Boston Sports Doc Injury Blog

Dr. Christopher Geary, your source for info on the latest sports injuries with a bit of a Boston slant…

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.

 

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…

 

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.

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.

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: https://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.

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. 

It has been known for several weeks now that the Red Sox’ second baseman has been wrestling with his options for his painful left knee. With the announcement today that Pedroia had undergone a “cartilage restoration” procedure on his knee yesterday, the logical question is – what does this mean for Pedroia in 2018 and moving forward? 

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Image courtesy of edraft.com


As has been detailed in a previous post here, https://chrisgearyortho.com/2017/10/11/pedroias-patellofemoral-pain-potentially-problematic-possibly-permanent/, the Sox’ second baseman had been considering non-surgical and surgical options for his painful left knee, which had undergone previous knee arthroscopy but had continued to cause him issues throughout the 2017 season. The downside of another surgical procedure on the knee was the long rehab, with a good portion of his 2018 season likely being sacrificed to rehabilitation for his knee and getting back into playing shape. The drawback of not going under the knife was the specter of another season of on-and-off knee pain, with additional trips to the disabled list likely if not definite. With this in mind, Pedroia yesterday elected for a “cartilage restoration” procedure at the Hospital for Special Surgery in New York City.

If this story sounds painfully familiar to Sox fans, it should- it is the same type of surgery that Steven Wright underwent earlier this year, at the same hospital. While it has not been announced exactly what kind of surgery Pedroia underwent – “cartilage restoration” is a broader category of surgeries which includes multiple different potential techniques- he most likely had a microfracture to address his cartilage injury. In this procedure, multiple holes are poked in the exposed bone of the knee joint in an effort to stimulate new cartilage growth and thereby remove the source of pain.

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Arthroscopic image of a microfracture of the femoral condyle of the knee (image courtesy of mayoclinic.org)

This is a well-established procedure with a proven track record for returning players to action – depending on the study you read, between 75-90% of patients have good results with this surgery. There are several examples of players in MLB who have had the procedure and returned to play – in the last few years, examples include Carlos Beltran (2010), Victor Martinez (2012), and Brad Ziegler (2014). There are also cautionary tales such as Grady Sizemore (2013), who had the surgery but never fully recovered to being the player he was before. It’s also possible that Pedroia underwent a different type of cartilage surgery – possibly the insertion of a plug of cadaver (allograft) bone and cartilage (OATS procedure). This is different from a technical standpoint but has the same goal (the growth of new cartilage) and largely the same recovery. 

The downside of the procedure is the long and arduous rehab – Pedroia will be fully non weight-bearing with crutches for up to two months, and will be in a continuous passive motion (CPM) device for 4-6 hours a day during that time. The CPM will bend his knee for him, with the goal of more successful cartilage growth. Following this will be a gradual return to weight-bearing, strengthening and eventually full activities.  The Sox have announced a goal of seven months for Pedroia to return to full baseball activities, a timeline which would potentially have him back at Fenway by mid-May. The caveat to this projection is that every rehab is different, and depending on the particular area of the knee affected -the patella (kneecap) and femur are the most common areas to undergo this type of surgery- the timeline may vary. It’s also important to not be too quick to compare Pedroia to Steven Wright, as the demands of playing second base (especially the way Pedroia plays it), batting, and running the bases are substantially different from throwing a knuckleball. That being said, the odds are in Pedroia’s favor that following his long rehab, he will be able to return with a knee which should allow him to stay on the field more reliably than in 2017.

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.

Bruins’ blueliner Adam McQuaid suffered a broken right fibula while blocking a shot Thursday night against the Canucks – while he broke one of the same bones as the Celtics’ Gordon Hayward, his recovery should be quicker

Adam McQuaid helped off the ice after suffering a broken fibula in last night’s game against the Canucks (image courtesy of WEEI.com)

Bruins’ defenseman Adam McQuaid is as toughas they come, but he has had tough injury luck in recent seasons, and that run of unfortunate injuries continued last night. After blocking two shots during a shift against Vancouver in theBruins 6-3 win, McQuaid had to be helped off the ice and did not return. He was later diagnosed with a broken fibula and it was announced that he would undergo surgery to fix his fracture on Monday.

X-ray of a fibular shaft fracture

(Image courtesy of eORIF.com)

News of this injury likely causes a shudder to run down the spine of Boston sports fans, as it was only days ago that we learned that the Celtics Gordon Hayward would be out most if not all of the season with a left ankle fracture of his own. The key difference for McQuaid is that his fracture is from a direct blow, in this case from a speeding hunk of vulcanized rubber traveling at speeds around 90 MPH. This almost always results in a fracture of the shaft of the fibula, the area in the middle of the bone, as opposed to a rotational injury like Hayward sustained, which causes damage to the ankle joint itself. Rotational ankle fractures (so-called because they result from rotation of the ankle joint/foot as opposed to a direct blow, as in McQuaid’s injury) result in damage to the ankle joint itself and frequently the ligaments of the ankle, which results in a longer healing time. Fibular shaft fractures do not damage the ligamentous structures of the leg, allowing for a quicker recovery time. On Monday McQuaid will have a plate and screws placed in his leg, allowing for the bone to be precisely aligned and to heal reliably. He may be able to start light conditioning (stationary bike) activities within a couple weeks, and will probably start skating within 4-6 weeks. He should be back on the ice for the B’s by late December at the latest.

While McQuaid’s latest injury is obviously another in an unfortunate run of injuries for the burly defenseman, he should be back relatively soon, certainly faster than Hayward for the Celtics. Moral of the story, if you’re going to break you leg, do it by taking a puck off the shin rather than dislocating your ankle. Or, you know, just don’t break your leg at all, that’s cool, too.

 

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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.

Full disclosure – I (obviously) did not perform either of the Red Sox’ surgeries yesterday. However, I did perform several orthopedic surgeries today and I have stayed at a Holiday Inn Express in the past, so let’s do this…


Two prominent members of the Red Sox had surgery yesterday, both performed by Dr. James Andrews in Pensacola, Florida. Let’s tackle the “easier” of the two first – Hanley Ramirez’ left shoulder surgery. The Sox’ DH/occasional first baseman underwent a left shoulder arthroscopic debridement – in simpler terms, a “cleanup”. Ramirez has dealt with shoulder issues in the past, including in 2015 when he ran into the left field wall at Fenway, and his shoulder issues caused the Sox to be hesitant to use him at first base on a regular basis this year. Despite being used sparingly in the field, it seemed that Ramirez’ shoulder woes may have sapped him of his usual power, given that he finished the season with only 62 RBI and an OPS of .750, both well below his career averages. With an eye towards restoring some of his lost slugging capabilities for next season, the DH went under the knife for a shoulder arthroscopy and debridement. The idea of this surgery is that if Dr. Andrews was able to clean up some loose cartilage or inflamed bursal tissue Ramirez’ shoulder might feel more comfortable and allow him to be more productive at the plate. With nothing being repaired, recovery should be quick, with a sling for only a few days for comfort and a return to full activities in a month or so. Whether or not Ramirez benefits from the procedure is yet to be determined, but the potential downside was so minimal it was likely worth a shot.

Sox starting pitcher Eduardo Rodriguez also had surgery with Dr. Andrews yesterday, in his case on his right knee. Rodriguez had several patellar subluxations (partial dislocations, where the kneecap slides to the side but does not come out all the way) of his right knee over the last year, which caused him to miss significant chunks of time over the last year and contributed to the lefty’s disappointing 2017 season. Patellar subluxations or dislocations are a source of significant pain and can cause athletes or patients to not trust their knee. Once someone has had a dislocation or subluxation of their patella, they inevitably stretch or tear their medial patellofemoral ligament (MPFL), one of the ligaments on the inside of the knee responsible for stabilizing the kneecap through its range of motion. In a way, it is like the ACL of the kneecap – important for stability but somewhat easy to injure.

Also similar to the ACL, once the MPFL has been torn or stretched the ligament has little inherent healing capacity, so recurrent instability can be a problem. Most patients with this condition can manage it without surgery, through physical therapy exercises and activity modification. Rodriguez obviously did not fall into this category, as his recurrent patellar subluxations caused his need for surgery.

There are several different techniques for this particular surgery, but the basic idea is to make a new medial patellofemoral ligament (MPFL) out of either the patient’s own tendons, typically the hamstrings, or a cadaver tendon (an allograft).


Diagram of MPFL Reconstruction

The new ligament is attached to the patella and femur by means of screws or anchors, and usually a knee arthroscopy is performed at the same time to address any cartilage issues. Post-operatively the patient is usually on crutches and in a brace for 6-8 weeks, with physical therapy at first focusing on range of motion, followed by strengthening at around three months and cutting/jumping sports between 6-8 months. The Red Sox have announced that Rodriguez is expected to resume pitching in about six months, which is consistent with this timeframe.  I would anticipate this would mean he would begin pitching in six months, but would have to gradually increase his arm strength and pitching activities, so it might be closer to 8-9 months before he is back to the big leagues, so a return to the Sox after the all-star break might be more realistic.

In terms of results, the odds are in Rodriguez’ favor for a full return with a stable knee. A recent meta-analysis (a group of studies whose results are pooled together) looking at results of MPFL reconstruction surgeries from the American Journal of Sports Medicine showed very favorable results, with 84.1 percent of patients returning to their sports and with recurrent instability being very low, at 1.2 percent. It is safe to say that while Rodriguez’ recovery may be long, his results should be predictable and reliable, while Ramirez will have a quick recovery but potentially less durable results.