History of the ACL Reconstruction

Analyzing the history of the ACL injury including high level athletes who were able to succeed without an ACL and potential complications later in life.

Welcome back to Banged Up Bills! Today’s post will take us back in time to the 1970’s and 80’s, before the Bills reached untold greatness and the legends of Orchard Park were coming into their own. Looking back to 1986, RB Thurman Thomas of the Oklahoma State Cowboys partially tore his left ACL in a pickup basketball game in the off-season, placing his junior season into question. Fortunately, despite recovering and achieving All-American status his senior year, the known history of this partially torn ACL ultimately caused his draft stock to slip, allowing the Bills to steal the future HOF in the 2nd round of 1988. The article above mentions that he suffered the ACL injury and had arthroscopic surgery to assess the damage, but the ACL was ultimately never reconstructed at the time. Recently, it was revealed on Twitter that Thomas successfully played his entire career with a partially torn ACL; according to him, 85%.

While some said he was a GOAT for playing with an injury of that magnitude, it is more astonishing that he was able to perform at such a high level despite knowing what we know now about ACL tears. Today’s post will explore the history of ACL repair, why Thomas most likely did not have the surgery, other NFL players who were able to succeed without an ACL, and potential complications they may have today as a result.

Looking at a brief history of the ACL injury, these types of maladies have been explored for centuries, going back to ancient times when the true gladiators battled against each other. When injuries such as the ACL tear occurred, doctors such as Galen would be able to further explore the inner workings of the knee through gashes suffered in battle and identify these complaints, though surgical intervention was centuries away. Fast forward to the late 1800’s, further examination and surgical intervention came into vogue with the advent of X-ray and a better understanding of the function of the ACL.

However, it would still take nearly 100 years to develop effective treatment of the ACL to what it is known today. In the 1970’s, doctors were aware that the ACL had an impact on knee function but testing for injury and surgical intervention were still in its infancy which led to many methods of repair with a wide variety of overall poor outcomes. Initial surgeries would open the knee up with rather large incisions and attempt to repair the knee with a variety of material including hamstring, patellar, cadaver, and synthetic grafts.

Surgical techniques were improved in the 1980’s with the use of arthroscopy, however, this time period also saw high rates of materials failure and complications several years after a repair due to synthetic grafts. There was also not a general consensus on the best method to repair the damaged ligament. In addition, there was published research arguing that nonsurgical interventions was just as effective as surgery in outcome scores with regards to function, though they did note that surgical repairs led to a more stable knee in comparison.

Attempts were made to identify a consistent rehab plan for the ACL as surgery techniques improved. Regrettably, the rehab plans were determined later to hinder the patient recovery and led to greater failure rates after returning to sport. Several pearls from the above mentioned ACL rehab plan that would not be considered today include:

  • casting and immobilization of the surgically repaired leg for 6-8 weeks
  • immobilization between 30-60 degrees in flexion
  • either toe touch weight-bearing or no weight-bearing allowed during this time frame

Most of these interventions were thought to preserve the integrity of the ligament by limiting movement with the ACL on slack with the knee in a flexed position. The thought was a fully extended knee placed undue stress on the repair and could cause premature rupture in weight-bearing.

Research later found patients that were non-compliant with their rehab protocol actually had better outcomes than those who followed the rehab precisely. Those that were non-compliant were removing their casts and beginning movement/strengthening sooner than advised but were found to be able to return to full function with less pain and overall greater satisfaction which forced the medical community to reevaluate the protocols.

As there was so many varieties of materials for repair, no gold standard for repair technique, and a poor understanding on proper rehabilitation, its no wonder that Thurman Thomas avoided having the surgery all together. He would most likely been worse off having the surgery than playing without a repair. I believe that with all the uncertainty of surgery methods/outcomes, the experience with ACL repairs of the treating orthopedic surgeon, and his potential career prospects, reconstruction was not performed. Fortunately, his knee was able to withstand the demands required of his position with protective bracing throughout his career despite the tear.

Thomas was not the only one that declined surgery and managed to play with an ACL deficient knee through their career. HOF QB John Elway tore his ACL in high school but was still able to recover without surgery and have a long career in the NFL. It is noted that this was his non-plant leg which reduced the incidence of pivoting which may have allowed him to avoid further issues. It has also been reported that Yankees great OF Mickey Mantle tore his ACL during his rookie season and was able to play his entire career without an ACL. I believe that Yankee fans are unanimous with how great he was despite his injuries. As I stated in my previous article, it is possible to live a normal life without an ACL, though still very difficult to play at a high level without one. Thomas, Elway, Mantle, and a more recent example of WR Hines Ward of the Steelers are several exceptions.

The only consistency that I see is that all of these players were relatively young; >20 years when they tore and may have still been growing into themselves, which allowed their bodies to adapt and compensate with the deficiency. However, pediatric ACL tears still benefit from surgical intervention with nonoperative management and potentially causes problems later in life which refutes the statement above regarding youth ACL tears.

Research supports the use of surgical intervention with some variances in techniques and rehab but generally, surgery is the gold standard in order to return to full ability. We have seen the power to return to sport after ACL reconstruction with an 82-95% success rate. Through rigorous studies, the medical community has also found that proper reconstruction has reduced future injuries and complications significantly. These included future meniscus tears, corresponding ligament injuries, and arthritis. In Thurman Thomas’ case, it is unknown whether he has had any further complications, though several reports in 2001 indicate that he tore the right ACL which ended his NFL career in Miami.

With these complications arising from avoiding ACL surgery as several studies supported in the 1980’s, eventually the ACL injury could have degraded the knee to where loss of function was significant and few interventions available to provide relief once it got to that stage. Knee replacements are available which restore function and movement, but those are typically reserved for those patients that are much older with ages into 50+ and have reduced their athletic activities. People in their 20’s-30’s are not ideal for a knee replacement and should not be considered unless certain exceptions arise which are typically not sport related. If the players mentioned above have not already had a knee replacement due to the punishment of the sport, they are most likely considering the possibility.

As a whole, ACL reconstruction continues to be the primary intervention to allow athletes to return to sport. There are doctors that have begun to swing the other way again, rejecting surgery in the case of Miami Dolphins QB Ryan Tannehill when he partially tore his ACL late in the 2016 season. The corresponding rehab was ultimately unsuccessful as he re-injured his knee in training camp the next year. Eventually there will be interventions which reduce the healing time in the surgically repaired knee or there may be effective non-surgical interventions. It took over 20 years to really establish a consistency for ACL repair; it may take even longer to identify interventions that don’t involve surgery.

I found this research to be fascinating as the history of medicine has changed so drastically over the years and its incredible to think that these previous methods were cutting edge at the time. Thankfully, studies and constant refinement of the process has allowed high level athletes return to full ability instead of potentially ending their careers. The quality of interventions will continue to improve with medical advances and maybe 30 years from now, we will be looking back and say “what were we thinking?” Until then, we will work with what we know best.

Continue to check back for the latest updates from @BangedUpBills on Twitter and at www.bangedupbills.com. I will be pumping out a lot of content with training camp coming up and as players begin to suffer injuries. As always, thank you for reading and GO BILLS!!

NFL Injury Series- ACL Tears

Complete analysis of the ACL injury and associated rehab including timelines for recovery.

Today’s article begins a series that precludes the start of training camp and will review the most commonly sustained season-ending injuries in the NFL. Objectives of this series are to help educate fellow fans on the severity of each injury and timelines for recovery. Unfortunately, when these injuries occur, Banged Up Bills will have you covered. Nearly all of these injuries are season ending or become chronic if not managed properly. The first post will assess ACL injuries.

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 keeps 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.

Credit: kneesurgerysydney.com.au/acl-reconstruction/

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 happen 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. 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: sex, age, playing surface, level of play, biomechanical variances, previous injuries to the knee, equipment, and environmental conditions. Recent research has also shown that concussions can possibly increase the risk for injuries such as ACL due to slower reaction times.

Credit: medline.gov

As with many injuries, players are not able to return to playing and require further evaluation once in the locker room. X-rays are taken to rule out fractures and special tests are performed including but not limited to: Lachman’s test, anterior drawer test, and pivot shift test. All of these tests rule assist in physically identifying that the ACL is damaged. Typically, when performing the Lachman’s or anterior drawer test, there will be increased laxity when moving the tibia in the opposite direction of the femur. There are 4 grades to determine ACL severity which grade out how much the tibia pulls out in relation to the femur. Grade 1 is <5 mm progressing in severity up to Grade 4 which is >15mm.

Another test that may be performed is a posterior drawer test. This is the opposite of anterior in that it tests for a PCL injury. The reason this is performed is due to the possibility of PCL injury instead leading the tibia to sag back which could initially mimic the laxity seen with the anterior drawer test. A pivot shift test mimics the injury mechanism of the ACL tear and will typically illicit pain and possible clunking which would signify a subluxation of the tibia. To confirm the ACL tear, MRI imaging will be performed once swelling is subsided. Otherwise, the excess fluid could occlude the view of the tear and make the imaging inconclusive.

Once the tear is confirmed and swelling has reduced, surgery is scheduled to repair the structural damage. Regrettably, the ligament cannot be repaired through simple means such as sewing it back together. The ligament has to be cleaned out and repaired through use of a graft. These grafts come from commonly the hamstring or the patellar tendon which are known as autografts or through the use of a cadaver also know as allograft. There are other options which include xenografts which come from animals and lastly, synthetic grafts made from carbon materials or Gore-Tex. While medical research has improved drastically, the preferred method still appears to be the autografts as this comes from within the patients body and have lower rates of failure. The surgery is performed by anatomically lining up the graft as the ACL would normally be in and screwed in to allow to heal to the bone.

Recovery from an ACL tear takes anywhere from 9-12 months to return to full, unrestricted activity. However, there may be concurrent damage sustained in the knee which could include meniscus tear, MCL/PCL/LCL tears, or cartilage damage which could lengthen recovery time. Once the surgery is completed, the first 2 weeks is spent allowing swelling and initial tissue healing to begin. Passive range of motion along with light strengthening of the surrounding muscles is performed. After several weeks have passed, range of motion is increased with emphasis placed on full extension or straightening of the knee which will allow the person to be able to walk fluidly through the gait cycle and fully bear weight.

As the range of motion increases, higher level strengthening activities may begin through the saggital plane which involves motion going forward/backward over the next 10 weeks. During this time, strengthening exercises are primarily composed of closed chain exercises. This means that the foot is in contact with the ground or other surface as the knee performs its movements. Open chain involved exercises that allow the lower limb to move freely which if performed too soon, may place excess torque on the repaired ligament which could cause potential failure if pushed excessively.

Once full ROM is re-established, balance exercises are incorporated to regain proprioception which allows a person to sense their joint and body in space. This awareness is crucial as if the athlete has a poor awareness where their body is at during movement, they are at a much greater risk for injury. After 3 months out, they may continue progressing to running exercises going forward, backwards, and slowly begin agility drills once fitted for an ACL brace. These braces are commonly used to prevent future ACL injuries by restricting rotary and hyperextension forces. The recovery timeline is so long due to the purpose of the ligament and its makeup. As stated before, a ligament attaches bone to bone which creates stability for the joint. Add in the stresses that the joint goes through during running, jumping, and cutting motions, proper healing is required so that the ligament can perform effectively. Lastly, ligaments unfortunately have poor blood supplies which slow down healing time unlike muscles or tendons which have a rich blood supply allowing those tissues to heal quicker.

Credit: betterbraces.com

Once a patient has reached the 6 month plateau in recovery, they must meet certain minimum criteria to begin even considering returning to sport. They must:

  • demonstrate quadriceps and hamstring strength at least 80% that of the noninvolved leg
  • full motion
  • no recurring swelling
  • demonstrate stability both with physical testing and mobility
  • completing a running program

In higher level athletes, the running, jumping, agility set them apart from the general population and because of that, these athletes require further training in order to return to their respective sport. Athletes must be re-educated to safely land, cut and change direction, and essentially relearn how to use their reconstructed knee. Overall, 6 months is a considerable amount of time to heal properly which explains why this is a season ending injury. As the NFL season is only 6 months long, even with the best rehab, it wouldn’t be realistic to return.

However, why if a person is able to get to full recovery after 6 months, why are they out longer than that? Research has shown that the risk for re-injury decreases by over half each month up to 9 months before returning to sport. Once a player does return from an ACL repair, they are at a much higher risk to re-injure with rates up to 20-30% for up to two years after injury. These are the reasons why it takes nearly a year to return to full ability prior to the injury. Overall, ACL reconstruction success rates today are between 82-95%, a significant increase from 50/50% success in the 70’s & 80’s.

Many high level players can and do return to full abilities with proper rehab and training. It is terrible to see a player put all that hard work and training into getting ready for a season for it to all end with an injury such as this, but until medical science improves the healing process so much that players can shorten that 6 month window for healing, we are stuck with the current system. As a fan, I am praying that the Bills continue to avoid major injuries such as this as they were fortunate last season.

This wraps up the first article in the sports injury series. Continue to check back at Banged Up Bills on Facebook and on Twitter @BangedUpBills for the latest articles. As always, thank you for reading and GO BILLS!!

Week 9 Recap- Jets & Zay’s Knee

Analysis of Zay Jones’ knee injury, Taiwan’s forearm, and a recap following the Jets game.

Whether you are a Bills fan or not, reading this, Thursday night was not a good game. Period. The offense never got moving until it was too late, the defense made Josh McCown look fantastic, and the Bills let one slip through their fingers. They’re now 5-3, 1 game back in the AFC East and currently holding the 1st wild card spot. Despite what the Bills fan base says after this loss, the sky is not falling. Every divisional game every year is a grind it out close game due to rivalry and pride. At the end of the day, the Bills came up short and now we will see how they respond. Last time they started 5-2, they lost 7 straight games. I don’t think this team is capable of a losing streak of that magnitude, but many men before me have been wrong.
Getting down to the injury side of things, it was one of the more rougher nights for the Bills this season. Several key players were returning from injury on a short week and several more key players sustained injury. First up is RB LeSean McCoy. McCoy injured his groin on the first offensive series of the game and had to leave briefly. McCoy was able to return shortly afterward but anyone could tell that he wasn’t the same. He lacked explosiveness, inability to cut hard, and unable to move the ball, rushing for only 25 yards. McCoy is the engine to our offense and if he goes down, then losses to the Jets are what happen. I don’t believe this will be a lingering issue as he was able to play the entire game and he has 10 days to rest. To add, he was able to run and perform some cutting, but lost the explosiveness he is known for. I would categorize this as a Grade 1 groin strain which should heal with proper management.
Next injury is WR Zay Jones. Jones suffered a right knee injury after being tripped late in the 2nd quarter. While trying to regain his footing and preventing falling down, Jones stepped awkwardly and hyperextended his knee, falling to the ground immediately. Upon initial observation, one may think ACL. The mechanism for injury was there but Jones avoided that. It appears as though he sustained a hyperextended knee, similar to what Bryce Harper sustained during this past MLB season. It is unknown whether he sustained a bone bruise similar to Harper but further evaluation is required.

Jones was remarkably able to return and play the rest of the game, hauling in several more passes before being injured again in the 4th quarter. There are several reasons why Jones was able to avoid the dreaded ACL tear. First, the knee acts as a hinge, similar to what is seen in a door. The knee bends and extends fully but with various forces, can go past their normal limits. In Jones case, his knee extended further than typically what is available. This injury happened due to the fact that he planted his right foot, attempting to stay upright while falling forward, leading to the joint to give.
Jones avoided a worse injury due to the fact that he was falling forward as he was planting his leg. His ankle joint was able to absorb some of the force, with the foot initially going into plantarflexion or pointed downward to stabilize as his knee was bending back. Thankfully, his foot did come up off the turf into dorsiflexion or bending up as he fell forward. Had his foot been stuck more in the turf or been hit directly through the knee, the injury would have been worse. Finally, it helps that he was not able to pivot to change directions laterally, leading to preservation of the ACL. In injuries such as this, there is concern for the PCL which prevents the knee from going backwards like that, but as he was able to return, it does not appear that he tore the PCL. There is concern for a PCL sprain or bone bruise upon further examination, but with the extended break, it may be inconsequential. As there is no updated information at this time noting severity, it is unknown whether he will miss any time. Chances are he won’t, but too early to tell. Either way, Zay Jones caught a very lucky break Thursday.
I’m overall surprised that he was able to return to the game and continue to run effectively after the injury. I believe that our medical staff would not put a player back out there that could risk further injury especially at a high level position. I did observe him wearing a compression sleeve but no bulky bracing which will assist for any swelling but provide minimal support.
Finally, Taiwan Jones got injured while trying to recover an onside kick late in the 4th quarter. Upon getting up to a seated position, the medical staff was supporting Jones’ left elbow indicating possible elbow injury or shoulder. Replays show that his arm got caught up in the pile and a helmet crashing into his forearm during the onside recovery. Unfortunately, reports indicated that Taiwan Jones fractured his forearm and will be done for the season.
A fracture is quite simple in terms of injury severity. A bone is broken at some point in the structure leading to instability and significant pain. Jones did not sustain a fracture which protruded through the skin which allows for the management to be more conservative. He will possibly require surgery depending on the severity and complexity of the fracture. He could hypothetically come back if they pushed recovery, but it is a bigger bone compared to what Jordan Matthews and Ramon Humber sustained and would require extra stability. Had this been McCoy or Taylor, it may be considered to push for a return. While Jones is an important part of the team, he is not what drives the offense. Placing him on IR will allow the Bills to bring in a new player to gain experience to provide depth and try out for next year.
As the Bills have an extended break between games, this allows these injuries to have a greater chance to get healthy with the exception of Taiwan Jones. As I’ve said before, no NFL team is immune from injury. The Bills are doing incredibly well with avoiding serious injury. However, despite that luck, the Bills still have to win those games that are winnable to turn things around for long term success. Going into the Saints game, while their offense continues to be high powered, their defense is suspect and will be playing at New Era Stadium which will provide a favorable atmosphere for the Bills to go 5-0 at home.

It has been reported that TE Charles Clay and CB E.J. Gaines should be returning from injury. It is surprising that Clay is able to return quicker than originally thought, but is a welcome addition. Gaines returning will provide an immediate upgrade to our secondary that without him, may be exploited by Drew Brees and the Saints.

Continue to check back for updates and new articles regarding Bills injuries and other topics of interest. As always, thank you for reading and GO BILLS!

2017 NFL Preseason Injury Breakdown

Final analysis of the 2017 NFL Preseason Injury Breakdown. Looking at the injuries that occurred, how many service years, position, and by team.

As promised, the long awaited preseason breakdown! This article has been difficult to write due to accuracy and constant changes. As the first game of the NFL season has already been played by the time of this publication, I can say these are the final numbers. At the end of the day, the NFL is a business, players are looking for jobs, and something as simple as an injury can derail those prospects. The intended purpose of this article is to identify types of injuries, breakdowns involving teams, years played, and when the injury occurred. At the beginning of training camp, at least 2,880 players vie to make an NFL roster. Of those 2,880 players, only 1,696 reach their goal. That’s only 59% of the players that make it. This doesn’t account for all those who were unfortunate enough to be injured, cutting short their chances even before they had a shot.

As of 9/8/17, 328 players have sustained some sort of injury during the preseason that has sidelined them to either miss significant time or season ending. Of those that had sustained significant injury, 211 went to IR, 117 went to IR with an injury settlement which meant that once healthy they could sign with another team. Out of those 117, 3 players have already resigned with different teams. To understand what an injury settlement means, please check out this article.

Out of the reported injuries, the knee was the most common body area for injuries. 66 players sustained injuries which includes 29 ACL tears with a scattering of general knee injuries and meniscus, other ligament damage, or patellar tendon tears. This was followed by 31 ankle injures, 29 thigh injuries mostly consisting of hamstring strains, and 23 shoulders consisting of generalized shoulder injuries. Following up the breakdown of injuries, 21 arm injuries consisting of arm, elbow, wrist, hand, finger; 15 head injuries consisting of concussions, 13 back injuries consisting of disc issues; 12 hip injuries consisting of groins, and finally 8 lower leg injuries with mostly fractures. The remaining injuries were 32 undisclosed and 59 unknown.

Some of the teams were hit harder than others with the injury bug. Leading the way with injuries was the Colts with 17. Following close behind with 16 was the Jaguars and with 15 was the 49ers and Ravens. Tied for 14 are the Texans and Panthers. This was followed by the Giants with 13; Titans, Jets, Chargers, and Bears with 12. The teams with the least amount of injuries were the Broncos, Vikings, and Raiders with 5 and Packers with 6. As this is a Bills blog, the Bills finished with 8 players injured. Most Bills players were waived with injury settlements which meant that had they not gotten injured, they may have been cut.

During this analysis of player injuries, the highest number of injuries by position was at WR with 60. This was followed by LB at 49, CB at 40, followed up by TE at 28, and S at 26. The least hurt position was K with 0 and P with 1. Considering that the highest injuries involved positions with a wide variety of high impact movements, this is not surprising. Overall, 162 Defensive players were injured, 162 Offensive players were injured, and 4 special teams injured.

It was found that if a player was new to the league, the chances of injury were drastically higher. Out of the years of service, 100 rookies were injured, 70 2nd yr players. 58 3rd yr players, and 37 4th year players. According to ESPN, the average NFL career is about 3.3 years. Out of the 328 players injured, 265 fell in that time frame which accounted for nearly 81% of injuries.

Finally, while there is little information on when the injuries occurred, I was able to find that as the preseason wore on, injures increased. Preseason game 1 brought 19 injuries. Game 2 brought 12, Game 3 brought 24, and Game 4 brought 31. There has been talks to reduce preseason games, reducing the last 2 games alone would reduce 54 injuries or 16.7% of injuries in the preseason. Many more occurred in practice or in an unknown, but NFL setting.

Going down the rabbit hole, out of the 29 ACL tears, 11 were rookies. Looking at other injuries, no other trends stood out that was alarming; a variety of hamstring, foot, ankle, and concussions. Out of 2nd year players, 6 had ACL tears, but no one other group of injuries lead the way. Looking at 3rd year players, 4 ACL tears occurred with no other significant injuries noted. So to recap, 21 of the 29 ACL injuries were sustained by players 3 years or younger in the league. This brings up the question, are these players coming into the league not physically prepared? Are they not adapting to the increased speed of game play? What is the root cause? I do not have the answers at this time.

Finally, out of the ACL tears, the 49ers and Patriots were hit hardest with 3 players lost for the season with ACL tears. There were several other teams with 2 which included the Bears, Dolphins, Ravens, Seahawks, and Texans. For 29 tears over the course of the preseason between 32 teams, 7 teams accounted for 18 of the 29 ACL tears which comes out to 62% of the tears this preseason alone. Once again, what are the factors behind this? Coaching? Field surface? Luck? Many different factors at play.

I know that this breakdown only scratches the surface of the injuries during the preseason. I know that further analysis can be inferred from the raw data. At the end of the article, the raw data will be available for you to analyze and process at your own leisure. If there are any questions, comments, or concerns, please message me and I will get back to you. Thank you for reading and please continue to come back for further information! Future articles will consist of revisiting the Kevin Everett cervical injury 10 years ago and injury breakdown following Bills-Jets game.

NFL Training Camp Injuries 2017

Preseason Injury Breakdown Part III

Highlighting the injuries around the NFL following Preseason Week 3.

Another week of preseason football down, another week of major injuries to report! These injuries are not bumps, bruises, scrapes that an athlete would sustain over the course of playing football. These injuries continue to be severe, career altering, and out of control. If you would like to review the injuries from this preseason, please read Part I and Part II. Right now, there are 170 significant injuries that have forced players to either be injured enough to be injured/waived, miss extended time, or season ending.

Digging into this week’s preseason injuries, 23 players have been added to the IR or expected to miss extended time. Most of the injuries reported this week occurred during preseason games. ACL tears this preseason alone continue to skyrocket at an alarming rate, currently at 26 players. WR Julian Edelman (Patriots), LS Patrick Scales (Bears), WR Cameron Meredith (Bears), DE Matthew Godin (Texans) and LB Albert McClellan (Ravens) all ended their respective seasons in preseason Week 3 contest with the exception of McClellan going down in practice on Friday. McClellan and Edelman’s injuries were non-contact tears and Meredith, Scales, and Godin tore during contact plays. Special note, there have now been 2 long snappers that have gone down for the season due to ACL tears. This is concerning as long snapper is a lesser known, but vital position to every NFL club.

Other significant injuries to note are LCL/PCL tears, fibula and foot fractures, quadriceps tears, and tibial plateau fractures. The other 13 injuries consisted of undisclosed/unknown or various sprains. Once again, injuries are expected to occur, but the severity is what is most concerning. There have been studies that analyze adjusted games lost compared to win totals. Some of the least injured teams still missed the playoffs, yet teams that lose more players to injury still make the post season often and go deep frequently. Football Outsiders did a fantastic job analyzing these trends with reports going back several years. I would like to note that the adjusted games lost does not equate to specific win totals, but may indicate how crucial depth is towards overall success.

Breaking down which teams got hit the hardest by injury include: Bears & Cowboys with 3 each followed by Giants, Jets, and Patriots with 2 each. It appears the Bears have been hit the hardest, sustaining 2 ACL tears along with another player requiring wrist surgery, missing extended time. The Patriots continue to be hit hard, losing players in back to back weeks with season ending injuries. No team is immune to this, but some are clearly more fortunate than others.

Once again, the Bills for the most part escape without any season ending injuries. It was reported that both Tyrod Taylor and T.J. Yates both sustained concussions and are currently in the league’s concussion protocol. This leaves Nathan Peterman as the only healthy QB on the roster at the moment. The Bills did sign QB Keith Wenning who is familiar with OC Rick Dennison’s offense, but don’t expect him to stick around once Taylor and Yates are cleared to play. Besides the two concussions which hopefully won’t keep either out for long, the Bills continue to maintain a relatively injury free preseason. How this will translate to regular season games is anybody’s guess, but having a healthy team with depth is one step towards long term improvement.

Finally, the preseason end is near! The Bills wrap up the preseason with the Lions coming to New Era Field in a Thursday night match up. This will allow the coaching staff to address some of the problems including O-line play, penalties, and scoring. As a fan, therapist, and writer; I pray that the Bills get through this game without major injury going into the Jets game with the best roster possible. As the Jets have been touted as one of the worst teams this season, I do not expect them to roll over, especially Week 1. Expect a tough, grind it out game for the early part, with the expectation that the Bills pull away due to the increased talent on their roster. Look for Preseason Injury Breakdown Part IV coming up after the Lions game. If there are any specific injuries or players you have questions about, feel free to contact me.

Big Problem with Streater’s Big Toe

Analyzing Rod Streater’s Toe injury sustained during Preseason game 2.

As the preseason drags on, injuries continue to occur and further shape rosters ahead of cut down day on September 2nd. Some players are already assured roster spots, but others that need to still prove it or that are fringe players, every snap counts. One of these players that may still need to prove it is Rod Streater. Until last week’s game against the Eagles, Streater has had a solid camp, rebounding from a pair of foot injuries with Oakland that cost him sizable chunks of two seasons before regaining his footing with the 49ers last season. As Streater went undrafted coming out of Temple in 2012, he has had to fight every year for a roster spot. Seeing Streater go down with a toe injury in the 4th quarter certainly strikes a blow to his chances for a roster spot.

Today’s post will evaluate the possible injury Streater sustained in the Eagles game. I will also briefly assess any other injuries that occurred during the game, which was largely injury free Bills wise. Streater’s injury was by far the most notable injury to come out post game. Considering that later reports narrowed down the injury to a toe helped reduce the number of possible injuries significantly. Reports have indicated that he is not in a walking boot, not expected to miss any significant time, and is week-to-week.

Knowing the previously mentioned information, we can eliminate any fractures, dislocations, or any other possible areas of injury. While there are not any specific reports of the exact diagnosis, I can safely assume that Streater sustained a turf toe injury. A turf toe injury occurs when the big toe becomes injured, specifically hyperextended or bent back abruptly. This could occur during landing on the big toe, causing it to bend backwards and cause immediate pain. It was reported that he was dragged down to the turf following a catch in which the toe could have been caught, leading to the injury. As every other part of the body, each bone is connected to another bone via ligaments. An injury such as this could stretch out the ligaments supporting the big toe and create instability.

As a toe may seem insignificant when there are much greater injuries such as ACL tears, broken ribs, concussions; it is still vital to the overall function of the athlete. The big toe is vital to running due to this being the area that is pushing off the ground. If humans did not have a big toe, the running stance would be greatly altered. Try to walk without pushing off the big toe, very awkward in walking, nearly impossible in running. The toe also assists in balance stability during walking and standing, allowing us to stay upright compared to our four legged friends.

Having an unstable area that prevents pushing off limits the ability to run routes and sprint. Turf toe injuries can become a chronic problem if not managed correctly or if forced to return sooner than possible. Thankfully, Streater’s injury does force him to sit out, he will not miss any vital games. At this time, he would not be a candidate to be sent to IR, but would most likely be placed on the roster until he is fully ready to play. Considering he is week-to-week with a toe injury indicates that it may be a Grade II injury marked by moderate swelling, partial tearing of the structures around the toe, along with range of motion limitation and pain. To further differentiate between the severity of the injury, Grade I would be minimal swelling and bruising with some pain. Grade III would be significant swelling, total disruption of the surrounding structures of the toe, noted weakness during toe bending, and concurrent instability of the toe.

Surgery would only be indicated if there was an avulsion of the bone, any concurrent fractures, significant deformity, or failed conservative treatment, among other complications. As there are not reports that he is immediately having surgery, Streater will require rehab focusing on restoring range of motion to the toe, allowing pain and swelling to reduce. Once this has taken place, strengthening exercises will be performed, slowly loading the toe to build up strength and not cause further injury to the area. Once Streater is able to walk without any difficulty and report no exacerbation of symptoms, then he would be progressed to running, jumping, etc, eventually being cleared to return. Streater may also be fitted with a stiff soled shoe to limit extra stress on the toe during push off to reduce re-injury.

Expect Streater to miss the next 2 preseason games, at worst missing the first game in order to return to full health. As he is not considered to be more than a 3rd to 5th receiver, there are other players that can step up in the interim until Streater is ready to return. According to mock 53 man rosters, he is not on the bubble as some other players, but would benefit being healthy to ensure his spot and adequate playing time.

Other injuries to note coming out of the Eagles game, TE Jason Croom injured his ankle during the game and has since been placed on injured reserve. Also, S Trae Elston injured his hamstring, leaving towards the end of the game. There have not been any additional reports regarding Elston indicating that it is not serious. The Bills are halfway through the preseason with no major injuries. As a fan and professional, I do not recall a time when they did not suffer some type of major injury in the preseason. Looking at the past 2 preseasons under the Ryan/Whaley era, there had been 4 ACL tears in 2016, 1 in 2015 along with various other injuries including Sammy Watkins foot injury. This is a nice change of pace for the Bills and hopefully this trend continues. Most of the big name players will be out against the Ravens this Saturday, allowing those injured to continue resting and prevent new injuries from occurring. Continue to check back with new updates following the Ravens game.

Preseason Injury Breakdown Part II

Highlighting the injuries around the NFL following Preseason Week 2.

The NFL has finished preseason week 2 and the only constants are that rather meaningless games are being played and players continued to be injured. Since Part I of my preseason injury analysis, 29 players have gone down with some type of significant injury. While it is difficult to gauge the exact players due to dates and delayed reporting by teams, there is still a sizable amount of players placed on injured reserve or expected to miss significant time. Please be aware, there are some players that have been waived with injury settlements that have either signed with a new team or they are in the process and will alter the numbers when final count is made at the end of preseason.

Once again, the Bills escape the injury bug with major role players. The only player to note is rookie TE Jason Croom was placed on IR with an ankle injury. Reports are scarce on the severity of injury, leading to the possibility that he may get an injury settlement at a later date. Previously, I had highlighted the fact that the New England Patriots missed the injury bug up to that point. Within a day of publication, rookie DE Derek Rivers went down for the season with an ACL tear and sprained LCL. This occurred during a joint practice with the Texans on kickoff coverage. Rivers was the Patriots top pick of this most recent draft in the 3rd round.

To add to the ever increasing ACL tear total, the current number is 21, adding 3 from last time. With the previously mentioned Rivers; also suffering torn ACL’s were LB Tank Carder of the Browns, and LT George Fant of the Seahawks. All of these tears occurred during the 2nd preseason game with the exception of Rivers who was injured during a full speed drill during practice. According to the ACL Recovery Club on Twitter, there are on average of 50 ACL tears/season. Already through 2 preseason games, the NFL is rapidly approaching the halfway mark.

While there is a smaller sample size with this article compared to the previous article, there still have been several other serious injuries. Shawn Williams of the Bengals dislocated his elbow and is expected to be out 4-6 weeks. Danny Shelton of the Browns sprained his knee and is expected to be out 3-6 weeks. Keeon Johnson of the Giants fractured his foot, requiring surgery, landing on IR. The rest of the injuries consisted of generalized ankle, hamstring, and unknown injuries. Depending on the value the team has placed on that particular player will determine whether he gets released or spends the season on IR. To make special note, I am not including Odell Beckham in this due the minor ankle injury he sustained in Monday nights game against the Browns. He is on track to possibly return Week 1 and has not reported any significant damage.

Thankfully, there are not any superstars on this most recent list. Unfortunately, there are some significant role players that did dent that particular’s team depth. I expect that several role players to go down, continue to see major injuries occur, and several teams fortunes change based on these outcomes. Of the teams hurt the most of the past week, the Browns and Giants lead the way with 4 players followed by the Seahawks, Colts, Buccaneers, and Bengals with 2. Continue to follow this blog for updates and new articles. If you have any specific injuries or players you would like me to analyze, please leave a comment, message me via Twitter at @kyletrimble88 or e-mail me at kyletrimble88@gmail.com.

Preseason Injury Breakdown- Part I

In depth analysis of the injuries occurring around the league. This article highlights areas of concern and injuries through the 1st preseason games.

Since Sunday’s post, every NFL team has played one preseason game. Depending on which fan base you speak to, it has either been a fantastic or horrible preseason. I’m willing to wager that those that rate their team’s preseason as horrible may be due to injury. If you’ve been following Twitter, ESPN, or local news, there’s been numerous reports about the significant injuries that have possibly derailed the regular season before it has even begun.

I have previously mentioned that I am focusing this blog on Buffalo Bills injuries. However, as I am a Physical Therapist, this allows me to expand as I wish into other areas of interest. Since the beginning of the preseason, I have been tracking nearly every injury that has occurred in camps around the NFL. Injuries that I deem worth tracking are ones that force a player to miss extended time, season ending, or placed on injured reserve. For my analysis, these injuries must have occurred during the preseason. Those that had off season injuries/surgeries or injuries from last year that are still recovering are not included in this analysis. This allows for a more specific time frame to be assessed. As of publication, I fully expect these numbers will change. Players will continue to get injured, waived, and reach injury settlements. My goal with this article is to highlight areas of interest and concern.

Of what has been publicly reported so far, there has been 119 players that have been either placed on injury reserve or expected to miss significant time. Of those 119 players, 26 have been released with injury settlements, allowing them to heal on their own time, get compensated, and seek out opportunities with other teams once they are cleared. If you would like additional information about the waived/injured status and process of injury settlements, please check out this article. Most of these injuries consist of hamstring pulls, ankle sprains, and unknown/undisclosed injuries. The most unique injuries of this group are a bruised lung and a Jones fracture, the same type of foot injury that sent Sammy Watkins packing to the Rams.

Of the 93 remaining players, 16 of these players have not been placed on injured reserve. These injuries consist of rather significant injuries consisting of various fractures and surgeries. These are injuries that the teams has deemed not appropriate to use the designated to return tag on injury reserve. If they used this tag, this would prevent the player from being cleared to play until at least Week 8. Considering that all NFL teams do not have to cut down rosters to 53 until September 2nd, there is incentive to allow these players to rehab and have them ready by Week 1.

This leaves 77 players whose seasons have ended before they even began. Think about that for a second, you have nearly a full roster and a half of NFL caliber players sitting on the sidelines recovering from injuries. Remember, the NFL has only played one preseason game so far. There are 32 teams in the NFL of 53 players on each active roster equating to 1,696 players. With the already injured players, you could add a 33rd team without difficulty if these players were healthy. Most of these teams have been in camp for only 3 weeks. While that is sinking in, I will continue to break down the injuries.

One of the highlighted injuries we see too often is ACL tears. Highlights of the mechanism of injury have been previously highlighted in my Reggie Ragland post. Already, we have seen 18 ACL tears and this is not stopping. Of all of the tears, 16 have been reported as ACL only, 1 reported as ACL, MCL, and 1 reported as ACL, MCL, PCL. Looking back at the past two years of training camp, 2016 training camp totals saw 16 ACL tears and 2015 training camp totals saw 15 ACL tears. At this rate, it would realistic to see the final number for this preseason reach the mid 20’s, possibly even equal the past two years combined. Of the 18 tears, 11 are defensive players, 5 are offensive players, and 1 special teams player.

One area that has improved so far is Achilles’ tears. To date, there have been 3 Achilles’ tears, compared to 6 in 2016 and 7 in 2015. Of the Achilles’ tears, 2 are defensive players, 1 is offensive. Breaking down the rest of the injuries briefly, several injuries of concern consist of spinal injuries which include lumbar and cervical complaints. Other injuries include torn hamstrings, pectoral tears, sports hernias, wrist dislocation/fractures, concussion, or undisclosed.

This is just a small sample size of what we as fans are seeing. There may be even more that have not been publicly disclosed yet or details still emerging. The NFL still has just over 3 weeks until Week 1 kickoff. I can tell you with the utmost certainty that these types of injuries will continue to occur. I expect some types of these injuries to decline as players continue to improve their conditioning and skills required for their position. I also expect these injuries to occur occasionally at practice and but with a higher frequency in preseason games. We have already seen stars such as Ryan Tannehill go down for the season during practice. I expect to see several other bigger name players go down for some time. Assume that players on the roster bubble to be the bulk of the serious injuries that remain. Several veterans have been injured, but of the 119 players injured so far, 98 of these players have 3 years or less NFL experience, which is the typical length of an NFL career.

Finally, I will take a brief look at teams who have been hit hard by the injury bug versus those that have mostly escaped major injury. Of the 32 teams, several have been hit quite hard. Leading the count with 8 players significantly injured or on IR are the 49ers, Dolphins, and Ravens. Following behind with 7 players are the Colts, Jets and Jaguars. Next with 5 players are the Chargers, Chiefs, Lions, and Redskins. The rest of the teams have 4 or less on IR. Two teams that I want to specifically highlight are the Buffalo Bills and the New England Patriots. The Buffalo Bills have only had 1 player be placed on injury reserve so far; Keith Towbridge with a foot injury. As much as I hate to state this, the New England Patriots are the only team that I have found to not have anyone seriously injured during this year’s training camp.

While I am a Physical Therapist and could continue to go down the rabbit hole with these injuries, I will save my commentary for future blog posts. Take these numbers for what they’re worth. Football is a rough sport, these statistics prove it. I would like to give credit to NFL Trade Rumors, Spotrac, and ESPN for providing the raw data and updates necessary for this post. As a fan and professional, I hope that the injuries for the Bills continue to occur at a minimum, allowing them to go into the season with the depth required to be successful. Continue to check back for future posts updating these stats along with further analysis of specific injuries.