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?

NLAN2264.JPG
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.

img_6955
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).

img_0031
Arthroscopic surgical image of a partial thickness rotator cuff (frayed tissue in red circle with normal biceps tendon in background)

 

img_0033
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.

img_0034
Arthroscopic surgical image showing rotator cuff repair in progress, with sutures in place on the right and suture anchor being inserted on the left
img_0036
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.

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?

img_0024

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.

fullsizeoutput_7ff7
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.

img_6631
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:

fullsizeoutput_7ff8
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.