2017 Colts – An UnLucky Season

When Indianapolis Colts QB Andrew Luck had right shoulder surgery this past January, the goal was for him to have plenty of time to heal up for the 2017 season. With the announcement today that he would be placed on season-ending injured reserve without having taken a snap all year, the natural questions arose: what didn’t go according to plan and what does it mean for Luck’s future?

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Image courtesy of HeraldBulletin.com

 

Over the course of the 2016 season, it became known that Colts QB Andrew Luck was dealing with an injury to his right (throwing) shoulder. Luck was listed on the injury report for the shoulder throughout the year and missed some practice time in an effort to manage the condition. Once the season had ended, Luck elected to have surgery on his shoulder with the goal of having a pain-free 2017 season. Luck underwent a shoulder arthroscopy with a repair of a posterior labral tear. The labrum is the ring of fibrocartilage which surrounds the glenoid (socket bone) of the shoulder.

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Diagram of shoulder joint with labrum surrounding glenoid (socket) – image courtesy of Frozenshoulderclinic.com

 

The labrum can be torn in several different areas. When it is torn in the front of the shoulder – usually because of a shoulder dislocation – it can cause recurrent instability (repeated dislocations). When it is torn at the top (known as a SLAP tear) or in the back (posterior labral tear) it usually results in pain.  In a young athlete such as Luck, these tears are usually the result of one discrete injury (a fall onto the shoulder, as in a sack) or repeated trauma (not uncommon in offensive lineman, with repeated blows to an outstretched arm while blocking resulting in a tear of the posterior labrum).  In many patients this can be managed with activity modification, physical therapy, and sometimes cortisone injections.  In younger active patients, and especially in overhead, throwing athletes such as Luck, however, this condition frequently necessitates surgical intervention to repair the tear and allow for pain-free function.  Labral tears are remarkably common in football players  – a recent study in the American Journal of Sports Medicine –  https://www.ncbi.nlm.nih.gov/pubmed/28974332 – revealed that over the years from 2012 to 2015 132 participants at the NFL combine had undergone prior shoulder labral repair.  The study also showed a high rate of continued ability to play in these players, which should, in theory, have been a good prognostic indicator for Luck.  So what went awry for the Indy QB?

The root of the issue for Luck is that soft tissue repairs of the shoulder (labrum, rotator cuff) in throwing athletes is a delicate business.  During surgery, the labrum is arthroscopically sewn back down to the bone to allow it to heal in an appropriate, hopefully pain-free, position.

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Arthroscopic image of labral repair with sutures (blue) holding labrum to the glenoid (socket bone) – image courtesy of miortho.sg

The difficult part from a surgical standpoint is to get the tension of the soft tissues just right.  It is important to get a tight repair so the tissue will heal, but too much tension can cause the tissues such as the labrum and capsule of the shoulder to be too tight, which can result in a solid repair but a loss of motion.  In an offensive lineman a slight loss of motion would not be a significant issue, as lineman use their arms almost exclusively in front of their bodies and not overhead.  In an overhead or throwing athlete, such as a pitcher or a quarterback, even a slight loss of motion can present significant problems, as the athlete may not be able to regain his normal throwing motion or may struggle with pain in trying to work back to a normal range.  This can be due to overtensioning of the tissues at the time of surgery or can be due to difficulties in rehabbing the tissue if the athlete becomes stiff due to his own anatomy or biology.  Through no fault of the athlete or their surgeon, some people are more prone to stiffness due to their own individual genetics.

So, what, then, happened to Luck to keep him out for the whole year?  Although I obviously was not directly involved in his care, it certainly seems from the information available that Luck had his posterior labrum repaired and during the course of his rehab he has been struggling with ongoing stiffness, resulting in persistent pain.  He has attempted several times to advance his throwing only to be shut down each time, and recently received a cortisone injection into the joint in hopes of decreasing inflammation and pain.  When this was unsuccessful, Luck and the team made the decision to shut him down for the rest of the season.  He has had several second opinions and doubtless a repeat MRI, and the consensus seems to be that no additional surgery is needed – he will rest the arm from throwing for the next few months and work on physical therapy and stretching before attempting to resume throwing.  The hope and expectation is that Luck will be able to return in 2018, but Colts fans will have to hold their breath until they see him back on the field.  While the odds are in Luck’s favor based on the statistics of labral repairs, it is by no means guaranteed that Luck will be able to return at his previous level, if at all.

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.

Celtics’ Gordon Hayward – Fractured Ankle, Likely Out for the Season

 

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By now, anyone who follows sports knows that Gordon Hayward suffered a horrific-appearing left ankle injury only six minute into his Celtics career.  The Celtics have since announced that he has a fractured ankle – from what I could see from the replays and pictures, he certainly seems to have suffered a fracture-dislocation, where the bones of the ankles are broken and the ankle joint itself subsequently dislocates.  It is along the same spectrum of injury as an ankle fracture, but is usually due to a higher-energy mechanism (such as landing awkwardly from a height, as Hayward did), and usually results in a more severe injury than a simple mis-step or slight fall might cause.  Most likely Hayward fractured both his tibia and fibula, and likely injured the syndesmosis, the ligament that connects the two bones at the ankle.

X-ray showing ankle fracture-dislocation

Hayward no doubt had his ankle reduced (provisionally put back in place) tonight in Cleveland at Quicken Loans Arena and splinted or casted to hold it in place for the time being.  Sometime in the next 7-14 days he will undergo surgery to definitively fix the fracture, resulting in a post-operative x-ray that will likely resemble this:

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Post-operative x-ray of ankle-fracture dislocation showing hardware (plate and screws) holding fracture in place

Post-operatively, he will be on crutches with limited weight-bearing for 6-12 weeks depending on the degree of the injury to the ligaments, specifically the syndesmosis.  He may need to have some of the hardware removed at the 10-12 week mark, again depending on the degree of ligament injury.  He will resume normal walking at that point, with no running for a couple months after, and jumping/more explosive activities likely at the 6-9 month mark depending on the degree of injury.

The most pressing question in Celtics fans’ minds tonight is – will Hayward be able to recover fully from this injury to be the player he was before? Without seeing his particular x-rays and given the variation in recoveries and rehabilitations from athlete to athlete it’s impossible to say at this early stage, but Celtics fans should be cautiously optimistic.  While the injury was certainly horrific-appearing, these are the kinds of injuries which should allow for near-full to full recovery – Hayward’s fracture will no doubt heal, and if his leg responds well to his rehab, which is more likely than not, he should be back for next season.  He may lose a little bit of explosiveness or quickness, especially in the short term, but I would look for him to return to the Celtics next season and hopefully have a long and productive career for the C’s.

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.

Welcome to Boston SportsDoc Injury Blog

Welcome to my blog – by way of introduction, I’m Christopher Geary, M.D.  I am a board-certified orthopedic surgeon with specialty training in sports medicine and arthroscopy.  I am the Chief of Sports Medicine at Tufts Medical Center and I am an Assistant Professor of Orthopedic Surgery at Tufts University School of Medicine.  I am also a lifelong diehard sports fan with strong Boston allegiances.  I’ll use my blog to give my insight into current sports injuries and their impact on performance and return to play.  I hope you find it useful – feel free to comment or contact me to ask questions about specific injuries or conditions.