TB 12’s Hand Injury – Thumbs Up or Down for the AFC Championship Game?

An important disclaimer as you read this… the news of Tom Brady’s right hand/thumb injury this week has me more than a little shaken up, so apologies in advance for any mis-spellings, grammatical errors, or wildly uncontrolled hyperbole. I am officially shook…

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Live look at me hearing that Brady didn’t practice today

By now anyone who follows sports knows that Patriots quarterback Tom Brady somehow injured his hand in practice yesterday – the exact mechanism of his injury wasn’t announced but speculation is that someone, likely a running back, ran into his right hand. Subsequent x-rays were apparently negative for fracture, but Brady was seen wearing a glove on his throwing hand at practice today with what looked like a brace on under the glove.

While Brady dressed for practice, he was listed as a non-participant and was not seen actually throwing by any of the media present for the first part of practice (this is where I start to freak out again, stay with me here). This has of course led to all kinds of speculation about what his actual injury might be and what that means for this weekend and a possible Patriots Super Bowl appearance. While I have no inside info on this (other than the pit of roiling acid that passes for my stomach since I heard about this), I’ll put forth my best guess as to what could be wrong with Brady’s hand and what that means moving forward.

The first question you have to ask is, What kind of injury could Brady have actually sustained to his hand/thumb by someone running into him? The official word was that he had a “jammed hand”, which is basically Patriots-speak for, “He injured his hand, we’re not telling you anything”. When I think of what kind of injury he could have sustained by someone running into his hand or possibly during an attempted handoff, I think of a sprain/tear of the ulnar collateral ligament (UCL) of the thumb.

Drawing of a torn ulnar collateral ligament

This ligament is at the base of the thumb on the inside of the thumb, towards the hand. It is a commonly injured ligament in sports – baseball’s Mike Trout missed two months with a torn UCL this year and Dustin Pedroia actually tore his in the first week of the 2016 season but managed to play the whole season before having it fixed surgically after the season. The ligament can be injured with a fall directly onto the thumb or by an injury where the thumb is “jammed” and pulled away from the hand. This is something that could definitely happen even in a low-intensity football practice, especially if there was a botched handoff forcing Brady’s thumb away from his hand. Additionally, in the picture of Brady’s thumb that everyone has been scrutinizing more than the Zapruder film, there seems to be a brace or wrap at the base of his thumb, which is where one would wear a brace for a UCL injury.

So, assuming I’m right, and I’m not sure I want to be, what does that mean moving forward? Injuries to the UCL range in severity from a sprain of the ligament, which would cause pain in the short-term but no long-term issues, to a full tear which would cause pain and weakness or instability with a grasping motion. A grasping motion such as… gripping a football. Yeah, I’m freaking out. If Brady does indeed have a UCL injury, he could likely play through it in at least the short-term with a brace and a boatload of anti-inflammatories (thankfully for us Pats fans Brady is already eating an anti-inflammatory, nightshade-free diet, soooo….). The question would be how effective he would be for the rest of the playoffs – if he has a great deal of pain or instability, it could affect his throwing to a significant degree. If it’s a more minor sprain, he might very well be near or at full strength and accuracy. Here’s hoping for the latter and not the former, but until we see him actually throwing a ball Sunday, I’ll be over here in the corner like…

Patriots Update 11/12/17 – Can a Black Unicorn Play in the NFL with a Torn Rotator Cuff? No, really, that’s an actual question…

 

Martellus Bennett, a.k.a. The Black Unicorn, a.k.a. Marty from the Imagination Station, was cut by the Packers earlier this week at least partly over the condition of his shoulder. Reports then surfaced that Bennett has a torn rotator cuff which might require surgery. Subsequent to this, Bennett was signed by the Patriots and passed a physical and practiced this week, a seemingly confusing sequence of events. So what’s the bottom line? Does Bennett have a torn rotator cuff? Does he need surgery? Could both of those things be true but Bennett still play for the Pats this year?

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Picture courtesy of BostonHerald.com

Martellus Bennett has always been a bit of an oddball in the NFL, with his penchant for writing kid’s books and his deep-rooted passion for bacon http://www.patriots.com/video/2016/12/29/martellus-bennett-shares-his-love-bacon (ok, there’s nothing weird about loving bacon, but that’s not the point here). This week he became a bit of a medical enigma due to the condition of his shoulder. The tight end played on the Patriots Super Bowl-winning squad last year (have I ever mentioned I was at that super bowl? I was, you should totally ask me about it sometime) despite multiple injuries including a shoulder injury which bothered him but did not cause him to miss any games. In the off-season as a free agent he signed a 3-year, 21 million dollar contract to play for the Green Bay Packers. Bennett had a minimally productive season for the Packers (24 catches over the first seven games for 233 yards and no touchdowns), and has not played or practiced for the past two weeks after apparently re-aggravating or worsening the condition of his shoulder in week seven. After some back and forth with the Packers and their medical staff, Bennett apparent opted for season-ending surgery on his shoulder, only to be released and then signed by the Patriots. Obviously the tight end did not have surgery, so how can he potentially be suiting up for the Patriots this weekend? Before we can answer this, we first have to consider what the rotator cuff is and what a tear of these tendons involves.

The rotator cuff is a group of four tendons ( the supraspinatus, infraspinatus, teres minor and subscapularis) which help to move the shoulder joint and ultimately to position the hand in space.

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Image courtesy of physio-pedia.com

When these tendons are normal and uninjured, they function in conjunction with the other shoulder muscles (including the deltoid, biceps, and pectoralis) to move the shoulder joint. Tears of these tendons are very common, as they see a great deal of stress even with normal use, resulting in a high number of “atraumatic” tears – tears which result just from normal day-to-day use or aging. Add in the additional stress seen when athletes are diving on their shoulders and sustaining high levels of trauma to their upper bodies from activities such as tackling or being tackled, and it is no surprise that these tendons might be torn at an even higher rate in contact athletes.

Some of the confusion with these tears comes from the fact that not all tears are alike – tendons can be torn in different places and the tears can be partial or full. I tell patients to think of the rotator cuff tendons like a piece of Velcro – similar to Velcro, you can peel off an edge (a partial tear) or rip the Velcro completely apart (a full tear).

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Arthroscopic surgical image of a partial thickness rotator cuff (frayed tissue in red circle with normal biceps tendon in background)

 

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Arthroscopic surgical image of full-thickness rotator cuff tear (torn tendon above metal probe, normal bone below)

While some of these tears are completely asymptomatic and require no treatment, most rotator cuff tears result in a loss of function and/or pain. Patients may report a sensation of weakness when using the arm overhead or in front of their body, and may complain of pain with use or even at rest. Many tears, especially partial tears or even full-thickness tears in older patients, can be treated without surgery with a combination of physical therapy and sometimes cortisone injections. Most symptomatic full-thickness tears, especially in younger patients and athletes, are treated surgically. The surgery is usually arthroscopic, in which we re-attach the tendon to the bone using specialized instruments designed to allow for less invasive surgery.

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Arthroscopic surgical image showing rotator cuff repair in progress, with sutures in place on the right and suture anchor being inserted on the left
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Arthroscopic image of completed rotator cuff repair, with sutures in place and tied down, reapproximating tendon to bone

Post-operatively patients are usually in a sling for 4-6 weeks, with physical therapy for 3-6 months after. Lifting and activity restrictions are usually in place for 6-9 months after the surgery depending on the extent of the tear and the patient’s progress with physical therapy.

With all that being said, where does it leave us with regards to Bennett and his shoulder? I obviously haven’t seen his MRIs, but it seems to me that he has either a full-thickness tear or a very symptomatic partial-thickness tear if surgery was even being contemplated. Despite that, if he is able to play through the pain and have a functional arm for football activities, even with a full thickness tear, he could play for the rest of the season. He will need a lot of time in the training room and may even need a cortisone injection at some point, but I would not be at all surprised to see him play the rest of the season for the Patriots and have surgery after the season. The mere fact that he is a carbon-based life form with opposable thumbs makes him a better bet than Dwayne Allen to contribute in the passing game for the Patriots, so the bar has been set pretty low for him. At the end of the day, it will come down to pain tolerance and functionality for Bennett with regards to his shoulder – given what he’s played through in the past, I wouldn’t bet against him.

NFL Weekend Injury Update, Monday October 23

Two starting quarterbacks, an NFL ironman and two important members of the Patriots’ suddenly-resurgent defense suffered injuries this weekend – here’s a quick look at their ailments and when they might return to their respective squads

 

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Carson Palmer being evaluated on the sideline for his left arm fracture (image courtesy of TheBigLead.com)

 

Cardinals’ QB Carson Palmer suffered an injury to his left (non-throwing) arm when he was sacked in the second quarter of Arizona’s eventual blowout loss at the hands of the Rams in London.  The Cardinals announced that Palmer had fractured “a bone” in his left arm and would need surgery.  From looking at the play and by making inferences from Palmer’s initial estimated return in 8 weeks from surgery, it’s safe to assume that he broke the ulna, one of the two long bones in his lower arm.

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Ulna (nightstick) fracture of the forearm (image courtesy of WikiRadiology)

This particular type of fracture is also known as a “nightstick” fracture, as it was once common for neer-do-wells and scofflaws to incur it while trying to protect themselves from a policeman’s nightstick – it almost always results from a direct blow to the forearm.  If the fracture is non-displaced (the fractured pieces of bone have not moved apart from each other) it can usually be treated non-operatively with a cast or brace for 6-8 weeks. If the fracture is displaced or if the patient is a high-demand athlete who possibly wants to return to play earlier than 6-8 weeks, surgery may be indicated.  Surgery involves an open incision and the placement of a plate and screws in the bone to re-align it and to ensure reliable healing.

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Example of a plate and screws fixing an ulna fracture (Image courtesy of ijoonline.com)

It was originally reported that Palmer would miss 8 weeks, but more recent reports have emerged that he would be seeking a second opinion and might return in as little as 4 weeks.  When he actually returns will largely be driven by his comfort level – it is potentially feasible that he could return in a month.  Even though the bone would not be fully healed at that point, the plate and screws could protect the healing ulna enough to allow for him to return with a still-healing fracture.  There is precedent for this in the recent NFL past – linebacker Jonathan Davis of the Panthers broke the same bone in the NFC Championship Game two years ago, had surgery almost immediately and played in the Super Bowl two weeks later.  Rob Gronkowski would serve as a cautionary tale for a fast return from this type of injury – he fractured his ulna blocking for an extra point (sigh…) in November of 2012, had surgery and returned later that season, but subsequently re-fractured the arm in the divisional round of the playoffs.  It seems safe to assume that Palmer will be back on the field this season, with the caveat that it will not be without some increased risk of re-injury.

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Jay Cutler down on the field after being sacked in the Dolphins game Sunday (image courtesy of Sun-Sentinel.com)

Jay Cutler was sacked in the Dolphins’ Sunday win over the Jets and didn’t return for the remainder of the game with what was initially announced as a chest injury – post-game x-rays and and MRI showed multiple “cracked” ribs.  This indicates that the QB broke multiple ribs, but the fractures are likely not at all displaced.  Not a whole lot to say about this injury except that it really, really, hurts.  Hurts to breathe, sneeze, cough, laugh… you get the idea.  Cutler’s return will be determined by when he can tolerate the rigors of being sacked by 300-plus pound defensive lineman, so it may be multiple weeks before the always-cheerful quarterback is back on the field.

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Joe Thomas holds his injured left arm in Sunday’s game (Image courtesy of Akron Beacon Journal)

 

Earlier this season, Cleveland Browns left tackle Joe Thomas became the first player ever to play in 10,000 consecutive snaps, having played every offensive play of every game since being the third overall pick of the 2007 draft.  That remarkable streak came to an unfortunate end on Sunday when he injured his left arm on his 10,363rd straight snap.  While blocking the Titans’ Brian Orakpo he injured the arm and did not play another snap.  An MRI was performed and it was revealed that Thomas had fully torn his triceps tendon, an injury which will require surgery (the tendon is re-attached to the bone) and has ended his snaps streak and his season.  No amount of *cough* deer antler spray *cough* will allow him to return to full football activity sooner than 6-9 months, but he should make a full recovery for next season.  While it is not a terribly common injury, it is one with a good track record for reliable recovery.

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Patriots Linebacker Donta Hightower suffered a shoulder injury during the Sunday night game (Image courtesy of BostonGlobe.com)

As for the Patriots, defensive stalwarts Donta Hightower and Malcom Brown each suffered injuries in the second half of Sunday night’s game which caused them to miss the rest of the game.  It was announced that Hightower had a shoulder injury while Brown was out with an ankle injury.  While the exact nature of their injuries is not yet known (of course not, it’s the Patriots we’re talking about here), their participation in practice this week will certainly bear watching.  This is especially true in Hightower’s case, as he has a history of shoulder issues, most recently having right shoulder labrum repair after the Pats’ Super Bowl win over the Seahawks in 2015.

To Operate or Not To Operate… That is the (Clavicle) Question

While it may not be quite Shakespearean, Aaron Rodgers’ clavicle fracture is certainly a tragedy for the Packers and their fans. With the QB heading under the knife soon, it raises the question- why do some clavicle fractures require surgery while others heal on their own?

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As Aaron Rodgers came crashing to the turf on Sunday under the weight of the Vikings’ Anthony Barr, so too, most likely, did the Packers Super Bowl aspirations, as it was later learned that the hit had fractured Rodgers’ right clavicle (“collarbone”). It was announced today that Rodgers’ injury would require surgical fixation, almost definitely ending his season. Rodgers’ injury brings up memories of other NFL quarterbacks with clavicle fractures in recent seasons – Rodgers himself in 2013 and the Cowboys’ Tony Romo in 2015. Both of those injuries resulted in the quarterbacks losing parts of their seasons – both missed 8 weeks but were able to return the same season without surgery. Rodgers was injured in week 9 but was  returned for the regular season finale and the postseason, while Romo was hurt in week 2 and came back in week 11, only to re-fracture his clavicle in week 12 and miss the remainder of the season. In both cases, the injured QBs were able to return in the same season without surgery – what was different about these fractures that allowed them to avoid the operating room?

One obvious difference is that Rodgers’ previous fracture and Romo’s fracture were in their left, non-throwing shoulder. That, however, is not the key determinant in whether or not a clavicle fracture benefits from surgery. The primary factor in whether or not to operate on such an injury is “displacement”, or the degree to which the bone fragments have separated.  Rodgers’ 2013 injury and Romo’s fracture were both “non-displaced”, meaning that the bone was broken but the pieces had not moved – essentially a crack in the bone.

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Non-displaced clavicle fracture in blue circle

Fractures such as these, or minimally displaced fractures which have moved only a few millimeters, can almost always be treated without surgery.  These still require 6 to 8 weeks to fully heal, as evidenced by Rodgers’ and Romo’s recoveries, with the arm being allowed to rest in a sling for comfort and healing purposes. Essentially all of these will heal without surgery and allow for a full recovery. Given the Packers quick announcement of the need for surgery for Rodgers’ current fracture, it’s safe to infer that this injury falls into another category of clavicle fractures, displaced fractures. In these types of fractures, the fracture fragments have moved apart to such a degree that they are less likely to heal without surgical intervention to re-align the bone.

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Displaced Clavicle Fracture

While surgery is not mandated in these types of clavicle fractures, it is often recommended for a number of reasons.  Most noticable for patients, stabilizing this type of fracture makes them much more comfortable in the short term, as the mobile fracture fragments are quite painful.  More importantly in the long term, however, is the fact that surgically realigning the fracture improves the function of the shoulder and arm by restoring the proper shape and length of the bone and decreases the chance that the bone might not heal on its own.  While non-displaced fractures have a rate of healing that approaches 100%, widely displaced fractures can have a 5-15% rate of non-union (failure to heal) when treated without surgery.  While an 85% chance of healing might be enough for the cheesehead in the discount double-check commercial, it’s certainly not high enough for the All-Pro quarterback in the same ad.  Primarily for this reason, Rodgers will undergo surgical fixation sometime in the near future, resulting in an x-ray that will likely resemble the following plate-and-screws construct:

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Clavicle Fracture After Fixation with Plate and Screws

Post-operatively Rodgers will likely be in a sling for 4-8 weeks, gradually resuming range of motion and light strengthening before resuming more aggressive workouts. Full contact would likely not be allowed for about four months, and given that this is Rodgers’ throwing shoulder, it will likely take him at least that long if not longer before he is comfortable making the throws he will need to make.  The end result of all this is that Rodgers’ season is almost definitely finished, but he should make a good recovery from this injury – the rate of healing after this type of surgery is very high and should allow him to regain full strength and throwing accuracy.  Long story short – don’t plan on getting any fantasy points out of Rodgers this season, but if you’re in a keeper league, hold onto him – he should be good to go for 2018.

Watt the Heck is a Tibial Plateau Fracture, Anyway?

Ok, that’s a terrible pun. But the Houston defensive star’s latest injury is no laughing matter 


By now, everyone knows that JJ Watt, All-Pro defensive end for the Houston Texans, suffered a season-ending left knee injury in the Sunday Night Football game against the Chiefs. Watt went down awkwardly while rushing the passer in the first quarter and had to be helped off the field, unable to bear weight on his left leg. It was later announced that he had a tibial plateau fracture which underwent surgical fixation, resulting in Watt being placed on Injured Reserve and ending his season. But what is this injury and what does it mean for Watt’s future?

A tibial plateau fracture is a fracture of the top of the tibia, where it makes up the bottom half of the knee joint.


A fracture of the tibial plateau, by definition, involves the knee joint itself, as opposed to a tibial shaft fracture, which is a fracture of the mid-portion of the bone between the knee and the ankle. This is an important distinction, because a tibial plateau fracture also impacts the structures inside of the knee, including the articular (surface) cartilage, and potentially the meniscus and ligaments of the knee.


Like most things in orthopedics, there is a classification system for tibial plateau fractures, from type 1 to type 6, with the severity of injury basically increasing the higher the number.

Most likely, based on the mechanism of Watt’s injury, he sustained a type 1 or 2 fracture – that involves the lateral, or outside, plateau. Early this week he underwent surgery to fix the fracture with a plate and screws, resulting in fixation that likely resembles this x-ray:


Following this, Watt will be on crutches for 8-12 weeks, with gradually increasing range of motion in a brace. He won’t be able to start significant strengthening until a month or two after that, and won’t be able to resume full football activity for 6 to 9 months after his surgery.

How about the prognosis for Watt’s leg moving forward – will he be the same player he was before the injury?  That’s a question that can’t really be answered based just on his x-rays – the most important factor is the status of the cartilage in his knee, both the surface cartilage and the meniscal cartilage. When a bone fractures into a joint, as is the case with a tibial plateau fracture, the surface cartilage is also injured. The degree of cartilage injury and the ability of the surgeon to precisely align the bones to allow the cartilage to heal as well as possible are important determinants of how Watt will do in future seasons. A significant degree of cartilage injury can be a source of ongoing pain and can even cause early arthritis.

The meniscus cartilage is also commonly injured in the setting of a tibial plateau fracture – most studies estimate between 30-50 percent of patients with lateral tibial plateau fracture also tear their meniscus. If the tear is significant or cannot be repaired, this can also be a source of ongoing pain.


Blue oval shows meniscus tear in a knee with a tibial plateau fracture 

No doubt JJ Watt will put as much effort into his recovery as he has with his previous injuries, including major back surgery last season. How his knee responds, however, will depend largely on factors beyond his control – the status of the cartilage in his knee due to the injury and how his body responds to any damage to those structures. The hope is that his leg heals well and he returns to being the same dynamic player that he was, but the cartilage in his knee will likely be the final determinant of how well he does.

Tom Brady and the Terrible, Horrible, No Good, Very Bad AC joint 

Ok, it’s not really THAT bad, but everyone’s still worried, right?


By now you’ve no doubt heard that Tom Brady apparently hurt his left shoulder in the Carolina Panthers game in week 4 (compliments of another of the NFL’s ageless wonders, Julius Peppers) and reaggravated it this past week against the Bucs (compliments of the Patriots’ sieve-like offensive line). Reports have come out that Brady had an MRI which showed no structural damage or tears, and he has been diagnosed with an acromioclavicular (AC) joint sprain.

So what does that mean for Brady and the Pats? First, a little about the AC joint in general. The AC joint is the small joint at the top of the shoulder where the acromion (the top of the scapula, or shoulderblade) meets the clavicle (collarbone).


It’s a commonly injured joint in contact sports – usually by falling directly onto the shoulder, not uncommonly with a very large person directly on top of you driving you into the ground with malicious intent, like, say, this:


This picture is, of course, Patriots backup quarterback Jimmy Garoppolo injuring his right AC joint against the Dolphins in week 2 last year. Garoppolo’s injury is similar to Brady’s but different in that it was to his throwing shoulder and was apparently more severe than Brady’s, given the amount of time (2+ games) he missed.

Like a lot of things in orthopedics, AC joint injuries can be of varying severity, denoted by the “grade” of injury. Most orthopedic classification systems don’t go very high in terms of grades because math makes our heads hurt, and AC injuries follow this formula – there are six grades of injury, with grade 1 being the least severe (a sprain of the joint) and grades 2-6 being increasingly severe disruptions of the joint (separations).


The vast majority of these are treated without surgery, but the more severe the injury, the longer the injured player will likely be out.

In Brady’s case he apparently has a grade 1 injury to his non-throwing shoulder, so the outlook is good for him to miss little, if any, action. He did miss practice today but this should be something which is manageable with a combination of training room treatment, Alex Guerrero/TB12 hocus-pocus, and potentially a numbing injection into the joint around game time. Brady’s ability to play will really come down to pain tolerance- he’s not putting his shoulder at risk structurally by playing – and he certainly has a track record of playing through pain in the past.  I’d put my money on Brady being out there this weekend but don’t be surprised if they are more likely to play Jimmy G sooner rather than later in the event of a blowout.  For the balance of the season, if the offensive line can keep Brady upright (big “if”, I know) his shoulder shouldn’t be a major concern.