, wear a brace, and has generally been ineffective on the football field.
Over the past two weeks, Knox has caught four passes for 27 yards on nine targets with several key drops. The wrist injury very likely contributed to these struggles and is a strong reason why he is undergoing surgery.
Below is how the injury occured, possible structures involved, and a return to play and performance timeline upon return.
The Injury
Above is the play that Knox suffered his right wrist injury on. You can see how the helmet hits the wrist as he cradles the football. He pops right up and then disappears off to the sideline to get his wrist taped but never received an in-game designation. He continued to play through the end of the game with adrenaline and the strong desire to win likely reasons why he was able to finish the game.
He was seen at a Sabres game with a wrist splint on the area suggesting the severity was greater than previously thought.
Here he was at practice catching several balls with the wrist taped.
However, in game action, he didn’t see many targets and struggled to block often, especially during the Giants game. Add in the drops or inability to haul in the ball further indicated the wrist was more of a problem than originally thought.
The Anatomy
Evaluating the anatomy of the wrist, the carpals and distal ends of the radius & ulna make up the wrist as you can see in the picture below. There are multiple ligaments in the wrist. Clinically significant ones include the scapholunate ligament, the lunotriquetral ligament, & the triangular fibrocartilage complex (TFCC), among others.
Functions of the wrist include flexion, extension, radial and ulnar deviation along with pronation, supination, and grip strength.
Possible Damage
Looking at the possible damage in there, there are several things to consider which help narrow down the specific injury. First off, if he had a fracture in the area, this would have likely necessitated some immediate time lost or surgery to stabilize the area afterward. But he played another two weeks on the injury.
Wrist/hand injuries have not been a big injury for the Bills in recent years, but in 2017, Jordan Matthews and Ramon Humber both underwent surgery after their respective thumb injuries to stabilize the fracture. Christian Benford suffered a metacarpal fracture and Knox suffered a metacarpal fracture in 2021 that required surgery to stabilize.
Other comparables include former Buffalo Bills Jerry Hughes. He played through torn ligaments during the 2019 season with his wrist braces up for every game before undergoing surgery in the offseason. The Bills were investigated for possibly not reporting the injury, but it’s likely that Hughes had a similar injury to that of Knox. Hughes is a defensive player which allows his ability to play through the injury as he didn’t have to catch the football.
Had Knox suffered a wrist dislocation, this would have been a more urgent surgery and no amount of tape or bracing to the area could have maintained stability. Recent examples of a wrist dislocation include the Kansas City Chiefs LB Nick Bolton and Baltimore Ravens S Marcus WIlliams.
An acute fracture and dislocation can be ruled out at this point which means that a ligamentous instability or cartilage damage could be initially played through. The only one that can be treated after the initial injury is the scapholunate injury in which surgery can be performed within 18 months of injury & splinting may be effective with incomplete tears.
Triangular Fibrocartilage Complex (TFCC) injuries are also considered in this case. It’s very possible that he injured either structure or both with this latest injury.
Scapholunate ligament tears are unfortunately the most common wrist ligament injury according to the literature. This ligament is important as it helps stabilize the proximal carpal rows and transmit large forces including axial loads without giving way.
Knox was likely dealing with clicking/clunking, difficulty gripping/weakness, decreased range of motion, and pain as he played through the injury.
It’s incredible to consider that he was able to play through this injury the past two weeks. Looking at the tight end depth chart, Knox was essentially forced into service. In the same Week 5 game, Dalton Kincaid suffered a concussion and was unable to play in Week 6. The following week against the Giants, Quintin Morris suffered a right high-ankle sprain, knocking him out of Week 7. Hence why I was surprised he even suited up.
Even if Knox could not catch effectively, the Bills still needed a tight end that knew the offense to block and occasionally catch. His struggles were more evident against the Giants; he was repeatedly seen blocking with his forearm/shoulder rather than keeping his right hand inside to direct the block. He couldn’t load the wrist which was a concern of mine heading into the game.
Surgery
Knox will undergo surgery to repair the damage in the wrist and does not have a timetable to return. Working with the idea that he sustained damage to the scapholunate ligament and/or the TFCC, these are typically longer timelines.
Normally, rehab timelines for a scapholunate ligament reconstruction that involve a full tear are anywhere from four to six months. While there are not any football players included in the study, there are rugby players which is a pretty strong comparable. These repairs should be done within three weeks of injury for the most successful outcomes according to research.
As for a TFCC repair, return to normal activities is around 12 weeks following surgery but heavy manual labor activities would take longer. 64 percent of athletes returned to their prior level of performance out of 15 subjects.
A Faster Return
However, there are other procedures that can take place that shorten the return to play timeline considerably. (Full disclosure: this took me down a rabbit hole digging into this injury).
Should he have a partial tear of the scapholunate ligament, one procedure involves electrothermally shrinking the partially torn scapholunate ligament. This would essentially shrink wrap the ligament to create stability within the wrist. They do this by using radio frequency to heat up the tissue briefly to allow it to shrink down.
A person would then be placed in an volar slab orthosis for two weeks followed by a hook and loop fastener brace for four weeks to allow for range of motion exercises in addition to strengthening and weight bearing activities to return to activities at week six.
It’s worth highlighting that this occurred with military subjects and one of the criteria was that they could return to duty and perform a push-up. Return to duty saw an 86 percent return and 79 percent were able to do a push-up.
While playing football is more physically difficult than military duty, there is still enough crossover to consider this as an appropriate timeline.
Looking at long-term follow up in another study, most of the participants (89 percent) were able to return to prior level of participation. Grip strength returned to equal that of the opposite side and range of motion grossly normalized. In this study, 90 percent of individuals returned to preinjury level. If he does have TFCC damage, they can clean that cartilage up and allow it to heal during this timeframe.
Despite what Sean McDermott said above, if Knox had continued to play through the injury, he would have been at risk to suffer scapholunate advanced collapse. This is a degenerative condition where osteoarthritis and subluxation occur leading to significant loss of function over time. Had it progressed, several options including a proximal row carpectomy would have been indicated which is what current Miami Dolphins LB Jaelan Phillips underwent in college. But Phillips doesn’t have to catch footballs for a living.
Timeline to Return
This is where there is some play in the timeline. He’s looking at roughly a six week recovery if he has the procedure above. Even when he returns, he won’t be 100 percent, but close enough to play. I would expect his catching to improve and his ability to block more effective.
If he pushes for four weeks, that takes him to a return in Week 12. The team could use the bye and give him a full six weeks to recover to return in Week 14 and only miss five games.
This would also likely mean a stint on IR and the team has already used one designation to return on Baylon Spector. They have to save a spot for potentially Damien Harris, DaQuan Jones and Matt Milano, plus any other injuries they incur down the road.
Based on the information we have, it’s reasonable to expect that Dawson Knox can return either Week 12 or Week 14. He could open his practice window sooner to start getting back into game shape and test the wrist after Week 11. What the injury situation looks like around that time may dictate his return as well.
Setbacks or previously unknown damage could affect this timeline, but this is best guess off what we know.
Either way, the Bills suffered a short term absence but not a season-ending loss like we’ve seen recently. We’ll see how this plays out, but performing this research allowed us to find far more positive outcomes than previously thought.
I wish Dawson Knox a quick and full recovery.
Top Photo Credit: WKBW Buffalo
