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.

Patriots Update 10/29/17 – Hogan Hurting, Stephon Still Sitting

Today started with the Pats’ high-priced new cornerback missing his third consecutive game with some combination of ankle/concussion issues and ended with Chris Hogan being knocked out of the game with what is being announced as a right shoulder injury 


Photo courtesy of BostonHerald.com

The above picture is allegedly of Stephon Gilmore practicing.  I say “allegedly”, because although he has apparently been a participant (albeit limited) in practice recently, that’s all we have to go on, as he was a late and somewhat unexpected scratch for the Chargers game today. Gilmore has been a bit of a medical mystery for the last month, as he played in the Bucs game, practiced the following week, but cropped up suddenly with concussion symptoms the day before the Jets game and missed that week. A combination of that and an ankle injury have kept him from seeing game action for the last three weeks, and the apparently sudden appearance of his symptoms combined with his up-and-down play (Ok, terrible, he was terrible)  have led to an abundance of conspiracy theories.  Were the Pats holding him out with a phantom injury so he could learn the playbook better? Was he in fact good to go but was being held out so we could all get more Johnson Bademosi in our lives? Was there something even more nefarious at play?


Ok, maybe not the last one. Personally, I think that Gilmore was probably close to playing but with the less-than-ideal field conditions in Foxboro today the Patriots opted to hold him out another week with the bye looming next weekend to get him as close to 100% as possible before the stretch run. I’d be shocked if he doesn’t play in Denver on November 12th. Unless, that is, Bademosi goes full Gillogly on him between now and then, in which case all bets are off. 


Chris Hogan injured his right shoulder on this fourth quarter play (image courtesy of BostonGlobe.com)

In today’s game, the Pats’ already-thin wide receiver core took another hit when Chris Hogan went down hard when he was hit in the fourth quarter.  At the end of a completion, Hogan was taken down hard by Chargers linebacker Hayes Pullard. Hogan was hit hard on the side of the right shoulder and was clearly in pain and was slow to get up. When he did leave the field, accompanied by Patriots medical personnel, his right arm was hanging limply at his side. After a short period on the bench he returned to the locker room and did not return for the rest of the game. Post-game reports indicated that Hogan was in a sling for his right arm and that he would be undergoing a right shoulder MRI tomorrow. 

By my view of the play, it seems likely that Hogan suffered a right AC joint injury – he was hit directly on the side of the shoulder and had obvious, immediate pain. Injuries to the acromioclavicular (AC) joint of the shoulder usually occur with a direct fall onto the shoulder (Jimmy Garopollo last year) or a blow to the side of the shoulder, as in Hogan’s case. This type of injury is very painful and usually results in at least some games lost. For an in-depth look at this type of injury, I wrote about it recently in connection with Tom Brady’s left shoulder: http://chrisgearyortho.com/2017/10/11/tom-brady-and-the-terrible-horrible-no-good-very-bad-ac-joint/

With the tweets that Hogan was in a sling and going for an MRI tomorrow, Patriots fans immediately feared the worst. I feel that in this case, as bad as it looked, the Pats and Hogan may have dodged a bullet. The sling is used for comfort with any shoulder injury, big or small, and MRIs are done for almost any soft-tissue injury to a joint in high-profile athletes. If my supposition is correct and Hogan does indeed have an AC joint sprain he will likely miss between 2-6 weeks depending on the grade of the injury and his response to treatment but he should be back this season with no long-term effects. Hogan, interestingly, is left-handed, so he should have no problem throwing the WR option pass when he returns (shades of Julian Edelman in 2014 vs the Ravens). Fingers crossed that I’m correct and tomorrow’s scan shows no additional damage – we may see Hogan back in time for the next Pats home game in late November.

Donta Hightower Update 10/26/17

Now that we have some clarity about the Patriots’ star linebacker’s shoulder condition, what are the short- and long-term ramifications for this injury?

Photo courtesy of BleacherReport.com

The unfortunate news about Donta Hightower’s shoulder/chest injury has started to filter out – when it was announced on Wednesday that he was already ruled out for Sunday’s game people began to fear the worst. Today those fears were at least partially confirmed when word began to leak that Hightower had an injury to his right pec muscle/tendon and would miss the rest of the year.  More recently, however, Adam Schefter tweeted that it was unclear if he would actually be out for the whole season and that the linebacker would be seeing Dr. James Andrews for a second opinion. 

The gray area with this condition comes with the exact anatomic location of the injury – the pec muscle/tendon unit can be torn at the area where the muscle turns to tendon (a musculotendinous injury) or the tendon can tear fully off of its attachment to the humerus. 


Pectoralis major and its tendon insertion onto the humerus (image courtesy of UWRadiology.com)

The differentiation between these two types of injuries is important, because if it is a musculotendinous tear it will cause short-term pain and difficulty using the arm but does not need surgery. If this is the case with Hightower he could certainly return sometime this season without an operation. If the tendon is torn fully off the bone, however, it would certainly require surgical fixation and cause Hightower to miss the rest of the season. It is not always readily apparent which kind of injury the pec tendon/muscle has sustained based on physical exam and history, hence the need for an MRI. No doubt Hightower will be bringing his images south to see Dr. Andrews, and while Andrews frequently seems to be the harbinger of orthopedic doom, there is a chance he will have good news for the linebacker. Pats fans will have to hold their breath for now and hope that the word “musculotendinous” is their favorite new addition to their sporting vocabulary. 

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.

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.