Wednesday afternoon marked the end of a crazy 24 hours of worrisome speculation regarding Buffalo Bills first-round CB Maxwell Hairston. The concern began shortly after Tuesday’s practice started when several beat reporters observed Hairston having his right knee assessed by head athletic trainer Nate Breske.
Video showed Breske performing a routine assessment of the knee before helping Hairston up to his feet and off the field. As time went on, speculation was rampant as to the extent of his injury including discussions of season ending surgery.
After heavy conjecture from various social media accounts with a strong emphasis on an ACL tear, official reports came out that Hairston suffered an LCL sprain and that he would be out for at least three weeks.
While this is incredibly promising news, Hairston still has a ways to go before a full return to performance. Read further for additional details about the anatomy, injury, rehab timeline, and expectations upon return.
Anatomy
The lateral collateral ligament, or LCL, is part of the posterolateral corner of the knee and provides lateral support to the outside portion of the knee. It connects the distal femur to the top of the fibular head and shapes more like a cord. This is the least commonly injured knee ligament, comprising just two percent of all knee injuries.
The LCL stabilizes varus forces or when the knee is pushed outward as though someone is bow-legged. It is the primary restraint for varus forces at 30 degrees of flexion and provides stability in extension of the knee along with external rotation. It’s often injured by a direct blow to the front and inside portion of the knee, forcing the knee to hyperextend and bow outward.
The LCL is part of several other ligaments in the knee that provide stability including the MCL, PCL, and ACL.
Injury
To my knowledge, no one got video of how Hairston went down. This was during a routine drill as part of individual work. The Bills do have this footage from video recording practice, but this will likely never see the light of day. What was seen was the aftermath of Head Athletic Trainer Nate Breske assessing Hairston’s knee.
What we see in the clip is Breske performing the Lachman test, the anterior drawer test, and posterior drawer test. Both the Lachman and anterior drawer assess the ACL while the posterior drawer assesses the PCL. There may have been other things assessed but it’s not clear from the video. Hairston was then pulled up and slowly walked into the medical tent with assistance.
From what we can see, the medial and lateral stability is not assessed but that was evaluated in the medical tent. Knowing the ACL and PCL were intact, they would have then looked at the posterolateral corner stability to either look for additional damage or rule out any remaining concerns.
Looking at the LCL as a diagnosis, a positive varus stress test would have been found when they pushed on the inside portion of the knee which stresses the outside portion of the knee, eliciting pain. He would have also had warmth, swelling, and bruising later present.
What we saw on video was a standard examination done which based on results allows the examiner to identify what to assess next. Looking back, the only clue we get that this is an LCL is when Hairston briefly motions to the outside portion of his knee, but he references more of the front of the knee which the ligament doesn’t quite reach up that far forward.
Knowing that Hairston was performing the drill noted below, there was concern for ACL or other structures such as meniscus. What likely happened was Hairston’s cleat got caught in the turf and his knee potentially hyperextended as his weight shifted outward.
Rehab Timeline
LCL sprains are pretty rare in general. Often, they’re seen as part of a posterolateral corner tear or multiligament tears. This has been my experience as a physical therapist.
In the case with Hairston, this is isolated, though it wouldn’t surprise me if he has some unreported damage that the team will address. He may also have an avulsion fracture where a small portion of the bone comes off with the ligament.
Based on the initial reports, he likely only sprained the ligament. This is possibly a Grade 1 or even Grade 2 which responds favorably to rehab. Research indicates that even Grade III can respond to rehab but if the ligament needs surgery, a reconstruction is preferred versus repair which has a 40 percent failure rate. I would expect surgery in the event of the injury not responding to rehab.
Going back to the research timelines, on average, Grade I sprains miss 1.3 weeks of practice and 1 game, Grade II miss 3.5 weeks of practice and 2.3 games, whereas Grade III miss 4.6 weeks and 3.9 games. Hairston is looking at between two and five weeks according to the literature. My bet is that he’s dealing with a Grade 2 based on initial reporting timelines.
Breaking down specific cases within the research, those with similar positional demands such as safety and wide receiver, all missed between three and five weeks of practice and between one and three games with one exception missing 12 games, suffering another injury during rehab. All the specific example mechanisms of injury were the result of direct contact with the exception of the player who missed 12 games. They were injured due to a missed tackle.
Once players returned to play, they did have residual laxity between 1 and 3 mm of laxity within the ligament with no players requiring a knee brace after the season they were injured. Furthermore, no player suffered an ACL or PCL tear for up to 3.8 years after the specific study. There also did not appear to be any restriction on length of career upon return.
Finally, another similar study showed highly favorable returns in high grade sprains (Grade III) with players managed non operatively returning in two weeks. Four out of five players mentioned in that particular study returned in 10 days in a smaller sample size.
Rehab Outlook
His rehab will be slow and tedious but faster than the general population. Many rehab protocols show a return to sport after several months but with the resources of an NFL tear, return can occur sooner. The rehab team will focus on protecting the healing ligament while working on strengthening at the hip and knee while restoring the range of motion. There are plenty of traditional exercises such as step ups, squats, and hamstring curls along with stretching until it transitions to single leg exercises.
They will then progress to working in multidirectional planes of movement allowing the knee to restore function both from a strength standpoint and returning to functional activities. According to Evan Craft, ATC and Aaron Borgmann, PT/ATC, both former ATC’s with the Kansas City Chiefs, they discussed how LCL rehab works. Evan described it as slow due to the athlete not wanting to aggravate the healing ligament and hard to progress without making it sore.
We may see Hairston with a hinged brace initially during rehab but I do not expect him to play with this brace. Once we see him get out of a hinged brace into a compression sleeve or even tape going through activities, then that will give us a clearer point for return. When he does return, I don’t expect him to want to wear any bracing other than maybe a sleeve.
Comparable Players
As noted above, isolated LCL sprains are rare. The ones that we know are documented are WR Zay Flowers of the Baltimore Ravens, WR Treylon Burks of the Tennessee Titans and former Washington Redskins QB Robert Griffin III.
Flowers missed two games after injuring his knee in Week 18 during the 2024 season. It’s possible he would have missed more time but the Ravens were eliminated by the Buffalo Bills in the divisional round.
However, Flowers had a unique mechanism of injury. He suffered his injury when a Browns player ran into his leg and his foot hit his teammate’s leg, placing the varus force through the knee.
RG3 missed one game during his rookie year when he took a direct shot to the right knee. He returned to play after missing one game and later suffered a right ACL, LCL, and meniscus tear in the playoffs. While the studies above did show that players don’t suffer ACL or PCL tears later, RGIII’s was more traumatic afterward in general than the other isolated tears.
Burks suffered a left LCL sprain during training camp in 2023 and missed three weeks of practice before returning in Week 1, securing two receptions for 18 yards in a 16-15 loss to the New Orleans Saints. He suffered this injury in mid-August which was about two weeks later than Hairston’s injury when compared to the same timeline in training camp.
Regrettably, Burks did later tear his left ACL during a special teams drill in October 2024. This was also the same one he tore in high school in 2018. So it appears there are several ACL tears after LCL sprains, but two isolated cases in Burks and RG3 which puts some of the research into question.
Season Outlook
Due to the cautious nature of the Bills staff during training camp, they are not rushing Hairston back out there. Three weeks takes him to the week of August 17 and that means that he will likely miss every preseason game. Given the nature of the cornerback demands as he reacts to the ball or receiver versus dictating the action, Hairston may require extra time to adjust to performing this comfortably again. There will also need to be an assurance that he feels comfortable working on the knee and performing pain free movements.
He could realistically be ready for Week 1 from a health standpoint, but I’m not certain how ready he will be from a reps standpoint. If you recall, Cole Bishop missed most of training camp last year dealing with his shoulder injury. He ended up way behind and the injury certainly affected his development. If Hairston doesn’t play Week 1, it’s because of his knowledge, not the injury, barring setback. I also don’t expect them to place him on injured reserve to start the season given when the injury occurred.
Overall, Maxwell Hairston dodged a bullet on Tuesday. He should return fairly quickly and this should not linger into the regular season. Barring setbacks, he won’t need surgery, and while there are several isolated cases in Burks and Griffin III, there appears to be minimal risk to suffer further damage such as an ACL without another different mechanism of injury.
The Bills know how they want to progress him and once we see him out of the brace if he does have to wear one, that may allow us to get a more concrete timeline for his return. Currently, I don’t expect to see him doing meaningful football activities until the end of August.
I would like to wish Maxwell Hairston the best of luck in his rehab and return to the field.
Top Photo Credit: The Sports Animal
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