Week 6 Bills Injury Review- Texans & Allen’s Elbow

Well this isn’t good, this isn’t good at all. The ultimate form of adding insult to injury, though reversed. The Bills lost a very winnable game, dropping to 2-4 on the year, losing to the flawed Houston Texans 20-13 on a QB Nathan Peterman pick 6 to give the Texans the lead and the game. Adding the injury part, QB Josh Allen suffered what appeared to be a rather innocuous elbow injury, glancing his elbow off DE Whitney Mercilus’ helmet. However, he was able to attempt one more pass before exiting the game. Unfortunately, recent news has shed light on the severity of the injury. Today’s article will assess what Josh Allen did to his elbow and what it means going forward.

To give a brief anatomy lesson, the elbow is made up of 3 bones: the ulna, radius, and humerus. The elbow is primary comprised of the capitulum on the humerus fitting inside the semilunar notch which is part of the olecranon process on the ulna to make a hinge joint. Surrounding the joint are ligaments that provide support to the joint to provide support. These ligaments are the lateral collateral ligament, the ulnar collateral ligament, and annular ligament. The lateral collateral sits on the outside portion of the elbow, mostly injured due to fracture or dislocation. The annular ligament holds the head of the radius in place along the elbow joint, and the ulnar collateral ligament sits on the inside of the elbow. This is similar to the MCL of the knee in its function. It is more of a stabilizing ligament due to the throwing motion required in the human body. This ligament is made up of 3 bundles that spread out like a fan to cover the entire inside portion of the elbow. The elbow is a rather stable joint as compared to the shoulder or ankle, but as with any joint, can be injured with the proper forces.

In true Bills fashion, QB Josh Allen suffered a UCL (ulnar collateral ligament) injury to the elbow. This was the result of a bang bang play as Allen got hit from the left by Clowney, followed by Mercilus hit from the right, coming up underneath, hyperextending the rookie’s elbow. Initial thoughts were that he hit his funny bone off the helmet and had some residual numbness, similar though, to a lesser extent of the QB Marcus Mariota injury. However, later video review showed the arm in hyperextension which was worse but not terrible injury. At that point, I began thinking maybe he can come back this week or miss one game. However, recent video from Thad Brown revealed ironclad proof that this is an injury more severe than anyone thought.

The ulnar collateral ligament helps to provide medial support to the elbow so that the ulna does not shift off the humerus during elbow flexion/extension. This ligament also provides support during the throwing motion seen in many sporting activities. Injuries occur to this area as the result of acute hyperextension, excessive external rotation of the shoulder leading to chronic issues such as pitching, or a sudden forceful lateral stress to the joint during elbow extension which was the case with Allen.

In the video above, you can see the medical staff performing a milking technique or moving valgus stress test. The arm is put into full external rotation and the elbow is moved throughout its range, attempting to assess whether there is a painful response. In the video, there is clearly a painful response indicating a positive test. This test would not specify which band is injured, only the area in general. Due to this testing along with the mechanism of the injury, an MRI was performed to determine the severity of the injury. At this point in time, we know that this is not a season ending injury and we know that he will not require surgery as reported by Dr. James Andrews following a second opinion.

The reason it was the UCL that was injured was due to where the force came from. It came from below and outside the arm, pushing the inner portion of the arm up and out via the hyperextension, partially tearing the ligament. The reason everyone is hyper-concerned is that this is a rather famous ligament made popular by Dr. Frank Jobe and baseball player Tommy John in 1974. This is the ligament that stabilizes the inner elbow when a pitcher is throwing a baseball 100 mph. Dr. Jobe was able to surgically repair the ligament that Tommy John had torn and John was able to return to playing, racking up more wins in the process than he had prior to the injury. Today, this is known as Tommy John surgery and is typically a death blow to a pitcher’s season, hence the concern with Allen. Incidentally, many pitchers have since tore this ligament as a result of being bigger, faster, stronger along with overuse and sport specialization.

According to Dr. Andrews, Allen does not appear to require surgery nor will he be sidelined for the remaining season with the information that we currently have. This is something that many of us in the medical community believed prior to the Andrews report. This is an injury that like any ligamentous injury, will take some time to heal. Many conservative rehab guides along with medical professionals are looking in the neighborhood of 6 weeks for this to heal to the point of playing which would take the Bills past the bye week. I believe within this amount of time, he would be able to come back and while not 100%, would be close enough to be effective and continue to grow as a player. There are reports that he could miss 2-3 games but I think the Bills would be foolish to rush him back that quickly. It is likely that he will have some type of bracing on the elbow for protection.

While this is incredibly terrible, this will allow the Bills to let Allen rest and learn until he is ready rather than rushing him back out there and causing further damage to his arm. If this had been his non-throwing elbow, it would be more likely he would have been back by next week with bracing. This is an injury that despite best prevention, could not have been avoided. It was a collision and even with padding and protection, forces can still overcome the preventative measures.

Overall, UCL injuries are relatively rare in the NFL. Studies show that from 1994-2008, there were 10 UCL injuries with 9 taking 26.4 days to return and not requiring surgery. In addition, from 2010-2018, there were 12 UCL injuries with only one requiring surgery. Based on the past 25 years from those two studies, there has been 22 UCL injuries to QB’s in the NFL with only 2 requiring surgery. These numbers are smaller due to the relatively small sample size available. This is evident in the difference of the style of the throw, the amount of times the player is throwing, how many consecutive times a throw is performed, and the speed of the throw; all significantly less in football compared to baseball. While it is the same injury, the incidence is drastically different.

Thankfully, from baseball, we know how to treat this effectively. The non-operative rehab will consist of regaining full, pain free ROM in the elbow. They will also begin light resistive training to the area involving bicep/triceps work and grip/wrist exercises to build the muscles up around the area to give support as the muscles that perform flexion in the wrist and hand attach very closely to the UCL on the medial epicondyle of the elbow. As the ligament heals, he will begin to work on dynamic stability with grip and weight bearing through the arm. He will progress towards throwing progressively weighted balls along with strength training all while managing pain before resuming football activities. This injury, along with all other injuries, DOES NOT fit the motto of no pain, no gain. That motto doesn’t fly in therapy and will only delay his return to the field. The limited NFL research along with what we know about the baseball injuries will dictate when he returns. As he is young, he can heal quicker than an older QB, but this is not an injury that he should play through before he is ready as greater damage may occur as a result.

While this was a majority of the article as it is a major topic, there were other injuries that occurred during the game. DE Trent Murphy injured his left ankle late in the 2nd quarter. He appeared to take an odd step and came up limping slightly, missing several plays. He was able to return and it does not appear that he sustained any noteworthy damage at this time.

OG Vladimir Ducasse suffered what was reported a left knee injury early in the 4th quarter and was questionable to return. He was able to jog off the field with a small limp and was seen after the game walking in the tunnel without apparent pain. On video, he got hit from behind and got rolled up on. My initial reaction thought maybe mild high ankle sprain with how he fell or some type of contusion to the calf region. He could have also came directly down on his knee due to getting hit, causing discomfort. Either way, it doesn’t appear to be serious and we will know more once the injury report comes out tomorrow.

While this was an incredibly lengthy article, I hope that you walk away from this knowing that Josh Allen will be ok, not all injuries are avoidable, and the Bills are still relatively healthy compared to other teams in the league.

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