Jon Feliciano’s Rotator Cuff Repair

How did Feliciano manage to play all season with a torn rotator cuff?

The injuries continue to pile up! The latest injury comes Wednesday afternoon when a tweet dropped from OG Jon Feliciano. The tweet shows him in a recovery room with a brace on his left arm with bulky padding on the shoulder. Considering it was at a lower angle, it was initially hard to determine if there were other telltale signs that could be observed signifying the specific procedure. 

This surgery is another in a line with DT Ed Oliver Tuesday with his core muscle surgery & Wednesday morning’s tweet of OT Cody Ford with a right shoulder surgeryShortly after the Feliciano tweet, Matt Parrino from NY Upstate reported that Feliciano had a rotator cuff repair Wednesday & that the original injury occurred during the Blue & Red scrimmage on August 2nd.

I noted back in August that he suffered an injury during the scrimmage after I attended, but the actual injury was unable to be observed due to the vantage point of the stadium & the multitude of activity going on at the time. What wasn’t known at the time was that Feliciano suffered a rotator cuff tear to his left shoulder that he managed to play for  5 months. 

To understand why he was able to play that length of time, the anatomy & function of the rotator cuff must be understood. The rotator cuff is made up of 4 muscles that include the supraspinatus, infraspinatus, teres minor, & subscapularis. These muscles assist in shoulder abduction, internal & external rotation. These motions are vital for a variety of activities that we perform daily from washing hair, putting a shirt on, throwing objects, reaching behind the back, & general overhead activities. The rotator cuff also helps keep the humeral head depressed and against the labrum so that it can create enough space within the joint for the humerus to move & not ram into the acromion during elevation. There are other muscles that assist with all these functions, but these are primary movers for the above-mentioned functions. 

301px-Muscles_Rotator_Cuff
Credit: Physio-pedia.com

We tend to hear more about rotator cuff injuries in baseball but they can & do occur in football at a variety of positions. The mechanism for injury to the rotator cuff can happen in a number of ways. It can occur as a result of landing on your arm outstretched, jamming the head of the humerus into the scapula. It can occur with a fall directly onto the shoulder area, throwing an object either with increased frequency or if the object is too heavy. It can also occur from an overload of the area such as a sudden pull on the area. Finally, it can occur over a period of time with impingement due to weakness in the area with altered biomechanics leading to a wearing down on the tendon insertion.  

There are two types of rotator cuff tears that can affect any of the muscles in the cuff area: Partial-thickness and full-thickness. Based on the names, the partial-thickness is a partial tear to the tendon that can be small & can even heal on its own at times. Full-thickness is when the tendon tears completely through & there is a significant loss of function noted in the area. Any of the muscles in the rotator cuff can tear but the supraspinatus is the most commonly torn muscle. It is anchored at the top of the humerus head & is more likely to bear the brunt of an injury or become worn down. 

Size-of-Rotator-Cuff-Tear-do-I-need-surgery-or-can-physical-therapy-help-300x138
Credit: physioworkshsv.com

There are also varying grades of partial vs full-thickness tears which further indicate the severity as seen above. The tear is measured in both size & depth. So it’s possible that there could be a big superficial tear that could be managed conservatively or there could be a tear that is deep that requires surgery as seen below. Most surgeries are indicated for tears medium & above.

full-thickness-rotator-cuff-tears-value-of-clinical-tests-2-638
Credit: Google Images

Feliciano likely suffered a partial thickness tear to at least the supraspinatus & possibly others as the rotator cuff covers the humeral head like a blanket. The injury could have started out as a partial thickness tear, potentially progressing towards closer to a full-thickness tear as the season wore on. The other possibility is that the partial-thickness tear just never got better, requiring surgery.

I don’t believe that he initially had a full-thickness tear as he would have missed some time due to profound weakness in the area and positive signs of several special tests. In the clinical setting, a full-thickness tear is quite apparent & even the toughest of people have difficulty moving the shoulder. If his shoulder were to be assessed during the season, there would have likely been a painful arc noted in the picture below. This is due to the activation of the rotator cuff muscles assisting in elevation of the humerus during the range of motion from 60-120 degrees

sh5-243x300
Credit: pivotalphysio.com

There was likely pain during every movement that Feliciano encountered throughout the season due to this tear. Between rehab, strengthening of the surrounding muscles & medications, he was still able to suit up for every game & at times play center. Thankfully, he didn’t have any issues with snapping the ball due to being right-handed. 

Feliciano’s glaring weakness would have been forcing to move his arm in abduction and external rotation, both of which would have been more difficult as a tackle, trying to keep the defensive end from bending around the edge. Thankfully, he was able to play inside & keep his arms closer to his body, taking stress off the cuff. Despite the rotator cuff not directly assisting with shoulder flexion, he still would have likely had pain with a general elevation of the arm due to the imbalance of the rotator cuff due to the injury. This could cause impingement where the rotator cuff gets pinched between the acromion & greater trochanter due to decreased space during shoulder elevation.

It will be curious to see if he did get beat more often on the left side when the pocket broke down & he was forced to use that shoulder more. It would also be interesting to note if Feliciano’s punching ability when engaging with his block was decreased due to not being able to put as much power through the left.

Either way, to play through this injury isn’t unprecedented in the NFL, but it is difficult. Cam Newton, Drew Brees, Kawaan Short, Alshon Jeffery & Johnathan Abram are just some of the examples that have torn their rotator cuffs & either tried to play through it or had their seasons end as a result. However, most of the names on this list continued to have incredibly productive careers, indicating that the injury alone isn’t a game-changer. 

To add insult to injury, the rehab for a torn rotator cuff isn’t fun either. It’s roughly a 4-6 month recovery & in some cases, take up to a year with severe tears. This is a tough surgery due to the variety of movements of the shoulder. In addition, the area where the rotator cuff attaches to the humerus contains a poor blood supply which means that it does not receive the needed nutrients to heal as quickly as other parts of the body. Reports indicate that Feliciano will take between 4-6 months which further supports the partial thickness tear that I had mentioned earlier.

The surgery is typically done arthroscopically unless there is a massive tear & they need to open up the shoulder to fully address the issue. Once inside, the tear can be further assessed, cleaned out & repaired. The repair is done by placing anchors that reconnect the tendon back to the bone to allow for proper healing of the area. Based on the severity of the tear will determine how many suture anchors are required.

449px-Rotator_cuff_high
Credit: Physio-pedia.com

Rehab protocols dictating the specifics of the timeline for rehab can be accessed here & here, but to simplify it, it is tedious having worked on a number of these during my career. The first 4-6 weeks are spent in a sling with PROM initiated to work on the motion but avoiding any strengthening directly to the shoulder area. Motion is slowly progressed to stretch the tissue but not place stress on the healing area with range of motion limitations set by the doctor.

Once the patient has been cleared to begin strengthening, isometrics are initiated which is when the muscle tensed up but is not actively moving, like pushing with all your might against a wall. As strengthening progresses, higher-level activities are incorporated to increase stability in the joint. The rotator cuff has to improve with strength, but the surrounding muscles also have to strengthen in order to help move the scapula up and out of the way in order to allow the humerus to elevate. 

Eventually, the muscles are all moving properly with scapulohumeral rhythm, there is full ROM/strength and no pain, this allows the ability to return to sport-specific strengthening & activity. Rotator cuff repairs do have overall good outcomes, up to 95%, but they need a lot of patience to get there. Fortunately, delaying surgery does not appear to have negative outcomes, hence why Feliciano likely chose to play the season with the injury.

Risks for re-tear are as high as 26% in the literature, but is relatively lower in younger patients as the quality of the tissue is improved compared to older patients with more chronic tears. Furthermore, there is a correlation that for every 1 cm the initial tear increases in size, the risk to re-tear increases two-fold.

As a PT, these repairs are rewarding to observe the improvement, but there is a distinct process to them. There may be areas where a patient progresses faster & can shave some time off the overall recovery time, but you can’t speed up the biology & healing portion of the surgery. These can be successful surgeries, but they just require a lot of time & patience in order to maximize the results. 

Feliciano will be around during OTA’s but expected to be limited. He should be able to perform cardio activities & perform non-contact drills as long as he’s cleared by the MD, which is very possible. There is a chance he would be able to perform at mandatory minicamp in June during Phase 3 of the OTA’s but may be held out as a precaution as he is a veteran. Barring any setbacks, he should have no concerns going into training camp for 2020.

This sort of injury is just the reality of the game of football & is a look into how tough these guys really are when it comes to suiting up every week. The only benefit to having an early exit to the playoffs is that these injuries can get addressed sooner. However, I believe most, if not all of the players in that Bills locker room would go through hell if it meant hoisting that Lombardi trophy in February. With how this team is built, the chances for that increase daily. 

Top Photo Credit:

Kiss985.radio.com

Wild Card Weekend Bills Injury Preview- Texans

What is the status of Nsekhe, Roberts, Lawson, & Wallace?

Well, we’re finally here, the playoffs are upon us! We are moments away from the Bills playing in Houston on Wild Card Weekend for the first NFL game of 2020! The Bills are beat up but still in a better spot than the Texans. While I could detail out every injury for Houston & compare it to how the Bills could take advantage, I may be better off writing the sequel to War & Peace. But if you want to get some detailed analysis of the Texans injuries, check out my latest appearance on Locked On Bills with Joe Marino. I have nuggets on JJ Watt, Johnathan Joseph, Bradley Roby, & Will Fuller V. Make sure to check out the pod below!

Locked On Bills 

If you want to know why Houston DE JJ Watt is able to come back so quickly from his pectoral tendon tear, check out my latest article at Buffalo Rumblings!

JJ Watt’s Unexpected Return

As this blog is a Bills based site, the Bills injuries are below & my impressions of them.

QUESTIONABLE

DE Shaq Lawson (left hamstring strain)

Lawson continues to recover from his hamstring strain suffered late in the Patriots loss but appears on the right track. He has been limited the past week, but with controlled activities, he has looked great on film.

I’ve stated all season that the hamstrings are vital for running & blocking, important responsibilities for a defensive end. It’s not a muscle group that can be babied or managed with certain bracing or necessarily protected. Even with the best rehab & rest, injuries can still occur and Lawson may be a casualty of that. 

He missed the Jets game & would probably benefit from another week off, but considering each game now is single elimination, Lawson should not miss. I have a strong suspicion that he plays.

WR Andre Roberts (foot)

Little is still known about Roberts’s foot other than it cost him another game against the Jets. Matt Parrino of NYUp.com noted that he was taking punt & kick returns in practice, accelerating up the field without issue. Any foot injury would limit sudden acceleration as the toes & foot act as a lever to push off the ground to move forward. 

If he had something such as turf toe, a foot sprain, fracture; there would be difficulty getting up to speed & slowing down. As long as Roberts is able to play Saturday, then it won’t really matter what’s wrong as long as he can add another dimension to the team.

OT Ty Nsekhe (right ankle contusion)

Nsekhe continues to work back from his right ankle that cost him 5 games this season. He was rolled up on again Sunday & but appears to be working through the injury just fine. This appears to be more of a contusion which was supported by the fact that he’s practicing all week & only has a brace on, the same one that he appeared to be wearing on Sunday.

I feel strongly that Nsekhe will suit up Sunday & will be in a rotation with OT Cody Ford with Ford taking a bulk of the snaps. 

CB Levi Wallace (right medial ankle sprain)

Wallace is the big iffy for Saturday. At the end of the day, he is still dealing with an ankle sprain that requires rest. The part of the ankle he injured was the medial side which is the inside portion of the ankle. The deltoid ligament is the strong inside portion of the ankle that provides stability between the tibia, talus, calcaneus, & navicular. This is the reason why it is so difficult for the inside portion of the ankle to suffer a sprain. If the outside portion of the ankle had the same type of structure, I would imagine we would all run very differently. You can see the makeup of the deltoid ligament below.

Deltoid-Ligament-Structure-location
Credit: medicpassion.com

The next picture below is a great example of how the injury occurred with Wallace with regards to the motion & the area injured. To note, the ligament does not likely tear that severely for Wallace or a fracture sustained as dictated in the picture.

medial-ankle-sprain419
Credit: http://www.sportsinjuryclinic.net/

If this was a regular-season game, Wallace would surely miss Saturday. Considering it’s the playoffs, I imagine that he will try to suit up with a heavy tape job similar to the one seen below. His major limitations will be pivoting, attempting to stay with his assignments. He will be able to run straight & cut off the left ankle, but forcing Wallace to jump, cut to the right, and backpedal will limit his effectiveness. I expect that CB Kevin Johnson gets the start & majority of snaps with Wallace as a backup or used in certain packages. 

Probable Inactives:

TE Tommy Sweeney

DT Vincent Taylor

S Kurt Coleman

S Dean Marlowe

OG Ike Boettger

RB TJ Yeldon

OG Ryan Bates

The Bills are in a great position to win their first playoff game since 1995 & move to the divisional round against a likely rematch with the Ravens. I could see this Bills team make a run like the Jaguars did a few years ago; anything can happen in the playoffs. 

On top of that, the injuries listed today won’t be real factors outside of Wallace heading into next week. There is always the possibility of new injuries, but thankfully the injuries we do have are at positions of depth at OT & CB. 

Regardless of the outcome, you will be hearing from me next week. However, I highly anticipate that I will be coming to you with an injury review & preview heading into the divisional round. GO BILLS!

Top Photo Credit:

USAToday.com

Week 17 Bills Injury Review- Jets

How bad are Wallace & Nsekhe’s ankle injuries?

Good thing that the game didn’t count for anything as the Bills finished 10-6. That 13-6 loss to the Jets was a rough one to watch, bringing shades of the past decade back with backups & fresh players off the street merely competing because there was no one else healthy. On Sunday, that wasn’t the case as Sean McDermott did his best to rest as many starters as he could in order to prepare for the playoffs. Unfortunately, there were a number of injuries varying in severity that will put some player’s availability in question for Saturday. 

CB Levi Wallace (right ankle)

Wallace scared a lot of people when he went down while catching an interception early in the 1st quarter without being touched. He was able to secure the ball before requiring assistance from training staff to get off the field. As with any non-contact injury, the knee is quickly assessed for any ligamentous instability before further evaluation is necessary in other areas. 

It was determined that Wallace suffered an ankle sprain, specifically a medial eversion ankle sprain. I had originally thought that he suffered a mild high ankle sprain as the mechanisms are similar, but he suffered the medial ankle sprain due to the foot being more in a neutral to plantarflexed position pushing off on the toe rather than the dorsiflexed, everted position seen with a high ankle. It is hard to decipher on film & I’m only confident in the medial ankle due to the recent reports. 

Wallace was observed leaving the locker room in a walking boot which is pretty standard following injuries such as this. He is considered day-to-day which usually translates out to missing a week or two. Medial ankle sprains have an incredibly strong ligament known as the deltoid ligament that prevents movement inward which helped reduce the severity of the injury.

We will have to see how he performs in practice this week. If he can’t go, capable CB Kevin Johnson gets the start against his former team. 

S Siran Neal (right side stinger)

Neal suffered a stinger during a tackle during the 2nd quarter where he hit directly over the top of his shoulder on a routine tackle. He was visibly uncomfortable, shaking his right arm out & moving around, trying to shake things out. 

That direct hit caused the stinger due to the sudden shoulder depression pulling on the cervical nerves just enough that he felt it down the arm to need a few plays off. Like Tre’Davious White against them Steelers game, the actual hit wore off & he was able to return. As long as Neal doesn’t continue to suffer these, then this shouldn’t be an issue moving forward. 

OT Ty Nsekhe (right ankle)

Nsekhe made his triumphant return after missing 5 weeks with a severe ankle injury in the win over Miami. Nsekhe was slowly reintroduced into the game plan & was rather unremarkable during his play. 

In a stroke of bad luck, Nsekhe went down again in the 3rd quarter with a Jets defender falling on the back of his foot as he went down. Nsekhe was immediately down on the ground rolling around in obvious pain. Trainers quickly came out to assess the ankle & got him off the field for further assessment. 

It was difficult to see what Nsekhe exactly injures as the bodies were in the way, but it’s clear that his ankle was rolled upon. He may have avoided serious injury due to his shoe getting knocked off during the play, preventing his foot from being planted. Nsekhe was also observed wearing an ankle support to limit medial/lateral movement which redistributes the forces away from the ankle. 

The hope that is he suffered a contusion to the area & can work through this injury to be available for Saturday. Some detractors may be out there saying he should have not been playing after coming off an ankle injury. I fully support the coaching & medical staff to allow him to get out there in order to get live reps and allow him to play if he’s healthy. Nsekhe is a veteran, he knows his body & the risks he would take in return to play. It comes down to simply horrible luck & there isn’t much else to be said.

OT Cody Ford (right trapezius/neck)

Ford suffered his own injury later in the 3rd quarter where he appeared to injure his right trapezius or neck. There wasn’t much of a mechanism of injury but Ford came off grabbing at his right trapezius muscle. This muscle connects up to the back of the head, out to the shoulder, and down to the middle of the back. This assists with head extension & shrugging the shoulders.

Trapezius
Credit: Youtube.com

The only possible place that I see where he could have injured this area would be when he took on the Jets defender, lost his block and had his head turned inward to the left & hit the back of G Spencer Long

Ford kept motioning to the area & even pointed to the training staff where his pain was at. He may have overstretched the muscle getting his head forced to the left & hitting Long. He may have also suffered a minor stinger due to the head stopping suddenly. 

Either way, he was able to return and outside of some stiffness & soreness, this shouldn’t limit him for Saturday.

CB Taron Johnson (right ankle)

Johnson was the last injury of the day when he got bowled over by Jets running back Le’Veon Bell. Johnson attempted to square up with Bell & plant his feet, getting knocked backward & injuring the right ankle. The injury occurred when Johnson was trying to keep his foot planted & got pushed, over pronating his foot & placing stress through the medial ankle. 

Johnson was able to walk off with a noticeable limp but was quickly able to begin running on it, even able to return at the very end to ensure that WR Isaiah McKenzie did not have to fill in at cornerback. This is similar to what Wallace dealt with earlier in the game but obviously less severe & less eversion noted at the ankle. This isn’t something that I expect will keep him out for the playoffs. 

Other observations 

Out of the inactives, the only known ones prior to the game were WR Andre Roberts & DE Shaq Lawson with their respective injuries. Having RB Devin Singletary, TE Dawson Knox, WR John Brown, WR Cole Beasley, & CB Tre’Davious White made the most sense being inactive due to how vital they are at their respective positions. 

McDermott & the medical staff did the best with what they could. There are injuries the public isn’t aware of despite my best efforts. There are also strategies in getting other players snaps in case the top players do go down. 

It wasn’t an ideal situation, but the other option was to play the starters & suffer injuries prior to the playoffs. The injuries suffered Sunday are absorbable especially at CB & OT as the team has managed without so far. 

There’s a lot going on this week prior to the game Saturday & it’ll be exciting to see how the Bills stack up against the Texans. This is a winnable game, especially with the defense that has performed all season when asked. If the Bills get beat, it will be because of talent & not because the Bills beat themselves or were too injured.

Top Photo Credit:

DemocratandChronicle.com

Week 17 Bills Injury Preview- Jets

Will this finally be the week that Nsekhe returns?

The big concern going into this game against the Jets is how long starters will play & what players will be inactive. This is especially worrisome due to the recent comments by Jets S Jamal Adams in which he stated they would be hunting along with Jets DC Gregg Williams. Along with that comment, Bills fans have to worry about cheap shots from DE Henry Anderson. If you recall, he blindsided K Stephen Hauschka last season which threw his game off for the rest of the season seen below. 

Thankfully, the Bills continue to manage their injuries well & are not forced to play players who are injured. Below are the injuries prior to the game & inactives.

OUT

WR Andre Roberts (foot)

Roberts was a surprise addition to the injury report following Saturday’s game. Reviewing the film, it’s not clear when he suffered his foot injury. There aren’t many plays that show when he could have possibly injured his foot, but a possible culprit is when he was blocking for QB Josh Allen on a designed run play early in the 3rd quarter, it appears he got kicked on the right ankle.

There was also another point in the 3rd quarter with 3:35 left in where he appeared to be limping slightly after the play. There didn’t appear to be a mechanism of injury prior to this play either which makes this difficult to identify the exact problem. Considering he hasn’t practiced this week & has already been ruled out, we can only hope that he will be ready for the playoffs. 

DE Shaq Lawson (left hamstring)

Lawson has not been able to practice this week due to a hamstring strain suffered in Saturday’s loss to the Patriots. This occurred after a tackle for loss in the backfield during the 2nd half of the game. The actual tackle itself did not appear to be an issue, but rather the celebration afterward. He began to get up & celebrate, grabbing the hamstring in the process.

He was able to continue playing for the rest of the game but the injury appeared to catch up with him later. Even after a slight strain, the muscle is still painful & sore, requiring frequent stretching & controlled movement to allow healing but not overwork the area in order to prevent further injury. As he has already been ruled out, this is the smart move to do considering how valuable he will be in the playoffs. It will be interesting to note how the coaching staff rotates the defensive ends as there are only 4 on the roster.

QUESTIONABLE

OT Ty Nsekhe (right ankle)

I feel like we have been having the same conversation for the past 6 weeks regarding his injury. But new information is available! He finally appears to have made the expected progress, participating in practice on Thursday & looking quite well on film. He is moving with the fluidity of someone who is close to returning & appears to be close to 100%. 

Considering how he is moving, I’m making the assumption that he could have returned sooner, but how OT Cody Ford was playing, he wasn’t needed immediately. At this point, it is unnecessary for Nsekhe to play in Week 17, but he has missed the last 5 games which means he would benefit from some live reps in order to prepare for the playoffs. 

CLEARED TO PLAY

C Mitch Morse (right low ankle sprain)

Morse scared many Bills fans late in the 4th quarter in which he had his ankle rolled up on, reportedly feeling several pops & having difficulty walking on it initially. Fortunately, he was able to practice in full this week & not appear to have any limitations despite what appears to be a low ankle sprain. 

Morse is yet another starter that may play several series but overall benefit from a well-deserved rest day or even being declared inactive in order to ensure his health.

OTHER INJURIES

DT Harrison Phillips (left ACL)

Phillips has been out since September, diligently working back from a torn ACL that ended his season prematurely in the win over Cincinnati. Occasionally, news is released of Phillps attending practice, performing his rehab, & still participating in team activities. While it wasn’t expected that Phillips would return until next season, it’s great to see the progress being done in rehab. In the first tweet, below is Phillips running on an underwater treadmill to reduce the stress that land-based running would cause. In the other tweet, you can see the progress that Phillips has made & is demonstrating the proper muscle control during his step-up routine with a weighted vest. 

Even though he is unable to play this year, Phillips still understands his job & purpose on the team which further validates the culture that has been instilled at One Bills Drive. I expect to see more clips in the near future & see him inch closer & closer towards returning to football activities.

Probable Inactives:

TE Lee Smith

RB Frank Gore

S Micah Hyde

S Jordan Poyer

DE Shaq Lawson

WR Andre Roberts

G Quinton Spain

This would be a game that the Bills would be foolish to not play all their reserve players for much needed live snaps. It is probably the best bet to allow some of the veteran players a true rest day, have all the starters play several series & then act as backups in order to get through the game. It would be great to get to 11 wins, but not at the cost of a key contributor going down. 

The Jets are still a talented team, this is the NFL after all. But this is the best-case scenario in where the backups can get extensive playing time & get some film for next season when the roster churns over. Plus, I don’t think in any circumstance that Terry or Kim Pegula are forcing the coach to play certain players as in the still hotly debated topic of QB Doug Flutie or Rob Johnson. This will be a good game to allow the Bills to play & not worry about the outcome. There are bigger fish to fry next week with either traveling to Kansas City or Houston, both being true tests.

Top Photo Credit:

SBNation.com

Week 12 Bills Injury Preview- Broncos

Get the comprehensive timeline on Nsekhe’s ankle & rehab process.

It was expected that the Bills couldn’t stay healthy forever. NFL games are a brutal endeavor & not everyone can avoid injury. While the Bills are down a few players going into Sunday’s game, they still appear to be on track towards making the playoffs which means they could get timely reinforcements when the health improves. The injury report is pretty cut & dry this week but there are still details to discuss especially as we are rapidly approaching 2 games in 5 days. Below is the injury breakdown prior to the game & outlook for the short week.

RULED OUT:

S Siran Neal (concussion)

Neal suffered a concussion with 7:41 left in the 2nd quarter on a routine kickoff following the 2nd FG of the day by K Stephen Hauschka. He appeared to bullrush his assignment and hit his head in the process before getting up appearing to be dazed. In a twist of irony, one of his teammates patted him on the head after the play, not exactly the ideal thing to do after a possible concussion. Neal’s day ended early, getting ruled out & placed into the concussion protocol. 

He was unable to practice all week & was observed watching practice from the sidelines which indicates that he is in Stage 2 of the protocol. He has already been ruled out & it is a guess when he will progress through the protocol to be cleared.

OT Ty Nsekhe (right ankle)

Nsekhe managed to avoid a severe ankle injury when Dolphins DE Avery Moss landed on the back of his foot during a routine run play midway through the 3rd quarter. I had originally stated that he suffered a fracture/dislocation & that his season would likely be done. I have the receipts to prove I am wrong. My buddy, Dr. Chao, aka @ProFootballDoc, also had thought the same thing but thankfully we are now looking at a week-to-week injury instead of season-ending IR. Below is a video detailing why he avoided a fibular fracture.

There were reports that Nsekhe was out at practice in a walking boot which appeared to rile up the masses in a good way thinking that the injury wasn’t as serious as it appeared to be. At the end of the day, he suffered a low ankle sprain which comes with it a still very real & arduous rehab timeline. The reason he was out in a walking boot was the fact that he didn’t have any restrictions in weight-bearing. In the rehab world, it’s encouraged to resume weight-bearing as tolerated unless specifically contraindicated in order to allow for the healing process to take place.

Yes, everyone has heard of PRICE (Protection, Rest, Ice, Compression, Elevation), but after that initial 24 hours of rest, exercise & mobility activities are encouraged for better outcomes. Multiple studies have shown that introducing exercise shortly after the injury reduces the time that one is out compared to immobilization with a 4-7 day reduction in the timeframe for return. Right now, that could be the difference between going to IR versus playing on Wild Card Weekend. 

Allowing weight-bearing allows for joint approximation is vital for the healing process. This allows the muscles in the ankle and lower leg to cocontract & increase joint stability. This also allows the joint to begin to regain proprioception which is the perception of awareness of the body in space in relation to its surroundings. These are all fancy terms, but what does this mean? This means that just by weight-bearing, he is improving his strength and joint positioning with each step he takes. As the pain & swelling reduces, he will continue to perform active strengthening in the area along with balance exercises, increasing the difficulty until he is able to begin walking without the boot. 

As he progresses to higher-level activities, jogging, running, football-specific drills will continue to increase until he is ready to resume playing. This process can take anywhere from 4-6 weeks for a Grade 2-3 sprain. As I previously mentioned in my article from Tuesday, Nsekhe is a big dude, all of 6’8” & 325 lbs. A human that big will require some extra time to fully recover from any lower-body injury. 

While this is not a great injury down this tough stretch of games, having OT Cody Ford with experience helps until Nsekhe is able to come back. The hope is that he’s back in time for the playoffs, but he could realistically come back in time for the Patriots game on the 21st. We’ll see how he progresses, but it’s hopeful that the new training center allows for him to shave more time off to shore up the offensive line. 

Final thoughts on Nsekhe, the team has been bringing in a multitude of offensive tackles to work out including former Bills Sam Young & Seantrel Henderson as possible options in case OT Ryan Bates can’t cut it as a backup or if Ford struggles. 

SUITING UP SUNDAY

DE Jerry Hughes (groin)

Hughes continues to battle through a nagging groin injury suffered sometime earlier in the season which forced him to pop up on the injury report late last week. He was able to play in a season-high 53 snaps on defense. Considering that Hughes is a right defensive end, it’s possible that he is dealing with a left-sided groin strain. He lined up most of his snaps at his natural right side but did line up several times on the left, most likely due to the particular scheme. 

Lining up on the right side means that his power is coming from his right leg driving around the corner. He appeared to not have any issues driving off the left side, but when the adrenaline is pumping, anyone can work through some pain. He was not ruled out or had any injury designation, always an excellent sign. Some may wonder why he was a DNP Wednesday & Thursday but practiced in full on Friday. This was due to veteran maintenance & to save him for Sunday. Hughes may have benefitted from sitting out the Dolphins game, but both he & the training staff felt he was ready to go.

This will be an injury that he continues to play through, unlikely practicing unless it’s a walkthrough practice in the several days between Sunday & Thursday, but barring any further injury should play Thursday as well. While Hughes has not had the stat-bursting season that was expected, he still continues to force teams to game plan for him & pressure the quarterback each and every snap. 

S Jaquan Johnson (hand)

Johnson was a full participant this week despite a hand injury that popped up on the injury report Wednesday. Trying to identify a minor hand injury on film is quite difficult & it’s not clear when he suffered the injury. Johnson is a very physical player & there were many instances where he could have got his hand caught in a jersey, fell to the ground, or during tackling. Either way, he will be able to contribute to special teams & hopefully make an impact.

DT Jordan Phillips (toe)

Phillips showed up on the injury report Thursday with a toe injury. We don’t know which side, which toe, or when it happened. My guess is that this happened Thursday in practice & that it was an injury to the big toe. The big toe accounts for 50% of body weight during walking & without the toe, significant balance & walking issues arise. Injury to the other toes are rather minor & wouldn’t warrant reporting unless they were stepped on, making it a pain issue.

If this an injury to the big toe, the team can give him a stiff-soled shoe to take the pressure off the area during running and blocking. He also did practice in full on Friday which may show that this wasn’t all that serious & that he missed some drills Thursday, but didn’t have issues Friday. If he has issues in the game Sunday, we will see them. 

Possible Inactive’s:

TE Tommy Sweeney

DT Vincent Taylor

WR Duke Williams

OT Ty Nsekhe

S Siran Neal

RB TJ Yeldon

OG Ike Boettger

The Bills host the 3-7 Broncos who despite their abysmal record, carry an elite defense into the game with several pieces on offense, making them still a very dangerous team to play even at home. Like many other games this season, this is a winnable game & the Bills have to control the run game like they did last week. To move to 8-3 would be huge as the next stretch of games against the Cowboys, Ravens, Steelers, & Patriots are no easy task. Continuing to stack wins will be vital in the march towards the playoffs. 

Top Photo Credit:

broncoswire.usatoday.com

Week 11 Bills Injury Review- Dolphins

How severe is Nsekhe’s injury?

Another week, another win. The Bills move to 7-3 on the season with a convincing win over the Miami Dolphins in Miami Sunday afternoon. This is the best start for the Bills since 1999 & 10th time in franchise history that they started 7-3, all previous Bills teams made the playoffs with varying degrees of success. While the Bills are continuing to march towards the postseason, they will be without a key contributor moving forward. This & other injuries will be detailed below. 

WR Isaiah McKenzie (left knee)

McKenzie suffered a left knee injury when he caught a pass going out of bounds with :55 left in the 2nd quarter. CB Nik Needham was close by but unable to break up the pass, instead falling & hitting McKenzie’s lower leg. It appeared to hyperflex his left knee, causing McKenzie to get up & limp off the field. 

Thankfully this was close to halftime where he was able to get some rest & get a quick assessment to ensure he could play in the 2nd half. This injury appeared to be minor & is not something I expect him to show up on the injury report with later this week.

S Siran Neal (concussion)

Neal suffered a concussion midway through the 2nd quarter on the kickoff with 7:41 left following Hauschka’s FG. Unfortunately, the video is not available yet as there was a touchback & the camera followed the ball & not the players. It was reported he was shaken up on the play, but once All-22 comes out, we may get a clearer view of what exactly happened. Neal enters the concussion protocol with no guarantee he is cleared for next Sunday. 

OT Ty Nsekhe (right ankle)

Nsekhe suffered a rather severe right ankle injury with 9:14 left in the 3rd quarter. This was a routine run play by Singletary up the middle when Nsekhe’s foot was caught from behind by Dolphins DE Avery Moss, landing on the back on Nsekhe’s heel, forcing the ankle to roll under the big man violently before his body caught up & he falls down in obvious pain. 

He was immediately placed into in an air cast & carted off, waving to fans but in significant discomfort. The result: a likely ankle dislocation with fibula fracture. There is a concern that he suffered a tibia fracture as well, but he may have spared the more significant bone due to the ankle rolling as much as it did before he fell over. 

300px-Fibula_Fracture
Credit: physio-pedia.com

According to Monday’s press conference, more tests were being performed on Nsekhe’s ankle with no definitive answer at this time. 

This could be for several reasons: 

  • The swelling may have been so great that imaging did not show the true extent of the damage.
  • There isn’t an actual break but significant ligament damage on the lateral portion of the ankle.
  • The Bills know exactly what is going on (they likely do) & are sitting on the info because they have no reason to release it until they feel they’re ready or can sign someone to replace his roster spot. 
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Credit: physiodirectnz.com

Looking at an alternative video angle from Thad Brown, there is the possibility that Nsekhe avoided a break but dealing with quite a severe inversion ankle sprain. He would have injured the anterior talofibular & calcaneofibular ligaments when Moss landed on his ankle. There is a slight chance he avoided a fracture due to observing the heel sliding out, relieving pressure off the fibula as he went down. 

The sheer fact that he was placed into an air cast & carted off without the ability to place weight through his leg isn’t ideal. His season is possibly done, heading to IR for surgery & rehab if my original suspicions are confirmed. I am not certain but if you go on NFL Gamepass & watch the replay, it appears as though the snap of the bone is audible. I’ve played it multiple times in a row. 

This may be a similar injury to what LB Matt Milano suffered last season. if so, a recovery timeline for Nsekhe would be 6-9 months with my guess being closer to 8-9 months. There are several factors including: 

  • Nsekhe is 34 years old, Milano was 24 during his injury.
  • Nsekhe is 6’8”, 325 lbs. Milano is 6’0”, 225 lbs. 
  • Nsekhe’s bones are thicker & are required to accept more weight than Milano’s, requiring a longer healing time & associated recovery.

While 34 is still a youthful age, it is getting up there when it comes to the NFL. Nsekhe can & should make a full recovery, but considering the mileage on his body, it’ll be interesting to see whether he is able to return to full form in order to compete for a roster spot next year. He should be close to, if not fully ready for training camp & should be able to participate in OTA’s in 2020. He is clearly a talented player, the Bills have him under contract for another year, it may come down to how he looks in camp.

For the interim, OT Cody Ford slides into the starting role he has alternated with Nsekhe all season. OT Ryan Bates will likely move to back Ford up. Once Nsekhe moves to IR, the team may elect to fill his roster spot with practice squad players OT Brandon Hitner or OT Victor Salako. The other option is to find a street free agent or another player off another team’s practice squad. Either way, GM Brandon Beane already has a preliminary plan in place. 

Other observations from today’s game injury-wise include noting Nsekhe’s replacement OT Cody Ford is still wearing a hinged elbow brace with a compression sleeve on the left elbow from the injury in the Eagles game. Each week he wears this brace further confirms that he suffered some type of injury to the UCL ligament in the right elbow & the brace provides protection as the ligament heals. 

Other injury news to note is that DE Jerry Hughes was active & played his usual snap count, highest among the DL group. I had originally stated that Hughes would miss the game & I was wrong. While I did not observe every single snap, he did not appear to be compensating or limited. This also creates the thought that the team is not sold on rookie DE Darryl Johnson. While no one expects that Johnson can be an effective player such as Hughes, it shows that an injured Hughes is still better than a healthy Johnson. 

The loss is Nsekhe is going to hurt. While he is older, he showed the ability to play very well with the offensive unit. Ford is able to step in & contribute, but his play has been marred by penalties & inconsistent play. He will suffice, but the quality of play at the position will suffer. However, the Bills are 7-3 & even with a 3-3 finish to the season will give the Bills double-digit wins for the first time this millennium. The Bills are still very much in control of their destiny & can make noise in the playoffs if they played like they did Sunday.

Week 10 Bills Injury Review- Browns

The Bills are healthy but not in the win column, will that change next week?

Well, this is awkward. I was expecting to write about how the Buffalo Bills earned yet another win to move to 7-2 over the lowly Cleveland Browns. Yet, they are now 6-3 with a ton of questions, questions that I don’t have the answers. On top of this, there weren’t any publically reported injuries during Sunday’s game which is unique in that rarely does a team enter a game fully “healthy” & exit the same. The only difference is that the Bills leave Cleveland with a loss.

Here I am, Banged Up Bills, a Buffalo Bills injury based site & I have no new injuries to discuss. But I will soldier on because when I mention “healthy”, there are still several players dealing with injury that are cleared to play. To note, McDermott did not note any injuries following Monday’s press conference.

OT Cody Ford (left elbow) 

The rookie tackle from Oklahoma played only 4 special teams snaps last week during the win over the Redskins after being listed as questionable heading into the game. This may have been by design, but considering that the team resumed their rotation between Nsekhe & Ford, this shows that Ford’s injury appeared to be more severe than I had originally anticipated. The snap counts didn’t show anything out of the ordinary, though Nsekhe once again won the numbers battle, 60% to 40%.

Ford may be dealing with a UCL sprain considering the hit he took against the Eagles late in the game. He could play through this as he doesn’t really have to put strain through his elbow like someone who throws the ball would deal with. The compression sleeve & hinge bracing may allow him to play while avoiding stress to the healing ligament. It will be interesting to note if he ditches the brace in the coming weeks, but he may wear it as another form of protection as it continues to get colder. 

There is also a possibility that he has elbow bursitis due to the hit, but there is more swelling & loss of range of motion associated with this injury. It’s unlikely that he would have a hinged brace with this, but as we don’t have the specific information, there is only speculation. 

CB Kurt Coleman (left hamstring)

Coleman returned to the fold this week after missing the last 2 games after suffering the injury against Miami. As expected, he did not appear to miss a step & was a contributor on special teams along with several defensive snaps. Coleman continues to be the latest example of the talent of this training staff to ensure players are fully healthy returning from soft tissue injuries. 

CB Kevin Johnson (left knee)

Johnson briefly appeared on the injury report Wednesday with a knee injury following the win against Washington. It’s possible he may have suffered a minor hyperextension of his knee after getting tripped up during a routine punt. He didn’t appear to be out of place with his contributions on special teams or his availability on defense according to the numbers.

WR Duke Williams (right shoulder)

Williams has now been inactive the past 2 games after suffering what appeared to be a right AC joint sprain during a hard fall following a catch in the Miami game. He did play in the loss to the Eagles, garnering 2 targets with 1 catch for 6 yards. Considering he is essentially a rookie despite having several years of experience in the CFL, I believe that he is inactive due to his inexperience in the NFL passing game compared to WR Isaiah McKenzie & WR Robert Foster. Recalling, Williams was a feel-good story but started the year on the practice squad. Due to the entire roster being healthy, someone has to sit & Williams is closer to the 53rd roster spot than McKenzie or Foster. I believe his time will come as inevitable injuries rear its ugly head. 

CB Levi Wallace (left shoulder)

Wallace suffered a left shoulder injury after getting run over by RB Boston Scott in the loss to the Eagles. Despite suffering a painful contusion, he did not miss anytime but his play appears to be more suspect over the last 2 weeks. I do not believe that he is limited by the shoulder, but rather his actual abilities as a player. This coaching staff does favor veterans over younger players but will give preference to individuals that have been in their system over guys like CB Kevin Johnson. If Wallace’s play does not improve soon, I wonder when the hook will come because getting burned like he does continue to create unfavorable matchups during this upcoming stretch of games. 

The Bills are healthy now with a 6-3 record; imagine how bad it would be if they were rife with injury & did not have the depth available. Regardless of the current health status of the roster, the quality of play & offensive production must improve in order to have any type of shot at making the playoffs, much less actually winning a game. We’ll have to see how this pans out with the Bills going to balmy Miami with a very winnable game against the Dolphins.