all. day. i. dream. about. sports.

Your injury information prescription to dominate your fantasy sports leagues

[mlb]

A day later, Ichiro’s 3,000th hit is still awesome.

[siphotos]

Seattle Mariners outfielder Ichiro Suzuki looks right at the camera during an at-bat against the Texas Rangers on April 12, 2012 at Rangers Ballpark in Arlington, Texas. Ichiro, who got his 3,000th major league hit on Aug. 7, 2016, with the Miami Marlins in a game against the Colorado Rockies in Denver, became the 30th player to join the 3,000-hit club. (Darren Carroll)

GALLERY: SI’s Best Photos of Ichiro Suzuki

[sbnation]

THIS IS STEPH CURRY AKA THE BEST BASKETBALL PLAYER ON EARTH ACCEPTING HIS NBA MVP AWARD

[marlins]

Wanna do it all over again Friday night? #StantonSmash #HechOfAPlay #Ichiro

[fantasyphysio]

GOAT

[fantasyphysio]

The Axillary Nerve

Starring Carson Palmer

             One of the most interesting injuries in the 2014 NFL season was Carson Palmer’s axillary nerve contusion. Touted as a sneaky sleeper in a high powered, vertical, Bruce Arians offense, Palmer, coming off an ACL injury, unfortunately was bitten by the injury bug again in the first game of the season (yes, he was on my team). The brachial plexus is a network of nerves that runs from the spine at the back of your neck/shoulder area and branches off into many different paths. The axillary nerve comes from the posterior cord of the brachial plexus and highways a series of sensory fibers to an oval shaped area over the lateral shoulder, innervating the deltoid and teres minor muscles. These muscles play a role in shoulder abduction (lifting shoulder away from the body) and rotating the arm in a throwing motion.

             An axillary nerve contusion is quite a rare football injury that is most often seen in car accidents [contusion is a fancy name for a bruise]. Direct trauma associated with shoulder dislocation or humeral fractures (Goslin & Krivickas, 1999) or sleeping in a position with the arms raised above your head could cause its surrounding muscles of the quardrilateral space to pinch on the nerve (Brown et al., 2015; Hoskins et al., 2005). This construct of muscles are formed by the teres minor muscle superiorly, humerus laterally, long head of the triceps medially, and the teres major muscle inferiorly. Patients will report a sharply-defined region of sensory loss over the lateral shoulder, weakness, and numbness (Goslin & Krivickas, 1999). This dulling sensation isn’t more intense because the shoulder and arm can recruit other muscles to perform its tasks.

             The timetable for recovery is usually set at 3-4 months. However, nerve injuries are a finicky ordeal and its comfort level may vary day-by-day. Conservative treatments such as physical therapy and exercise to maintain range of motion are the first course of action, but more invasive, surgical procedures are available. Nerve grafting is usually deemed as a last resort for severe lesions and for those who don’t improve in the first few months of conservative measures and recurrent shoulder dislocations (Steinmann & Moran, 2001; Perlmutter, 1999).

Relevant Players:

Carson Palmer, QB, Arizona Cardinals: Carson Palmer was hit at the end of a run during a Week 1, 18-17 victory vs. the San Diego Chargers. Before the injury, Palmer was having a solid outing, throwing for 304 yards, 2 TDs, and rushing for 29 yards. Palmer came back from injury, but only 6 games for the rest of 2014, throwing for 1,626 yards, 11 TDs, and 3 interceptions. Not quite the bounce back the Cardinals were expecting, as they were plagued with QB injuries all season, having to plug in Drew Stanton, Logan Thomas, and Ryan Lindley. Nevertheless, the Cardinals finished 11-5 in a tough NFC West division to punch their ticket into the playoffs. Though they didn’t last long in the post-season (due to said quarterback injuries), their 2014 season shows the offensive mastermind of Bruce Arians. Luckily for Palmer, there were no structural damage to the shoulder and he should be operating at a full, 100% entering 2015. The Cardinals resigned Larry Fitzgerald to anchor their young, budding WR corps and still don’t have a premier running back, which means that they will likely throw, throw, throw. This works perfectly to Palmer’s fantasy stock and I think he could put up numbers similar to those he did in Week 1 each game next year barring his health. Again, Palmer could be a sneaky QB 2 sleeper with a low, top-10 QB ceiling. He is definitely someone that I suspect that could be forgotten until late, or even go undrafted.

On Deck: Todd Gurley’s ACL

In the Hole: Julius Randle’s broken leg

[fantasyphysio]

The Torn Patellar Tendon

Starring Victor Cruz

      The 2014-2015 fantasy footballseason was not my year. It was a year where Adrian Peterson, my #1 overallpick, lost for the year due to child abuse charges. It was a year where I bounced back, wheeled and dealed to get LeSean McCoy AND Eddie Lacy BUT STILL missed the playoffs. It was a year where Jay Cutler threw 18 interceptions and lost the confidence of his head coach despite having two #1 WRs in Brandon Marshall and Alshon Jeffrey. It was a year where the tone was set when I saw my Victor Cruz carted off the field, bawling because he will no longer be able to salsa for the rest of the season.

      Before the Cruz injury, I was holding on to the thread of hope of scoring a garbage time TD during the 27-0, Philadelphia Eagles pounding of the New York Giants. While running a route to the back corner of the end zone, my hopes were dashed as Victor Cruz jumped awkwardly and clutched his knee in pain throughout his flight. A torn ACL was the first thing that jumped into mind when I saw the year ending prognosis. However, the salsa dancer was diagnosed with a torn patellar tendon, a much less common injury for those under 40 years old but usually occurring during an explosive movement (Saragaglia et al., 2013).

      The patellar tendon connects the quadriceps muscle to the shinbone or tibia. It may be confused as a ligament, connective tissue that links bone to bone, because it helps in keeping the patella (kneecap) attached to the tibia. However, it is most commonly called a tendon, connective tissue that connects muscle to bone, because it is part of the quadriceps tendon that stretches from the quad muscle to the tibia, which helps extend the leg. The patellar tendon originates at the inferior end, distal to the patella and inserts at the tibia turbecle. In contrast, the quadriceps tendon lies proximal to the patella (Hak et al., 2010).Complete tendon tears usually occur 2 cm distal to the patellar tendon insertion or 2 cm proximal to the quadriceps tendon insertion. Many patellar tendon tears are often associated with patellar avulsion fractures, which is when a fragment of bone is separated from the main mass of bone as a result of trauma. ACL tears and other injuries may also be associated.

      A patellar tendon rupture usually occurs during an acute, explosive event where a sudden, strong contraction of the quad muscles occurs (jumping or changing direction) or when the knee is flexed, fixed to the ground while the upper trunk is driven backwards (Brooks, 2009). Another instance is when the knee is already flexed at least 60 degrees and an external force causes the knee to increase its degree of flexion. For example, a volley ball player that lands on someone's foot so that their already flexed knee suddenly has to flex even more while absorbing the force of the landing. A pop, followed by swelling, sharp knee pain and difficulty to bear weight ensues. Chronically, patients may suffer from patellar tendinopathy which is prevalent in 50% of jumping sport athletes (Lian et al., 2005; Peers & Lysens, 2005). Glucocorticoid injections also may pose a higher risk for such injuries to occur (Chen et al., 2008). Patients suffering from a torn patellar tendon will have limited knee extension, can't maintain a straight leg, or raise the leg against gravity while laying down (supine).

      Non-surgical and surgical options can be effective but the time of diagnosis is one of the biggest influences on its recovery. Early diagnosis, within one week of injury, and prompt surgical intervention for repair vastly improves outcomes (Ilan et al., 2003). Conservative approaches include RICE (rest, ice, compress, elevate), stretching to improve range of motion, and isometric strengthening to restore the extensor mechanism muscles. However, for more serious ruptures, surgical procedures are required to manually tie the torn ends of the tendon together and apply the proper tension. In serious cases, the surgeon may need to reattach the tendons to the bone itself. The trickiest part of the procedure is in determining the proper amount of tension that needs to be applied on the tendon. Too lose, and the knee cap will be unstable, but too tight, and range of motion will be compromised. The normal timetable for recovery is 3 months until normal daily activity and 4-6 months until sport can be resumed. However, long term weakness may be experienced and Victor Cruz may not be the same receiver who reeled off more than 2,000 yards and 19 TDs in two seasons before the injury.

 Relevant Players:

Victor Cruz, WR, New York Giants: Speaking of the importance of an early diagnosis, Victor Cruz was wheeled into the operating room less than 24 hours after the Giant's Sunday Night loss in Philly. Dr. Russell Warren, the Giant's team physician, performed the surgery at the Hospital for Special Surgery in Manhattan. Cruz may never be the receiver he once was and if you have the kind of luck I do, I think it is best to approach him with caution next year. Odell Beckham Jr.'s torrid 2014 campaign in which he put up 91 receptions, 1,305 yards, and 12 TDs in 12 games will be Eli's first option next year. To put Beckham's incredible year in perspective, only the great Randy Moss has had a better fantasy season in their rookie year except Moss had all 16 games to put up his numbers (1,313 yards, 17 TDs). I think Victor Cruz's return will benefit the teammates around him, especially Beckham's, because defenses still need to respect Cruz's resume. Even when Cruz was 100% in 2013 and 2011, compared to Beckham's 2014 in which he had similar numbers of targets, Beckham still posted the better stats. Simply put, Beckham is the more explosive player and the New York Giant you want to target. In addition, I think Cruz’s return makes Eli Manning an interesting sleeper. Only if the time is right and Cruz free falls down draft boards, can Cruz be a great value pick. As it stands, I would put Cruz currently standing at a WR5 tier with a ceiling of a WR3.

On Deck: Carson Palmer’s Nerve 

In the Hole: Todd Gurley’s ACL

References

Hak, DJ., Sanchez, A., Trobisch, P. Quadriceps tendon injuries. Orthopedics 2010; 33:40

Ilan, DI., Tejwani, NM., Keschner, M., Leibman, M. Quadriceps tendon rupture. J Am Acad Orthop Surg 2003; 11:192

Lian, OB., Engebretsen, L., Bahr, R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med 2005; 33:561

Peers, KH., Lysens, RJ. Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations. Sports Med 2005; 35:71

Saragaglia, D., Pison, A., Rubens-Duval, B., Acute and old ruptures of the extensor apparatus of the knee in adults (excluding knee replacement). Orthop Traumatol Surg Res 2013; 99:S67

[fantasyphysio]

The Ulnar (Medial) Collateral Ligament - Tommy John Surgery

Starring Richard Sherman

UPDATE: Sherman will opt for conservative measures and rehab, for now, instead of surgery per SB Nation. 

        Last week, I raved about the exciting 2015 NFC Championship game finish between the Seattle Seahawks and Green Bay Packers. But, your 2014-2015 NFL experience would not be complete if you missed the Super Bowl last Sunday. After a ridiculously miraculous Jermaine Kearse catch, the Seahawks looked like they were destined for back-to-back championships. However, unheralded Patriots safety, Malcolm Butler, had other plans and picked off Russell Wilson’s pass at the 45th second mark in their own one-yard line to bring Super Bowl XLIX to an abrupt end. The 28-24 Patriots victory was chock-full of storylines: Pete Carroll’s decision to pass on the two-yard line instead of handing the ball off to BeastMode; Bill Belichick’s choice to withhold a timeout and let the clock tick below the minute mark with the Seahawks inches away from taking the lead; Chris Matthews’ heroic 109 yards, 1 TD performance only months after jumping out of his Foot Locker day job; “Deflate Gate”; Tom Brady’s 4th Super Bowl win.

        Buried under the pile of headlines was the injury status of the Seattle Seahawks’ Legion of Boom. Even more criminal is the absence of debate of who was the best cornerback in the NFL between Richard Sherman and Darrelle Revis. The injury that Sherman sustained in the NFC Championship game may have averted such comparisons for another time. As James Starks raced down the right sideline, Sherman and “Bam Bam” Kam Chancellor converged to maul Starks out of bounds. It seemed like a routine tackle, but Sherman was visibly in pain as he picked himself up, favoring his left elbow. Instead of calling it a night, Sherman stayed in the game and kept his elbow in a bent position as if it was in an invisible sling. After the inspiring performance, an MRI indicated a sprained elbow, which Sherman played through again after two weeks of rest. Once the confetti has settled, Coach Pete Carroll told the media that Sherman may have suffered ulnar nerve damage and may need Tommy John surgery to repair the ulnar collateral ligaments (UCL).

        Elbow pain may be caused by damage to the joint or it surrounding structures. The elbow joint most resembles the hinge model, which consists of the humerus (bone of upper arm), ulna (larger bone of lower arm), and radius (smaller bone of lower arm). Surrounding structures of the joint include:

Epicondyles (medial and lateral) – Bony prominences on the sides of your elbow. Origin of most tendons of muscles that flex and extend the wrist. Most common source of pain.

Olecranon bursa – the hard part of your elbow.

Radial and Ulnar nerves – courses through the elbow joint. May cause pain when pinched as a result of trauma or repetitive elbow flexions.

Biceps and Triceps – controls arm flexion and extension.

Radiohumeral and proximal radioulnar articulation – located below the elbow joint and play a role in palm rotation. Biceps muscles supinate (palm face up) while the pronator teres pronates (palm face downward).

        Sherman’s sprained elbow is the result of a ligament strain that is seen most often in throwing athletes. The UCL is part of the network of ligaments that support the elbow.  Tears in the UCL may occur when there is an acute, traumatic injury to the elbow resulting from a fall on an outstretched arm or a twist on a planted hand.  Research on throwers with ruptured UCLs found that 50% had a single catastrophic event while the other half had symptoms before the event itself (Jobe et al., 1986). The cumulative effect of repetitive throwing may chip away at the ligament because the force generated during the cocking and acceleration phases of throwing causes valgus stress on the elbow (Behr & Altchek, 1997).  When the arm is fully extended, valgus stability is divided equally among the medial collateral ligament, anterior capsule, and bony articulation. When the elbow is flexed 90 degrees, the anterior capsule’s load is taken up by the medial collateral ligament, which contributes about 55% of the stabilizing contribution to valgus stress. Meanwhile, varus stress is resisted by the anterior capsule (32%), joint articulation (55%) and radial collateral ligament (14%) (Morrey & An, 1983). These studies elucidate that the UCL is under the most stress and subject to injury during the throwing motion.

        Tommy John Surgery is the premiere surgical operation for UCL damage. Previously known as ulnar collateral ligament reconstruction surgery, the procedure involves replacing the damaged UCL with a tendon from elsewhere in the body. Donor tendons are usually spliced from the palmaris tendon in the forearm of the same or opposite elbow, patellar tendon from below the knee, or a cadaver (donor). Dr. Frank Jobe, orthopedic surgeon and Los Angeles Dodgers team physician in 1968-2008, performed the first UCL reconstruction surgery procedure and coined the term after the patient of his first case. Tommy John, pitcher for the Dodgers, missed the entire 1975 season rehabbing his arm after going under the knife in 1974. Before the surgery, he had won 124 games. After 1975, Tommy John won 164 games and pitched until he was 46 years old. Dr. Jobe’s Tommy John surgery resurrected Tommy John’s career that included an NL Comeback Player of the Year in 1976 and 2nd place finish in the Cy Young voting of 1997. At the time of Tommy John’s operation, Jobe put his chances at 1 in 100. Today, 83% of throwing athletes who have the procedure will return to previous or high levels of competition in less than 1 year (Cain et al., 2010).

Relevant Players:

Richard Sherman, CB, Seattle Seahawks: When asked about Sherman’s recovery timetable, Pete Carroll joked, “I really don’t think so [it will take a long time], as long as Sherm doesn’t want to become a late-inning reliever.” Organized team activities (OTAs) generally start around June, which will give Sherman a good 6 months to have the surgery and recover. Like Carroll said, the Seahawks are lucky this isn’t Russell Wilson we’re talking about because Sherman’s positional demands don’t require him to make throws downfield. All-Pro defensive end, DeMarcus Ware, had a similar elbow surgery in February 2014 and was able to recover in time for the season. There won’t be any question that Sherman can return with full force, in time for the upcoming season and thrusting himself back in the discussion of who is the best cornerback in the game. The only question that still lingers is if there would have been a different Super Bowl XLIX outcome had the heart (and the mouth) of the Legion of Boom been healthy.

On Deck: Victor Cruz's PCL

In the Hole: Carson Palmer's Nerve

References:

Behr CT, Altchek DW. The elbow. Clin Sports Med 1997; 4:681-704

Cain EL, Andrews JR, Dugas JR, Wilk KE, McMichael CS, Walter JC, Riley RS, Arthur ST. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med 2010; 12:2426-34

Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. AM J Sports Med 1983; 11:315

Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am 1986; 68:1158

[fantasyphysio]

The Calf Strain

Starring Aaron Rodgers 

       WHAT. A. GAME. Last year’s NFC Championship game had set the bar high on the thriller scale and this year’s game did not disappoint. Up until the last 3 minutes of the game, the Seattle Seahawks were still down 19-7 against the Green BayPacker. Russell Wilson had already thrown, a personal worst, four interceptions and the 12th man were starting file towards the aisles. But with Richard Sherman playing through an elbow injury and Marshawn Lynch who refused to be denied, an inspired Seahawks team scored a touchdown to make it 19-14 at the 2:09 mark. An onside kick recovery, another Marshawn Lynch touchdown, and a2-point conversion later put the Seahawks up by 3; 19-22. Mason Crosby drilled a 48-yard field goal as time expired to push the game to overtime but the Seahawks, riding on a wave of momentum, threw a 35-yard touchdown bomb against a Packer defense that was expecting a run. Game Over. Seahawks are Super Bowl bound. The end to the top 5 games I have ever seen in my 23 years of life.

       The biggest headline before the momentous game was zeroed in on Aaron Rodgers’ “severely”strained calf and partial tear as reported by ESPN’s Chris Morenson. There aremany overlapping muscles and tendons that make up the anatomy of the calf, butwe will focus our attention to two of it’s main muscles: the gastrocnemius and soleus (Bianchi & Martinoli 2007; Dixon, 2009). Both muscles are attached to the Achilles tendon, a tendon that stretches all the way down and attaches to the calcaneus (the heel bone), and play a role in ankle plantar flexion (pointing the foot away from the body). A calf strain involves a tear to either of the two calf muscles and occurs at the muscular tendinous junction where the muscles meet the Achilles tendon. About 20% of patients report prodromal symptoms like soreness/tightness in their calf muscles prior to the injury (Campbell 2009).

       The gastrocnemius is the biggest of the two calf muscles, attaches above the knee joint, and lies at the middle of the junction between the muscle and tendon. It contains both slow and fast twitch muscle fibers, thus accounting for most of the power generated by the calf during plyometric exercises such as sprinting or jumping. Most injuries occur at the musculoskeletal junction of the gastrocnemius or the aponeurosis between the medial head of the gastrocnemius and soleus muscles (Delgado et al., 2002). This injury is most commonly known as “Tennis Leg” because of it’s high occurance in tennis players.

       Complementarily, the smaller soleus muscle originates below the knee joint and lies underneath the gastrocnemius. Composed of mostly slow twitch muscle fibers, the soleus maintains the strength and endurance for repeated plantar flexion during activity. Soleus strains can develop when the ankle is passively dorsiflexed while the knee is flexed like during a landing when running up hill (Campbell 2009). Strains of this nature usually develop chronically, stemming from overuse.

As with any strain, each are graded based on level of severity:

Grade 1: minor tear, up to 10% of muscle fibers effected. Experience tightness and mild discomfort.

Grade 2: up to 90% of the muscle fibers torn. Sharp pain when walking. Swelling and mild to moderate bruising.

Grade 3: severe pain. Will likely be unable to walk. Considerable bruising and swelling. During a full rupture, the muscle can be seen bunched up towards the top of the calf.

Relevant Players

 Aaron Rodgers, QB, Green Bay Packers: Rodgers sustained the injury in Week 16 against the Tampa Bay Buccaneers and didn’t receive any favors when N'Damukong Suh “inadvertently” stepped on his leg in Week 17. Nevertheless, Rodgers threw for 316 yards and 3TDs, shredding the Dallas Cowboys in the NFC Divisional Playoff game. However, once he faced Seattle, he struggled to repeat his performance, throwing for only 178 yards, 1 TD, and 2 interceptions. Many people forget that Aaron Rodgers mobile ability is an ace that he likes to keep up his sleeve. I’m not saying that his mobile ability is what his success is attributed to, but you could tell that Seattle were not worried about him scrambling out of the pocket during the game. Rodgers, with his new MVP award, will likely be the top QB drafted in next year’s fantasy football drafts

On Deck: Richard Sherman's elbow

In the Hole: Victor Cruz's PCL

References

Bianchi S, Martinoli C. Leg in : Ultrasound of the musculoskeletal system. Springer, New York 2007. p. 745

Campbell JT. Posterior calf injury. Foot Ankle Clin 2009; 14:761

Delgado GJ, Chung CB, Lektrakul N, Azocar P, Botte MJ, Coria D, Bosch E, Resnick D. Tennis leg: clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology 2002; 224;112 

Dixon BJ. Gastrocnemius vs. soleus strain; how to differentiate and deal with calf muscle injuries. Curr Rev Musculoskeletal Med 2009; 2:74

[mlb]

Ichiro brings milestones and grace to South Beach. #HotStove

[fantasyphysio]

The Hip Injury

Starring Quintorris Lopez “Julio” Jones

            Before the world knew Ray Rice for his domestic violence case in 2014, I knew him as an unforgivable, fantasy football bust in 2013. After being selected in most leagues as a top 5 draft pick for the last 3 seasons, Rice only totaled 660 rushing yds, 4 TDs, 321 receiving yds, 0 reception TDs in 15 games. These numbers were nearly half of his production in previous seasons. In addition, Pro Football Focus ranked Rice dead last among RBs in yards per carry with 3.1, also a career low. “The injury I had this year wasn’t something that you just bounce back from and say, ‘Oh you know I had a hip’. It was definitely very hard to play through week in and week out. So when I look at things like that – statistics – I don’t worry,” Rice explained to the Baltimore Sun in February. But you know what, Mr. Rice? We fantasy owners do have to worry; statistics are the crutch of our success. As a listener described during Matthew Berry’s Fantasy Focus Football podcast, “Ray Rice looks like a fat kid running in a snow suit.”

            This article would make more sense if it were written before Week 16, when a questionable Quintorris Lopez “Julio” Jones and the Falcons wait to punch their ticket into the playoffs against the New Orleans Saints. Yes, the Falcons had a legitimate shot at the playoffs despite having only six wins. And yes, Julio Jones’ real name is Quintorris. Sorry for the extremely late post, but I guess laziness happens during the holidays.

            Anyways, the hip joint’s ball-and-socket model is similar to that of a shoulder joint. The ball (femoral head) and socket (acetabulum) allows for a wide range of motion for your legs to drive your body in every which direction. The acetabular labrum is a cartilaginous ring that surrounds the socket and increases the surface area of contact with the femoral head to deepen the socket. This cartilage prevents dislocation (subluxation), distributes pressure, absorbs the shock, and lubricates the joint. When all of these intricate parts work together, the hip joint can bear up to eight times its body weight during a simple jog (Anderson et al., 2001).

            From my research, I’m having a tough time sifting through the differences of groin and hip injuries. Because both the groin and the hip play complementary roles, I can see why both body parts are often lumped together in medical diagnoses. In fact, it is suggested that hip stiffness can later develop into chronic groin injury (Verrall et al., 2007). In most conversations, hip injuries usually refer to some type of trauma to the hip bone, while groin injuries are involve injury to the hip flexor muscles. I realize now that last weeks article on the groin could very well be this week’s hip article (in fact, it may be more of a case of iliopsas tendinopathy). The secretive nature of NFL coaches also does not help our investigation so instead, let’s delve deeper into hip labral tears.

         There are three main ways in which a labral tear can occur:

Trauma – This seems to be the most likely cause of Julio’s injury as often occurs in contact sports and automobile accidents. The femoral head may pull out of the socket, causing subluxation, and tear the acetabular labrum, which will result in impaired hip motion, pain, and inflammation. Contact to the hip may also result in contusions, another name for bruise.

Femoroacetabular impingement/wear and tear – The acetabular labrum will eventually corrode under the constant force of friction between the head of the femur and the hip joint. This can lead to osteoarthritis.

Chronic conditions (dysplagia/degeneration) – this may be a combination of genetics, trauma, or wear and tear that leads to friction. If not fixed, this condition may be career ending.

There are two types of labral tears:

Type 1 – detachment of the labrum from the surface of the joint

Type 2 – A tear within the labrum itself

Nonsteroidal anti-inflammitary drugs (NSAIDs) and rest are often the primary treatment plan. There are surgical options but usually require a longer healing time.  For severe Type 1 labral tears, absorbable sutures are used to anchor split ends onto the pelvis. Type 2 tears require the torn labral tissue to be debrided, the removal of unhealthy tissue to promote healing. A majority of hip injuries, not just labral tears, have a return of play of two weeks. However, intra-articular injuries, injuries situated within the hipbone, demand longer healing times. Labral tears are a part of the “sports hip triad”, a common source of injury for athletes, which also includes adductor and rectus strains (Feeley et al., 2008).

 Relevant Players:

Quintorris Lopez “Julio” Jones, WR, Atlanta Falcons: Before sustaining his hip injury, Julio put on a clinic against the Green Bay Packers secondary in their Week 14 matchup. Before going down in the middle of the 4th quarter, Julio garnered a whopping 17 targets, 11 catches, 259 yds, and 1 TD in arguably his best game of his career. Julio was held out of Week 15, but came back with 107 reception yards in Week 16 against the Panthers. 2014 was a banner year for Julio, totaling 104 receptions, 1,593 receiving yards, and 6 TDs. The lack of TD production isn’t too much of a concern because I believe TDs are not a useful predictor of talent. Luck has a bigger influence on TD numbers, where as player’s reception totals displays the importance of a player in the offensive game plan. Julio will surely be a top 10 WR in drafts next year, probably going in either the 2nd or 3rd round. However, his injury history still lingers and the Falcons have been known to throw injured players out on the field as decoys (ahem, Roddy White, ahem). A lot can happen between now and August, including what a new head coach will bring, but it’s never too late to start making your Draft Day cheat sheets!

On Deck: Aaron Rodger's calf

In the Hole: Richard Sherman's elbow

References:

Baltimore Sun. http://www.baltimoresun.com/sports/ravens/ravens-insider/bal-ray-rice-says-hell-contemplate-retirement-when-he-turns-30-20131218-story.html

Feeley BT, Powell JW, Muller MS, Barnes RP, Warren RF, Kelly BT. Hip injuries and labral tears in the National Football League. Am J Sports Med 2008; 11:2187-2195 http://ajs.sagepub.com/content/36/11/2187

Verrall GM, Slavotinek JP, Barnes PG, Esterman A, Oakeshott RD, Spriggins AJ. 2007. Hip joint range of motion restriction precedes athletic chronic groin injury. Journal of Science and Medicine in Sport 2007; 10:463-466

[fantasyphysio]

The Groin Injury

Starring Montee Ball and Arian Foster

                  “I didn’t know Montee Ball was a 1st round pick! I should’ve kept him!” exclaimed my buddy through a text just before our fantasy football draft for a 12-team, standard keeper league. I smiled to myself, thinking the fruits are ripe for my picking. I plucked Ball of the draft board at the 10th pick of the 1st round, excited to build my team around a budding Bronco in a Peyton Manning offense. But maybe I should have let him slide because fantasy karma wasn’t too keen on gloating and struck Ball with subpar production and a groin injury. Just to tease, Ball came back after being sidelined for five games and went on to limp back to the sidelines after reinjuring his groin on the first play back.

                   The groin is the region between the lower abdominals and thigh on either side of the body. These sets of muscles that make up the groin allow you to shuffle from side-to-side and change direction while stabilizing your hip. During a jog, the hip joint bears up to eight times its body weight which may result in acute and chronic injuries (Anderson et al., 2001). The ball-and-socket model of the hip joint doesn’t have as wide range of motion the shoulder joint has, but is nonetheless very similar in structure. It is stabilized by the acetabular labrum, a ring of fibrocartilage, dense connective tissue attached to the bony rim of the acetabulum (socket). In a hip joint replacement procedure, the acetabulum is restructured and a new socket is essentially made for the femoral head to attach to.

                  Groin injuries have many different sources, but the most common cause may be due to a labral tear, which could decrease the stability of the hip joint. Articular cartilage damage will significantly increase the stress on the hip, causing pain, clicking, locking, catching or a “giving away” sensation when patients attempt to plant off a foot to change direction. Such injuries may be treated by physical therapy or arthroscopic surgery with the latter being more immediate but a longer recovery price. Sports hernias are often classified as groin injuries in NFL injury reports, but, as I wrote in a past article, are more specific in that they are caused by damage in the inguinal region. Understanding the groin anatomy also reveals that low back pain may also contribute to weaknesses in hip abduction and extension strength. Nadler et al. (2000) observed that female athletes had differing responses to proximal hip musculature to lower extremity injury or lower back pain compared to their male counterparts. The following year, Nadler et al. (2001) confirmed that hip muscle imbalances may be associated with lower back pain. The hip abductor functions to stabilize the pelvis in an upright position during an athletic stance. When hip abductor strength is compromised, lateral trunk stabilizers such as the quadratus lumborum try to over compensate to stabilize the pelvis. Thus, increasing abductor strength is an important strength and conditioning strategy to prevent lower back pain.

Relevant Players:

Montee Ball, RB, Denver Broncos: Montee Ball was one of those fantasy sleepers who never woke up. He had a solid Week 1 in which he scored 13 fantasy points, but was mostly mediocre before injuring his groin in Week 5. This led to the emergence of Ronnie Hillman, leaving fantasy owners to wonder why Ball wasn’t able to produce as Hillman had. A highly touted prospect in the stable behind Knowshon Moreno last year, Ball was stashed in many desperate owners’ rosters through his injury. His return to play in week 11 only ended with even more disappointment as he left the game aggravating the same groin. In the same game, Hillman also went down, and CJ Anderson snatched the starting job unapologetically. Ball should be returning to play this week, but by the way Anderson is playing, I don’t really see Ball as a fantasy factor anymore. This past week, the Broncos beat the Bills 24 to 17 behind Anderson’s play. However, what makes me raise my eyebrows at this seemingly mundane Bronco win is the fact that Peyton Manning’s consecutive 51-game-passing-TD streak came to an end, 4 TDs shy from the record. I think that when records are on the line, coaches will do what they can to put their players in situations to make history. Therefore, it says a lot when Coach Fox largely depended on Anderson’s shoulders, instead of Manning’s arm, to the victory. When Ball returns, I’d imagine he would have a similar role he had last year as a back up to Knowshon Moreno, safe to drop in all standard leagues.

Arian Foster, RB, Houston Texans: Foster pulled his groin in Week 9 which left fantasy owners sighing with disappointment as the annual “Arian Foster Soft Tissue Injury” arrived. Not only does Foster have a history of soft tissue injuries (mostly groin and hamstring problems), but he is also very slow to recover from such ailments. Foster knows it as well, slamming his helmet down in frustration after sustaining the injury. Alfred Blue took the reins and was not shy to display his running ability, totaling 533 yards from scrimmage and 2 total TDs in limited play. But unlike Montee Ball, a healthy Foster remains a top 5 RB and was very effective in his Week 13 return. The biggest take away from these turn of events should be that Alfred Blue is a necessary hand-cuff to all Arian Foster owners. Blue is very capable of producing Foster-like numbers, and with the margin of error cut to a minimum in the fantasy playoff season, the last thing you want is to face a team that uses Blue against you.

Sammy Watkins, WR, Buffalo Bills:  After obtaining the AFC Offensive Rookie of the Month award, Watkins has been on a steep decline in production that is largely attributed to a nagging groin injury. Watkins was unable to finish practice on 11/5 because of the injury and only managed 13 receptions, 105 yards, 0 TDs in the whole month of November. However, Watkins is bouncing back into his old self in December, catching 7 passes, for 127 yards against the Broncos this past week. Going forward, Watkins should be a solid WR3/Flex play in the fantasy playoffs, facing the Packers, Raiders, and Patriots to put the finishing touches on his Rookie of the Year campaign.

On Deck: Julio Jone's Hip

In the Hole: Aaron Rodger's Calf

References:

Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001; 29:521.

Nadler SF, Malanga GA, DePrince M, Stitik TP, Feinberg JH. The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes. Clin J Sport Med 2000; 10:89.

Nadler SF, Malanga GA, Feinberg JH, Prybicien M, Stitik TP, DePrince M. Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil 2001; 80:572.

[fantasyphysio]

The Epidural Injection

                  Up until a few weeks ago, I have only heard of epidural injections in the context of the labor and delivery of an expecting mother. An epidural injection is a safe, common, and effective method for administering analgesics in order to provide pain relief for mothers in labor (Melzack, 1984). Thus, you can imagine my confusion/dumbfoundedness/excitement/relief when my friend asked me to write about this topic. Confused because a man doesn’t have the necessary childbearing, reproductive organs of a female. Dumbfounded because, after putting two and two together, I thought my friend had impregnated somebody. Excited because of the possibility of meeting a mini-version of my friend! But, honestly, relief because no one is pregnant. That was a lot of emotions in a 5-minute span and I’m exhausted recalling the memory. But on that day, I learned how the epidural injection might also be fantasy relevant. 

                  Along with providing pain relief for mothers during childbirth, an epidural injection may also be used to relieve low back pain. It is commonly called an “epidural” because a needle is inserted into the epidural space near the spine, allowing drug administration directly to the site of injury. The epidural space is the outermost part of the spinal canal and encloses layers of dura mater, arachnoid mater, subarachnoid space, cerebrospinal fluid, and the spinal cord. Imagine the spine like the rings of a tree stump with the epidural space as the 2nd most outer ring while the vertebra (bone structure of the spine) that contains it is the outer most ring. Lymphatics, spinal nerve roots, loose fatty tissue, small arteries and a network of internal vertebral venous plexus may be found in the epidural space, which plays a role in the immune system and maintaining the nervous system it contains.  

                  Now, the epidural injection just refers to the method of drug delivery. Depending on the injury, these drugs themselves can vary from analgesics to glucocorticoid. There are three approaches in which epidural injections may be administered: translamina (via the spine’s interlaminar space), transforaminal (through the neuroforamen, dorsal to the nerve root), or caudal (via the sacral hiatus at the sacral canal). Radiculopathy, spinal stenosis, and various nonspecific low back pains can be treated with epidural injections, but more research still need to be done to confirm the effectiveness of these treatments. Choi et al. (2013) presented conflicting evidence, finding that epidural injections didn’t significantly improve pain/disability after 6 months. In addition, the number of patients with nonspecific back pain who underwent surgery compared to placebos and other treatments did not decrease either.

                  The best benefit of an epidural injection is when it is used to treat radiculopathy due to a herniated disc. Radiculopathy occurs when multiple nerves are affected and don’t work properly. A herniated disc, or a “slipped” disc, is when the rubbery cushion (disc) that lie between individual bones (vertebrae) slip out, causing radiculopathy that may result in pain, numbness, tingling, and weakness in the limbs. These particular epidural injections usually contain glucocorticoids, a type of steroid, and are more of a short-term fix, improving leg pain and disability for up to 3 months, but losing its effects after 1 year (Pinto et al., 2012). Krych et al. (2012) studied the effectiveness of glucocorticoid epidural injection for NFL players suffering from a lumbar disc herniation. In the study, players received the injection an average of 4 days from injury and were able to return to the field 89% of the time, losing an average of 2.8 practice days and 0.6 games (range from 0-2 games). A combination of glucocorticoid injection and surgery may be attractive as players who underwent surgical treatment went on to play more games after treatment than those treated non-operatively (Hsu, 2010).

                  But for the civilian patient suffering from a herniated disk, surgery is not usually a necessary option. More often than not, surgery may be required only when conservative measures fail to improve symptoms after 6 weeks. The human spine is able to eventually correct the herniation with rest, pain management, and physical therapy. Adverse events from epidural injects are rare, but may have serious side effects including loss of vision, stroke, paralysis, and death. It is not recommended to have more than three injections at the same site in 12 months because each successive injection increases the risk of vertebral body fracture due to bone fragility (Mandel et al., 2013). Despite these side effects, epidural injections are still considered conservative treatments for lower back pain because of its high success rate.

  Relevant players:

None yet: I couldn’t find any current players with a recent epidural injection treatment, but there are many athletes that have undergone the procedure in the past. Superstars such as Tony Romo, Dez Bryant, Steve Nash, and Dwight Howard took to the needle to speed their return to play. Tony Romo is the most recent athlete to receive the injection, receiving the injection sometime around late December 2013 after a Week 15 victory against the Washington Redskins. Romo went on to miss his next game the week after and, with the Cowboys missing the playoffs, had the whole season to recover. In contrast, Dez Bryant, who suffered a herniated disc at the beginning of the same season, didn’t miss a game due to the injury or epidural injection. Therefore, if you have a player receiving an epidural injection in the future, I would monitor his progress during the week, but rest assured that they probably wouldn’t miss more games than two.

  On Deck: Montee Ball’s Groin Injury

In the Hole: Julio Jone's Hip

  References:

Choi HJ, Hahn S, Kim CH, Jang BH, Park S, Lee SM, Park JY, Chung CK, Park BJ. Epidural steroid injection therapy for low back pain: a meta-analysis. Int J Technol Assess Health Care 2013; 29:244.

Hsu W., Performance-based outcomes following lumbar discectomy in professional athletes in the National Football League. Spine (Phila PA 1976). 2010;35(12):1247-51.

Krych AJ, Richman D, Drakos M, Weiss L, Barnes R, Cammisa F, Warren RF. Epidural Steroid injection for lumbar disc herniation in NFL athletes. Med Sci Sports Exer 2012; 44(2):193-8.

Mandel S, Schilling J, Peterson E, Rao DS, Sanders W. A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections. J Bone Joint Surg Am 2013; 95.

Melzack R. The myth of painless childbirth (the John J. Bonica lecture). Pain 1984; 19:321.

Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med 2012; 157:865.

[fantasyphysio]

The Sports Hernia (AKA Atheltic Pubalgia)

Starring Kyle Rudolph

            Given how specific medical terms can be, it is hard to believe that the medical community named the “sports hernia” wrong. In fact, a sports hernia doesn’t involve a hernia at all. The official definition of a hernia is a protrusion of an organ through a body wall that normally contains it (usually the abdominal wall). On the other hand, a sports hernia is a unilateral (one-sided) pain in the groin that involves no such protrusion, but is still distinguishable from other groin pains such as a groin pull or osteitis pubis (inflammation of the pubic tubercle). Sportsman’s hernia, hockey groin, and athletic pubalgia are other terms that describe this injury, but the misnomer “sports hernia” exploded in popularity as an increasing number of popular athletes underwent surgical treatment for it.

            There are many ways to obtain a sports hernia, but they basically involve some sort of disruption of the external oblique muscle aponeurosis with injury to the ilioinguinal nerve [Aponeuroses are layers of flat, broad tendons that join muscles to bones most commonly found in the abdominal, lower back, and pelvis. The ilioinguinal nerve is branch of a nerve that innervates the oblique muscle, spermatic cord, and thigh].  In a study in the UK, 67% of 35 sports hernia patients had an external oblique aponeurosis injury with the remainder of patients having a variety of problems ranging from conjoined tendons, small direct hernias, weak posterior walls, and lipomas of spermatic cord [A lipoma is a benign tumor made up of fatty tissue that may pressure cords involved in the male reproductive system]. Other conditions like osteitis pubis and musculotendinous strain of the adductor muscles could also aggravate the sports hernia (Kumar et al., 2002).

            Sports hernias often result from chronic, repetitive trauma to the musculotendinous portion of the groin, namely the inguinal region. It can develop quietly without a sudden onset of pain. During a study with hockey players, predictive groin injuries were found in those with a history of similar injury, older players, and those who lacked conditioning (Emery & Meeuwisse, 2001). Sports that require athletes to bend, lean forward, and maintain the “athletic stance”. Twisting, turning, and torqueing (and maybe twerking, be careful Miley!) could strain the aponeuroses. Sports hernias make it painful for patients to perform simple, exercise maneuvers such as sit-ups, or crunches (LeBlanc & LeBlanc, 2003). Intra-abdominal pressure like sneezing, coughing, and defecation may also aggravate symptoms.  

            Conservative measures such as resting, icing, non-steroidal anti-inflammatory drugs, and physical therapy may be used to treat sports hernias. However, recovery is often slow and leaves a higher possibility for recurring symptoms compared to those who opt for surgical treatment. For high performance athletes who have paychecks and championship aspirations on the line, surgery is the primary option. In a study with athletes who have shown sports hernia symptoms for more than 3 months, 27 of 30 patients with laparoscopic surgery and mesh replacement returned to athletic activities within 3 months. In contrast, only 8 of 30 patients who underwent a physical therapy regimen managed to recover within the same time frame. A laparoscopic surgery is a minimally invasive procedure in which a small camera is inserted through a 1.5 cm incision to help provide a visual of the wound. In most cases, a mesh is then inserted to repair the injury. In the same study, at the one-year follow up, 29 of 30 surgical patients have returned to full activity while 7 of 30 patients who were treated conservatively eventually opted for surgery. The remainder of nonsurgical patients continued to have recurring symptoms (Paajanen et al., 2011). Today, with the rise of technology and understanding of the injury, long-term improvement is seen up to 90% of surgically treated patients (Paajanen et al., 2004; Meyers et al., 2008). For fantasy purposes, a typical timetable for return varies from 3-8 weeks.

  Relevant players:

Kyle Rudolph, TE, Minnesota Vikings: The TE position has been a desolate wasteland this year. Besides Jimmy Graham and Julius Thomas, there really isn’t anyone you can depend on to provide consistent production. Rookies (Larry Donnel) and veterans (Antonio Gates) alike have been performing very inconsistently, like a “fantasy whack-a-mole” as the great Matthew Berry would say. However, the Vikings will be returning one of the more consistent TEs in the league from a sports hernia injury this week. Kyle Rudolph left the Week 3 (9/21) matchup against the Saints and returned to practice on 11/4. Although he missed Week 10, the Vikings are banking on a Week 11 return in the division battle against the Bears. Over his past 26 games, which spans 3 years, Rudolph has scored 13 TDs. With Teddy Bridgewater taking the helm for the Vikings, Rudolph should see his production increase compared to his before the injury when he was catching passes from Matt Cassel. Looking at the rest of the league’s TEs, there’s nowhere else to go but up with Rudolph. I’m feeling a 4 receptions, 45 yards receiving, 0 TD game as he gets acclimated into game speed.

Donnie Avery, WR, Kansas City Chiefs: Avery underwent sports hernia surgery on 10/2 and has already missed 5 weeks. He suffered his sports hernia injury during the Chief’s blowout win against the Patriots in Week 3. The Chiefs have continued to win without Avery and it seems like there is no rush to hurry him back on to the field. After the attention he received from Alex Smith in Week 1, where he was targeted 13 times, he averaged just a little over 2 targets per game. Here’s also another crazy stat: through Week 10, no Chiefs WR have caught a receiving TD yet. All of Smith’s TD passes have gone to either a TE or RB. Even when Avery returns, his fantasy stock is minimal at best and shouldn’t be on anyone’s roster.

Jason Kelce, C, Philadelphia Eagles: Slowly, key pieces of the Eagles OL have been returning from injury, transforming them into a very dangerous team in the postseason. The latest addition was Jason Kelce, who returned to anchor the OL in Week 9 after having sports hernia surgery late September. Often overlooked and underappreciated, the OL is vital to a team’s offensive success (just ask Cam Newton and the Carolina Panthers OL, ouch). If the Eagles start winning the battle up front, it won’t be a surprise if the fantasy stocks of all Eagles skill players (RB, WR, QB, TE) rise. 

On Deck: The Epidural Shot

In the Hole: Monte Ball's Groin Injury

References:

Emery CA, Meeuwisse WH. Risk factors for groin injuries in hockey. Med Sci Sports Exerc 2001; 33:1423.

Kumar A, Doran J, Batt ME, Nguyen-Van-Tam JS, Beckingham IJ. Results of inguinal canal repair in athletes with sports hernia. J R Coll Surg Edinb 2002; 47:561.

LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia 2003; 7:68.

Meyers WC, McKechnie A, Philippon MJ, Horner MA, Zoga AC, Devon ON. Experience with "sports hernia" spanning two decades. Ann Surg 2008; 248:656.

Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia). Surgery 2011; 150:99.

Paajanen H, Syvähuoko I, Airo I. Totally extraperitoneal endoscopic (TEP) treatment of sportsman's hernia. Surg Laparosc Endosc Percutan Tech 2004; 14:215.

[fantasyphysio]

The Shoulder Sprain

The Curious Case of Jimmy Graham

            Although NFL teams are bound to reveal their injured players to the league office and public, there are some cards they can choose to keep close to themselves. As I wrote earlier this week on the NFL injury policy, teams do not have to indicate the severity of an injury. This allows for an element of surprise for opposing coaches and fantasy owners – a strategy the New Orleans Saints are taking full advantage of with Jimmy Graham. Currently, Jimmy Graham, superstar tight end of the New Orleans Saints, is diagnosed with a very vague “shoulder sprain”. In order to make educated guesses on his “shoulder sprain”, we must understand the complexity of the shoulder anatomy and the different types of injuries that may be associated with it.

            The shoulder is the most mobile, but also most unstable joint in the human body. Also known as the glenohumeral joint, the shoulder joint’s versatility is due to the shallow depth of the glenoid fossa (‘socket’) and its limited contact with the humeral head (ball). In fact, only 25-30% of the humeral head is covered by the glenoid, thus requiring the labrum, a fibrocartilaginous ring attached to the outer rim of the glenoid, to provide stability and depth. A complex network of muscles, tendons (tissue that connects bones to muscles) and ligaments (tissue that connects bones to bones) are required because the shallow depth and small surface area of the glenohumeral joint make it vulnerable to injury and instability. Glenohumeral ligaments and the rotator cuff serve as static and dynamic stabilizers respectively. The rotator cuff keeps the ball in the socket by compressing the humoral head into the glenoid fossa and counterbalances the forces from the deltoid and other muscles acting on the humerus (Harryman et al., 1990; Vanderhooft et al., 1992). This allows the shoulder to rotate your arm internally, externally and abduct. The clavicle (collarbone), scapula (shoulder blade), proximal humerus (your upper arm) make up the framework of bones called the shoulder girdle that serve as scaffolding for its soft tissues. To top it all off, the suprascapular nerve innervates parts of the rotator cuff (supraspinatus and infraspinatus tendons). Injury to the nerve can cause peripheral neuropathy, which is estimated in 1-2% of pathologic shoulder conditions (Gosk et al., 2007; Martin et al., 1997).

            Outside of the “ball-and-socket” anatomy, another network of joints and ligaments, called the extraglenohumeral structures, have roles in further stabilizing the glenohumeral joint. Acromioclavicular and sternoclavicular joints determine shoulder motion and can compensate for an injured glenohumeral joint. Scapular motion and stability allows the humeral head to remain seated in the glenoid cavity during abduction, providing a solid base for the rotator cuff muscles to move the humerus. Common muscles that you often work-out like the latissimus dorsi, pectoralis major, and trapezius also provide additional dynamic stability to the glenohumeral joint.

            As with all complex structures, identifying the source of a problem may be difficult. A couple months ago I found out, to my dismay, that my malfunctioning MacBook was due, not because of a faulty hard drive, motherboard, or RAM, but because of broken wiring. Shoulder injuries may cause similar frustrations as most ailments have similar symptoms. From my research, I have found that most shoulder injuries are the cause of some sort of impingement of tendon, ligament or muscle that may lead to ischemia, degeneration and, eventually, a complete tear. These injuries make it uncomfortable for football players who have to overcome the pain associated with their injuries, as well as the extra weight of their shoulder pads while playing. Reading a long paragraph can be a drag, so here’s a list of possible causes of shoulder injuries and their symptoms:

Dislocated Shoulder: A direct blow to the shoulder may dislocate the humeral head out of its glenoid fossa – the ball could pop out of the socket. This can happen in many different directions. Reduction, or “popping the shoulder back in”, includes 10-15lbs of weight to place the humerus back into place. This procedure does not require painkillers, but some muscle relaxants may be used since popping the shoulder back into place is a lot harder if the muscles surrounding it are contracting. Common complications include recurrent dislocation, which occurs in 50-90% of patients under the age of 20 and 5-10% of patients over the age of 40 (Chalidis et al., 2007; Stayner et al., 2000).

Impingement Syndrome: The subacromial bursa and the rotator cuff are subject to compression by the node of the humeral head and the edge of the acromion process. Rotator cuff injuries are the most common shoulder injury in patients ages 30 and up (Chakravarty & Webley, 1993). Injuries to the tendons, especially the supraspinatus tendon, are always at risk for compressive forces of subacromial impingement, which could lead to thinning and tendon tearing. When this occurs, patients usually experience persistent weakness in their shoulders.

Tendinopathy: Thinning, degeneration of the tendon due to repetitive activity causes Tendinopathy. Patients will experience pain associated with reaching, pushing, pulling, lifting, and positioning their arms at shoulder length. However, it usually isn’t tied to any acute trauma or pain when the shoulder is immobile. Tendinopathy injuries have limited range of motion that is largely due to pain.

Adhesive Capsulitis AKA Frozen Shoulder: In contrast, while the limited range of motion in tendinopathy is largely due to the pain experienced with mobility, a frozen shoulder’s diminished range of motion is due to lack of use. Any shoulder pain or disability that may cause immobility like stroke, Parkinson’s, chronic pulmonary disease may lead to frozen shoulders.

Tendon Tear: Tendon tears are the product of subacromial impingements that are not treated appropriately or timely. A combination of progressive tendon degeneration and trauma may cause tendons to tear. Shoulder weakness, intense pain and popping/catching sensations are characteristics of a tear.

Acromioclavicular (AC joint) pain: The AC joint is a common site of trauma and arthritic change. Injury to the AC joint can be described as a shoulder separation and is common in contact-sport athletes. We can discus AC joint injuries in further detail in a future segment, but AC joint injuries frequently prevent patients from being able to reach their hands above their head.

Labral Tear: The glenoid labrum, part of the glenoid ligaments, is a fibrocartilaginous rim attached around the margin of the glenoid cavity in the shoulder blade. Patients will experience deep shoulder pain, catching, instability, and popping. The labrum is continuous with the tendon of the biceps brachii.

Biceps Tendinopathy/Rupture: Patients with injuries to the biceps tendon may complain of anterior shoulder pain because the long head of the biceps tendon passes through the humerus. Carrying objects like shopping bags may aggravate the pain experienced in the anterior shoulder.

Scapular Instability: Weakness of muscles that stabilize the scapula predisposes patients to impingement syndrome.

Multidirectional Shoulder Instability AKA Subluxation, Loose Shoulder, or Partial Dislocation: symptoms are nonspecific and can include dead arm, looseness, and crepitation (crackling sound). An excessive range of motion with internal and external rotation may be observed.

  Relevant Players:

Jimmy Graham, TE, New Orleans Saints: As you can see, the complexity of the shoulder joint and the variety of injuries that come with it make it difficult to determine, with confidence, what to do with Graham. After his Week 5 injury, the Saints had a bye and only deployed Graham on special Red Zone packages in Week 7, where he failed to record a catch out of his two targets. He went on to catch touchdowns against the Packers and Panthers, but boy is he still in a lot of pain. The tight end position is one of the most physically demanding jobs in football; having responsibilities as a blocker and pass catcher. Along with his touchdowns, I also saw a different side to his play. I winced when I saw Graham meekly brace himself as he attempted to block Clay Matthews (I mean, I would also curl up in a ball if I was told to block Clay Matthews, but hey, this segment isn’t about me). He also got pancaked, destroyed, lit up by the Panthers D on an interception return, leaving him to lie on the turf for several minutes. Needless to say, there is no doubt that Graham is playing through pain. However, Graham is still performing up to his fantasy draft stock and receiving ability – being able to reach every which way to snag incoming passes. I speculate that his injury is not the more serious AC joint, shoulder separation, which bodes well for Graham owners. Although he may not be operating at 100%, if you are fortunate enough to have him in your lineup, you are starting him no matter what because he’s a physical specimen, three cuts above other tight ends, a position that has been a fantasy wasteland this year.

Alex Smith, QB, Kansas City Chiefs: Smith apparently suffered a sprained shoulder injury in the first half of the Week 8, 34-7 rout of the St. Louis Rams. The injury was not known to the media until after practice the following Monday. He continued to play, passed for 199 yards and 2 TDs, and led the Chiefs to another win against the Jets in Week 9. I think his shoulder is not an issue at this point and should be fine going forward. Smith’s methodical style of play doesn’t call for deep, downfield throws that take the emphasis away from his shoulder strength. Smith will continue to be a solid fantasy back-up in all standard, 1 QB, leagues.

On Deck: The Sports Hernia

In the Hole: The Epidural Shot

References:

Harryman DT 2nd, Sidles JA, Clark JM, et al. Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg Am 1990; 72:1334.

Vanderhooft, JE, Lippitt, SB, Harris, SL, et al. Glenohumeral stability from concavity-compression: a quantitative analysis. Orthop Trans 1992; 16:774.

Gosk J, Urban M, Rutowski R. Entrapment of the suprascapular nerve: anatomy, etiology, diagnosis, treatment. Ortop Traumatol Rehabil 2007; 9:68.

Martin SD, Warren RF, Martin TL, et al. Suprascapular neuropathy. Results of non-operative treatment. J Bone Joint Surg Am 1997; 79:1159.

Chalidis B, Sachinis N, Dimitriou C, et al. Has the management of shoulder dislocation changed over time? Int Orthop 2007; 31:385.

Stayner LR, Cummings J, Andersen J, Jobe CM. Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000; 31:231.

Chakravarty K, Webley M. Shoulder joint movement and its relationship to disability in the elderly. J Rheumatol 1993; 20:1359.

[fantasyphysio]

A Word on the NFL Injury Report

                  For fantasy owners, it is hard enough to keep track of: who’s starting or being benched, who’s hot or in a slump, and who’s on a bye or active. But injuries to your star players can really throw a wrench into your fantasy playoff hopes. The dreaded, red “O”,”D”,”Q”, or “IA” letters that litter your roster are a part of what makes fantasy football challenging and addicting. The elusive fantasy championship cannot be won through a good draft alone. Keeping up with the NFL injury report and a lot of luck are vital for fantasy survival. 

                  Besides using published weekly rankings and analyzing statistical trends, fantasy owners can turn to the NFL injury report to assess their rosters. The NFL injury policy requires teams to submit weekly reports to the league office on their injured players. It was introduced in 1947, after the league suspended members of the New York Giants who were suspected to have ties with gamblers trying to “fix” the 1946 NFL Championship Game. The idea was to give the public access to injury information in hopes of discouraging gamblers from attempting to establish relationships with players to obtain secret, inside information. Now, it is mandatory for teams to indicate any player who may or may not play in the game and their area of injury. The NFL’s official injury policy states that, “Information must be credible, accurate, and specific within the guidelines of the policy”. Injury reports are to be submitted four days before game day (which usually is Wednesday for Sunday games) and to be updated everyday leading up to the game. From Friday on, the probable, questionable, or doubtful designations are added and adjusted as needed. Players are tagged as “probable” (P), “questionable” (Q), “doubtful” (D), or “out” (O) if they have a 75%, 50%, 25%, 0% chance to play respectively.

                  Although teams let it be known that certain players may be operating at less than 100%, teams are not required to divulge the extent or severity of their injuries. This loophole inevitably leads to gamesmanship amongst coaches and heartburn amongst fantasy owners. It is common for coaches to exaggerate or downplay an injury to gain an upper hand in the psychological chess match before games. For example, from 2005 to 2007, Coach Bill Belichick listed star quarterback Tom Brady on the injury report with a questionable shoulder injury every week. On the other hand, former coach Bill Parcells avoids reporting his players unless they were totally unable to play. Former coach Bill Cowher also admitted he would misidentify the location of an injury to protect his players and the area in question. Such coaches are the bane of each fantasy owner’s existence and are part of the reason why I make it an unbreakable promise that I won’t ever own a Patriots running back! There are consequences for falsifying information, but such punishments are rare. Fines for inaccurate injury reports can range from $5,000-$25,000, but there have only been 13 cases in 1997-2007 according to USA Today report.

                  Thankfully (sometimes unfortunately) the weekly NFL injury reports give an element of skill for fantasy owners to harness – rewarding those who scour the practice reports. But the subjective nature of the status designation and the deception of NFL coaches are reasons to hate and love fantasy football. Heartbreaking tweets of a player sidelined 15 minutes before kickoff are matched by the thrill of seeing your player emerge from the tunnel, dressed to lead your fantasy team to victory. Good and bad luck (and Andrew Luck) are still very large parts of fantasy sports, which is why ESPN Senior Fantasy Analyst, Matthew Berry, preaches, “fantasy football is about minimizing risk and giving yourself the best odds to win.” Not necessarily maximizing reward as one would think! Although I am doing my best to help you in your decision making processes, take the advice with a grain of salt. It is still very hard to make educated guesses without access to the true medical report that teams so often keep to themselves. Also, keep in mind that I usually will try to post my articles on Thursdays, leaving a lot more time for news to evolve over the weekend. Use my article as educational value and I hope you will be able to use the information to answer questions like, “Is my player going to have to play through pain? And if he does, is this going to affect his production based on the position he plays? Is a 65% healthy Calvin Johnson a better start than a 100% Jordan Mathews?” The choice is ultimately yours in this world we call "fantasy".

For more information:

USA Today - Analysis: Injury report is a game within a game (http://usatoday30.usatoday.com/sports/football/nfl/2007-11-22-injury-report-cover_N.htm)

eHow - NFL Injury Report Rules (http://www.ehow.com/list_6714978_nfl-injury-report-rules.html)

Nashville's City Paper - How the NFL injury report is supposed to work (http://nashvillecitypaper.com/content/sports/how-nfl-injury-report-supposed-work)

[fantasyphysio]

The Medial Collateral Ligament (AKA Tibial Collateral Ligament)

Starring Rashad Jennings

            Strangely, the one experience that made me feel like a professional athlete was when I injured my medial collateral ligament (MCL, AKA tibial collateral ligament). Playing in my JV year of Amador Valley High School football, the weekly Wednesday night practices were a team favorite because playing on turf and under the lights added to the feeling of primetime. But on that particular Wednesday night, after catching a pass on a drag route, I planted, turned and embarrassingly collapsed onto the turf. My MCL was torn; out of service for 6 weeks. Sometime after, I saw Dallas Clark, Tight End of the Indianapolis Colts, catch a pass from Peyton Manning, turn, and collapse the same way I did! His tight end position, drag route, lights, and collapse onto the turf in a non-contact injury were all similarities I held with the underrated Dallas Clark. A 6-year, $41 million contract extension was the only thing that separated our lives! Well…maybe just one of a few differences…

            The MCL is an 8-10 cm long, hour glass shaped, ligament on the outside of the knee that connects your femur (thigh bone) to your tibia (shin bone). Along with the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), the MCL is one of many ligaments that support the medial knee. Its location, along with other medial structures, resists valgus forces (knock knees) and external tibial rotations. Changes in direction and lateral movements are very demanding on the MCL.

            Risk factors for MCL injuries include prior history of MCL injury, level of play, involvement in contact sports, access to equipment, and the shoe-surface interface. 40% of all knee injuries involve ligament damage (Bolten, 2000) with the MCL being the most common casualty (Wilk et al., 1996). Traumas to other ligaments are observed in 20-78% of all MCL injuries (Indelicato et al., 2003). These multi-ligament injuries occur frequently because the MCL and posterior oblique ligaments attach to the medial meniscus, a fibrocartilaginous tissue in the knee joint that disperses the friction generated between the femur and tibia.

            When the knee “buckles” and collapses, an MCL injury could occur. Receiving a direct blow to the knee, getting “rolled up” under a pile or catching onto the playing surface with your foot are events that could involve an external tibial rotation. Amador Valley High School “Wall of Fame” Center and fellow victim of a Grade II MCL sprain, Mike “Slim” Lady, recounts one such event, “As I ran upfield [to block a linebacker at the next level], I felt someone trip over my planted right foot from behind and fell on my leg. I felt a couple of pops as I went down…” These pops are often the result of a ligament or tendon that has been stretched over a bony lump around the joint and then snapping back into place. More than one pop could also occur when the knee is hyperextended, which could be more of a cause for concern, as it usually includes multiple ligaments and the peroneal nerve, a branch of the sciatic nerve that supplies movement and sensation to the lower leg, foot, and toes (Takagi et al., 2002).

            As usual, a Grade I-III scale is used to measure the severity of the MCL sprain:

Grade I – Few fibers are torn but the MCL is largely intact. Less than 5mm of joint opening.

Grade II – An incomplete MCL tear with some remaining ligamentous integrity. 5-9mm joint opening.

Grade III – A complete tear and laxity of the knee joint (more than 10mm joint opening) may suggest that other knee ligaments are involved.

Depending on the degree of sprain, scar tissue will form, causing a decrease in range of motion. Initial symptoms of injury may also differ between cases. For example, I had to be carried off the field and couldn’t bear any weight after my Grade II sprain. In contrast, Slim was able to jog back to the huddle after the same sprain grade and attempt another play before deciding that he shouldn’t be playing on a Slideboard. Could this be simply a question of toughness? Haha, no comment. However, all MCL sprains heal in four classic stages of hemorrhage, inflammation, repair, and remodeling.

            Fantasy owners can breathe a sigh of relief, as MCL sprains do not require surgery for repair. As mentioned earlier, this may be because of its well-vascularized and innervated anatomy, which allows the area of injury to be supplied with the nutrients they need to recover quickly. MCL injuries demonstrate better healing and faster recovery compared to proximal or distal ligaments (Creighton et al., 2005). Halinen et al. (2009) could not identify any significant differences in stability, motion, strength, or speed of return between nonoperative and surgically repaired Grade III MCL sprain patients. In addition, Sandberg et al. (1987) found no difference in outcome among 200 randomly selected patients who received nonoperative or operative treatment for their MCL injuries.

            Diagnosis of the MCL involves feeling how loose or far the knee deviates away from the joint. Upon examining Slim’s knee, his physician observed that his leg “really opened up”. RICE-ing (rest, ice, compress, and elevate) and gradually returning to exercise is vital for recovery but may seem like a slow progress (especially if you were competing for a starting position like Slim was!). Players usually return sporting a custom-fitted knee brace to protect and limit the chance of reinjury although most NFL players will complain that its bulk slows them down (some NCAA teams make it mandatory for all their linemen to wear knee braces, but upon arriving to the NFL, most shed the brace in favor of the split second of quickness they previously sacrificed) (Creighton et al., 2005). On average, a return time of 3-6 weeks is expected, but this depends from athlete to athlete.

  Relevant Players:

Rashad Jennings, RB, New York Giants: Early reports indicate that Jennings will need more time to recover from his MCL injury in Week 5. In addition to the last three weeks, Jennings will have a few extra days to be evaluated because of the Monday night kickoff time. This is already a longer recovery time than a similar injury he suffered during Week 1 of the 2012 season in which he missed only 2 games. I am a little surprised that the Giants were quick to determine him unavailable for this week’s contest because of the extra time he had to recover. This has me suspicious of a more serious injury than the previous consensus and I would be worried of his ability to perform in Week 10. But past next week, I have no doubt that Jennings will be a fantasy stud. Since Tom Coughlin took the helm, the Giants have deployed more running plays in the red zone than any team in the league. In the fantasy playoffs (usually Week 14-17), the Giants will have enticing matchups against the Titans, Redskins, Rams, and Eagles.

Darren Sproles, RB, Philadelphia Eagles: I am still nervous after hearing Sproles’ injury was diagnosed as only a “mild” sprain. A dynamic, speedy, don’t-blink-because-he-might-reverse-it-for-a-TD player, Sproles demands the most out of his MCL because of how much he changes direction in his running style. The bye two weeks ago helped him miss only one game, but the requirements of his playing style and the emergence of LeSean McCoy have me hesitating. 

Ryan Mathews, RB, San Diego Chargers: Mathews may have the most serious MCL injury out of all of the players discussed in this column. He has already missed 6 weeks and the high level play from Branden Oliver has put a damper on his fantasy stock. Mathews was spotted running agility drills and sprints in the Thursday, Week 8 matchup against the Denver Broncos and could possibly play Week 9. Many fantasy analysts are forecasting a 50-50, Mathews-Oliver split when Mathews returns so if you only need 3-5 points, go for it.

Nick Fairley, DT, Detroit Lions: One of the league’s premier pass rushers, Nick Fairley has helped the Detroit Lions rank #1 in total defense and #2 in rush defense (#5 in Pass Defense just in case you were wondering). Needless to say, spraining his MCL and PCL is a big blow to the Lions D. Fantasy owners shouldn’t rush to drop them, but I would keep a close eye on their fantasy production going forward.

Jadeveon Clowney, DE/LB, Houston Texans: In contrast, the Houston Texans have someone coming back from injury to bolster their defense. After missing 7 weeks with a MCL sprain, Clowney returned to a Texans defense that ranked 23rd in total defense. He only made 1 tackle and is probably, understandably rusty. However, don’t forget that Clowney is only a rookie and was injured midway into his first game of the season, which means that last week’s performance was his first full game of his career. The Texans D could be a sneaky pick-up for the fantasy playoffs (Jaguars, Colts, Ravens, Jaguars) and once Clowney gets more acclimated to game speed.

    On Deck: Jimmy Graham’s Shoulder Sprain

In the Hole: Donnie Avery’s Hernia

And special thanks to my teammate, neighbor, and longest friend, Mike “Slim” Lady, for contributing to this piece!

  Reference:

Wilk, KE, Andrews, JR, Clancy, WG. Nonoperative and postoperative rehabilitation of the collateral ligaments of the knee. Op Tech Sports Med 1996; 4:192.

Indelicato, P, Linton, R. In: DeLee and Drez Orthopaedic Sports Medicine, DeLee, J, Drez, D, Miller, M (Eds), Saunders, Philadelphia 2003. p.1937.

Takagi T, Nakao Y, Takayama S, Toyama Y. Traction injury of common peroneal nerve associated with multiple ligamentous rupture of the knee: a case report. Microsurgery 2002; 22:339.

Creighton, RA, Spang, JT, Dahners, LE. Basic Science of Ligament Healing: Medial Collateral Ligament Healing With and Without Treatment. Sports Med Arthrosc 2005; 13:145.

Halinen J, Lindahl J, Hirvensalo E. Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study. J Bone Joint Surg Am 2009; 91:1305.

Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. J Bone Joint Surg Am 1987; 69:1120.

[fantasyphysio]

The Turf Toe

Starring AJ Green and LeSean McCoy

                  Despite the creative alliteration, a turf toe injury is no laughing matter. Much like the Achilles heel (a topic we can investigate further in another week), your big toe (AKA hallux rigidus) play a much more significant role in your daily activities than just merely being the biggest of toes. Unlike your other toes whom are made up of three phalanges, the big toe is composed of only two that attach to the first Metatarsophalangeal (MTP) Joint of the foot. Various tendons and cartilage provide stability to the joint, which allows you to stand, jump, and run. Out of all the other toes, the hallux rigidus of the MTP joint withstands the greatest stress during the running motion. When the hallux rigidus is hyperextended because of this stress, a turf toe injury occurs.

                  To everyone’s surprise, turf toe injuries most commonly occur on artificial playing surfaces, like turf. This is because artificial playing surfaces have increased friction and motion with light, flexible shoes (Bowers & Martin, 1976). A player may suffer a turf toe injury when a force is applied axially onto the player's heel while the foot is fixed in an equinus (“on the balls of your feet”, heel elevated) position. This often occurs when the hallux gets “caught” on the turf and the heel crumbles either under their own or another player's weight after falling. 60 degrees of dorsiflexion is required to walk normally, but when the angle reaches 100 degrees or more, the plantar capsule, plantar ligaments, and sesamoids are pulled distally, away from the MTP joint. The plantar tissue will rupture and tear the capsuloligamentous structures of the metatarsal neck. The hyperextension and dorsiflexion strain of the ligaments and tendons could cause various metatarsophalangeal instability (Mullis & Miller, 1980).

                  Football players suffering from a turf toe injury will most likely miss at least two weeks because of the pain they experience during the foot-strike phase of running. Depending how a player twists their toes (either varus/outward, or valgus/inward) will affect the ligaments and tendons they tear, but to keep it simple, the results are often the same. It is very important to rest and recover fully from a turf toe injury. Rushing back onto the playing field when there is still residual pain could cause athletes to compensate when running to reduce the load on the big toe, causing lateral forefoot pain. Turf toe injuries are graded from I to III with increasing severity:

Grade I – mild injury, pain, and swelling. Out 1-2 weeks

Grade II – partial rupture of the capsuloligamentous structures has occurred with moderate swelling, tenderness, bruising, and restrictions of first MTP joint motion. Patients can bear weight, but experience pain. Out 3-4 weeks

Grade III – unable to or experience severe pain during weight bearing. Complete rupture of plantar plate and ligamentous complex of the 1st MTP joint. May lead to residual impairment. Out 6+ weeks.

Surgery may be used for grade 3 sprains when there is particular joint instability or fractures that could be associated with a prolonged recovery period (Anderson, 2002).

                  Turf Toe injuries are treated just like any sprain in the lower extremities. Along with rest, ice, compress, elevate (RICE), anti-inflammatory drugs and glucocorticoid injections may provide relief. Preventative techniques such as proper running techniques and wearing the appropriate shoe with a wider toe box, stiff soles, rocker bottoms, and low heels are important in reducing the impact of the 1st MTP joint.

Relevant Players:

AJ Green, WR, Cincinnati Bengals: As some may know by now, AJ Green will be inactive for the Bengal’s Week 8 game, making it the third week he will be missing because of the turf toe injury. The residual pain, stiffness, or instability from serious turf toe injuries could potentially be career ending.  Despite 6 months of rehab, a study recorded that at least 25-50% of patients have residual pain and limited dorsiflexion (Frey et al., 1996). AJ Green’s injury is probably not as career threatening, but Cincinnati’s recent underwhelming play compounded by the emergence of other teams in the AFC North, they might have AJ take the field to be more of a decoy. If you're a Calvin Johnson owner this year or Roddy White owner last year, you know that this is a very annoying predicament to be in.

LeSean McCoy, RB, Philadelphia Eagles: It has been a very frustrating half of the season for LeSean McCoy owners and I don’t see it getting much better. McCoy has a ‘small version of turf toe’, which could be the culprit of his play. With Darren Sproles out with a more severe knee injury, I think the Eagles will lean heavily on an 85% healthy McCoy. Watch out because this nagging injury can play out for a couple more weeks.

Patrick Willis, LB, San Francisco 49ers: The 49ers defense isn’t what it was like last year (and I’m not just saying that because I’m a Seahawks fan). With Navaro Bowman still out with a torn ACL from last year’s NFC Championship game, the 49ers received another blow to their previously stout linebacking corps. Patrick Willis suffered a turf toe injury late in the second quarter in the 49ers win against the Rams two weeks ago. Willis has already missed one game, but the bye couldn’t have come at a better moment for this star linebacker.

On Deck: Rashad Jennings' MCL

In the hole: Jimmy Graham's Shoulder Sprain

References

Anderson RB. Turf toe injuries of the hallux metatarsophalangeal joint. Foot Ankle Surg. 2002;1:102–111. 

Bowers KD, Martin RB. Turf toe: a shoe-surface related football injury. Med Sci Sports. 1976;8:81–83. 

Frey C, Anderson GD, Feder KS. Plantarflexion injury to the metatarsophalangeal joint (“sand toe”). Foot Ankle Int. 1996;17:576–581. 

Mullis OL, Miller WE. A disabling sports injury of the great toe. Foot Ankle. 1980;1:22–25.