Injury Rounds: OTA Update

Photo: USA Today Sports

It's been five full months since the end of the 2015 regular season. Aside from a handful of vanilla press conferences just after the season and around draft time, NFL teams have not had to face the media much since January. That changed in late May when players were forced to show whether they were healthy enough to participate in post-draft OTAs and coaches had to answer questions about players who weren't available.

Not surprisingly, that led to some "surprise" reports about players who underwent surgery after the season ended like Sammy Watkins, Ameer Abdullah, and Donte Moncrief. It's also the time of year where players who could no longer avoid surgery and still be ready for the regular season like Tyler Eifert choose to go under the knife.

The month of May doesn't always bring bad news. Lots of players have returned to offseason activities and reassured that last season's injury issues are well behind them.

***If you're interested in an extended discussion on this offseason's major injury storylines, I was a guest on Sigmund Bloom's On the Couch podcast in May. We talked about larger injury trends in the NFL and delved deeply into many of the injuries I'll cover below. I also shared some NFL-specific notes from a recent sports medicine conference -- more on that below -- and revisited our annual offseason conversation about injury-prone athletes.***

QUARTERBACK

The news was uniformly positive among the many quarterbacks with medical issues this offseason. Every quarterback expected to be ready for OTAs was on the field. Some, including Tony Romo and Mark Sanchez, were taking more snaps than expected. Only one -- Joe Flacco -- wasn't cleared to participate in at least some part of OTAs. Even that isn't a major concern. Every report on Flacco's rehab and recovery has been positive and he's expected to be ready in advance of Week 1.

The majority of these players will come off this list on the next update.

TONY ROMO | LEFT CLAVICLE FRACTURE / RESECTION

Without going into great detail on the specifics of the procedure, Romo chose to have a small part of the end of his troublesome collarbone removed in early March to limit the risk of future injury. While not a major procedure, it's still a good sign to see Romo cleared to take some non-contact snaps in team drills. Though the Cowboys have a strong offensive line and added talented Ezekiel Elliott in the first round, Romo's playing style will continue to expose him to hits. It's a risk of which Romo is clearly aware and likely contributed to his decision to have surgery.

RUNNING BACK

The list of running backs to track into the preseason remains long. And there are still a handful of tricky reads here. While Le'Veon Bell and Jamaal Charles and Arian Foster and Melvin Gordon and Carlos Hyde and Dion Lewis and Thomas Rawls all look to be in a good spot right now, none is a lock for a return in training camp just yet.

LE'VEON BELL | RIGHT PCL/MCL SPRAIN

To briefly revisit what I wrote in February: The Steelers and Bell have only confirmed surgical repair of an MCL injury. There's been no corroboration of Jason La Canfora's report of an additional PCL injury and it's not clear whether Bell had the PCL repaired surgically or not. Those details aren't critical, but they would help inform whether Bell's current rehab status was concerning or not. I'm going to work from an assumption that Bell has an MCL/PCL injury with only the MCL repaired surgically. I'm also writing with an assumption that Bell had no other associated injuries to the back corner of his knee, which can often complicate PCL sprains.

Even if the PCL sprain didn't require surgical repair, it's the more concerning of the two ligament injuries. Many players, including running backs, have recovered from PCL sprains without long term issue. Other players take inexplicably longer, as stiffness and a feeling of ongoing looseness in the knee joint delay their return. That's likely what plagued Breshad Perriman last year. 

Early this offseason, the Steelers -- who are generally quiet with injury information -- weren't willing to say anything other than that Bell's training camp status remained in doubt. As OTAs opened, Bell sounded much more optimistic, saying he'd be fully recovered for training camp. He backed his optimism up by participating in some individual drills, which means he and his medical staff feel his knee is stable for football-related activity. That's a very positive sign in late May.

Bell still has to be cleared for contact and he still has to make it through the reconditioning period without any setbacks, but I feel better about his Week 1 availability now than I did in February.

One note for Bell in the longer term. Although neither injury has been confirmed, I think there's a strong argument Bell had a PCL sprain in December of 2014 in addition to last November's injury. Unlike ACL tears (where there's a known risk of re-injury to the ACL graft in the same knee and a known risk of injury to the healthy ACL in the opposite knee), I'm not aware of any long-term data on recurrent PCL injuries. But it's a data point in Bell's medical file to monitor over time.

THOMAS RAWLS | LEFT FIBULA FRACTURE / LIGAMENT SPRAIN

I thought Pete Carroll's comments on Rawls as OTAs began in Seattle were odd. The mechanism of Rawls' December injury was obscured on replay, with both a high-grade high ankle sprain and a high-grade sprain to the inside of his ankle as possibilities. The Seahawks reported the injury as an ankle fracture and ligament tear. Were those injuries in the high ankle area, Rawls would have had surgery to stabilize the injury. So that seems unlikely. Most ankle rehab protocols -- surgical or not -- are in the 4-6 month range.

Which is why hearing Carroll lump Rawls in with Jimmy Graham as Week 1 "hopefuls" and recent reports that Rawls may be held out of preseason work should raise flags about the severity of Rawls' injury and whether his rehab has gone as smoothly as would've been hoped.

It's too soon to overreact to Carroll's comments, but if Rawls starts camp on the PUP list without a clear and brief timetable to return to practice, it's our clue that there's more to Rawls' injury and rehab.

MELVIN GORDON | LEFT KNEE MICROFRACTURE SURGERY

Prior to May, Gordon's knee surgery was thought to be a meniscus repair. It's a surgery that carries a four-month recovery period but is generally better for an athlete in the long term. That assumption proved incorrect, with Gordon actually having microfracture surgery in early January.

Microfracture has replaced Lisfranc as the most "dreaded" term in football injury jargon -- with good reason. Though there are many examples of recovery from microfracture surgery, including Travis Kelce's strong return as a recent shining example, success in high-level football players has been in the 75-80% range over the past decade. It's difficult to regrow cartilage. And any cartilage that is regenerated is more of a rough scar than a soft cushion. Players recovering from microfracture surgery must also have their knee immobilized for a period of time to protect the new cartilage. That affects the strength of thigh muscles and leads to long rehab periods -- 7-12 months depending on progress.

Orthopedic surgeons know that microfracture surgeries are more likely to be successful if the area of cartilage loss is small and in a location where blood supply is relatively good. The Chargers told reporters this was the case for Gordon, who is already doing some individual work. While moving quickly through the early stages of rehab is a strongly positive sign, it doesn't guarantee Gordon will be pain-free in training camp. The Chargers will tell us how well Gordon is doing in early camp. If they're limiting his practice time significantly, expect a slow start to the season. If he's cleared to participate in early preseason games, he's much more likely to be added to the 75% success column than not.

ARIAN FOSTER | RIGHT ACHILLES TEAR

From February:

Ignore all the snarky injury-prone comments you'll hear about Foster again this offseason. While not without merit, it's sad to see Foster's career take yet another detour through a complicated rehab process. Ignore the likely discussion about how players struggle to recover from Achilles' injuries and Foster has no chance of returning to form. The conclusion -- Foster's career is over -- may prove true. But it's lazy thinking to jump to that conclusion without a fair assessment of Foster's situation.

Foster has been cleared for light jogging and continued plyometric work, which means there have not been any surprises through four months of rehab. Though there aren't many good running back comps for a successful return from Achilles' repair, there are many wide receiver and edge rushers who have returned to productive form within 9-12 months of their injury. So, there are reasons for optimism here.

Unfortunately, this is Arian Foster. His long history of various and significant soft tissue injuries cannot be ignored. His long history of aggravated or compensatory soft tissue injuries cannot be ignored. And his age -- he's entering his age 30 season in 2016 -- cannot be ignored.

I refuse to write off Foster altogether. He's proven he can successfully rehab from soft tissue injury and return to elite production. But his age and the totality of his soft tissue injuries are impossible to dismiss. I'm approaching Foster's 2016 as I approached Victor Cruz in 2015. Which means I'll be rooting very hard for a successful recovery, but will remain pessimistic until I see Foster staying in productive from after multiple consecutive full practices.

Best case scenario for Foster is clearance to return some time in training camp with a smooth return to full practice without soft tissue setbacks. Give him an outside chance to begin the season ready to assume a 20 touch workload, but the odds are far from even money.

Nothing has changed since I wrote the above in February. Foster has navigated three additional months of rehab in the interim, but he's not yet ready to pass a physical. Expect to hear more rumors of teams interested in adding him to see what he can do in camp. A healthy Foster is an elite player. But make no sizable investment in him yet. He's an upside flyer with a week-to-week timeframe.

AMEER ABDULLAH | SHOULDER LABRAL TEAR

Abdullah was one of many players added to the recovery list after reporters learned he had a January shoulder labrum repair. Skill position players recover well from labral repairs with a much lower risk of instability than before surgery. It's a 4-6 month recovery timetable but Abdullah should be able to maintain his football conditioning without much difficulty. He should be ready for training camp without concern.

wide receiver

The list below is a who's who of NFL number one wide receivers. There's a little of everything on this recovery list, but ACL tears and fifth metatarsal fractures are the most common injury here. Thankfully, both injuries are associated with full recoveries. A full return to form after an ACL tear is almost taken for granted at this point. It's a testament to how much orthopedic surgery and physical therapy have progressed in recent years and how special the athletes who return to pre-injury levels truly are.

The fifth metatarsal fracture is one of a trio of foot and ankle injuries -- along with Lisfranc injuries and high ankle sprains -- that are on the rise. There is no single cause for this increase, but the NFL is paying particularly close attention to the footwear its athletes choose.

I was fortunate to attend a sports medicine conference where many of the league's head orthopedic surgeons, athletic trainers, and physical therapists presented in May. I was fascinated to learn the league hired a team of professionals who previously studied the biomechanics of automobile crashes looking into the biomechanics of the NFL. I've written about and discussed arguments that the "speed shoe" -- a lighter and more shallow shoe with a thinner sole -- is responsible for much of the increase in these injuries. In response, the league has extensively tested how the shoes from the major shoe companies perform on all forms of turf. Shoes that didn't pass muster, specifically because they didn't provide adequate support or were more likely to catch in the turf, were highlighted on a poster hung in every NFL locker room as shoes to avoid. The shoe companies involved responded by pulling those shoes and replacing them with better options.

Obviously, there's still work to be done. But it was fascinating to see how the league -- with the blessing of the NFLPA in this case -- is approaching this issue.

SAMMY WATKINS | FIFTH METATARSAL FRACTURE

DEZ BRYANT | RIGHT FIFTH METATARSAL FRACTURE / revision surgery

JULIAN EDELMAN | LEFT FIFTH METATARSAL FRACTURE / REVISION SURGERY

The diagnosis is essentially the same for each of these players, but the details and surgical approach have been different.

Watkins had a stress reaction in his bone last year that didn't heal. While the bone may not have been broken in the traditional sense, it's an injury that needed to be fixed surgically. Bryant tried everything short of David Blaine level magic to beat the standard 6-8 week timetable last season. He returned the field, wasn't himself, and later chose to readdress the injury with a revision surgery after the season. Edelman took a little more time than Bryant but also required a second procedure this offseason.

Stress reactions and revision surgeries aren't phrases that inspire confidence. But full recovery after surgery to fix these injuries -- assuming appropriate and full rehabilitation -- is very common. Julio Jones is the most striking recent example. Michael Crabtree and others have fully recovered. DeVante Parker is on his way to being another reassuring data point. That's not to say every player is a lock to recover. But Dr. Robert Anderson, the surgeon nearly every NFL player goes to for this procedure, has published data showing a near 100% success rate after revision surgery in NFL players.

The usual reconditioning caveats apply and there's a risk of recurrent injury or screw failure here, but it's reasonable to expect all three elite wide receivers to be ready for Week 1. Whether they're cleared for contact early in training camp remains to be seen.

DONTE MONCRIEF | LEFT TURF TOE SURGERY

Moncrief battled turf toe during the second half of last season. After taking a few weeks to rest and rehab, he chose surgery to tighten up the ligaments around the base of his big toe in March. Moncrief, like many players, opted for non-operative methods of recovery until there was no other alternative. Most players need 3-4 months to recover from this procedure. Moncrief had surgery in mid-March, which would put him on target for a training camp return. That's also the current expectation from the Colts. 

It's not unusual for players to still require an orthotic for some months after surgery. Teams customize orthotics and shoes now, so this won't likely be an issue. But watch Moncrief's route running carefully during camp. If he needs an extra step to decelerate or change direction, he may have a slow start to the season even if he's cleared for contact on time.

BRESHAD PERRIMAN | RIGHT PCL SPRAIN / right partial acl tear

Another pearl from May's sports medicine conference is that there's no consensus on how to treat the most difficult PCL cases. While 90% won't need surgery, some cases remain befuddling over time. That's almost certainly what happened with Perriman last year.

After not progressing as well as hoped initially then suffering at least one setback, Perriman required surgery to address ongoing instability and stiffness. Finally cleared to run in April, Perriman did some work in OTAs and some observers felt he was showing the same burst and speed he had before the injury. And that'll be the key here. Full return to form isn't guaranteed after surgery.

Click here for my separate feature on what to expect after Perriman's partial ACL tear.

VICTOR CRUZ | PATELLAR TENDON TEAR / CALF STRAIN

After restructuring Cruz's contract and minimizing his calf injuries as an unusual strain he was expected to fully recover from, I believed the Giants would get Cruz back on the field as early as possible this offseason. After drafting Sterling Shepard -- who isn't directly in competition for Cruz's usual slot snaps -- I felt the team would want to see where Cruz stood in his recovery to help direct their offseason playbook plans.

That's not what's happening. 

Cruz was not ready for more than some individual work in May practices. The team -- despite the fact Cruz has not been a part of the offense in over 18 months, choosing to restructure his contract, and adding another dynamic receiving option -- says that was planned and that they still see him as a key contributor.

I'm not exactly out on a limb when I paint such a pessimistic picture. Cruz is entering his age 30 season, is trying to recover from an injury we've seen very few successfully recover from, and has already had multiple soft tissue setbacks. I'm rooting for Cruz this offseason, but we're many, many months removed from his calf strains. His limited work in May is not a good sign for a full recovery.

TIGHT END

Jimmy Graham was the only notable player on this list in February. Since my last update, Tyler Eifert's condition went from jammed heel to requiring surgery to tighten an ankle ligament four months into an unsuccessful rehab. Jared Cook went under the knife for a probably fifth metatarsal stress fracture. And there's ongoing angst about Ladarius Green's recovery from an ankle surgery that occurred before he signed with Pittsburgh in free agency.

TYLER EIFERT | ANKLE SURGERY

Details on injured Bengals are often limited, but multiple beat writers were able to get specifics on Eifert's injury. Originally reported as a jammed heel and foot injury, Ian Rapoport tweeted that Dr. Robert Anderson repaired a loose ligament on the side of his foot in late May. Reports, including one from the team, put Eifert's timetable at 3-4 months. Adam Schefter carefully worded a vague tweet on Eifert to say he "could miss the first couple of games of the season."

(As a quick aside, the phrase "carefully worded a vague tweet" is a messy oxymoron. But it's also accurate. Teams, beat writers, and national media reporters do this all the time. Sometimes, it's because they're trying to provide information where there's really no clear answers to be found. Sometimes, it's because they can't release everything they know. It's amazing how much or how little can be gleaned from 140 characters -- or images of Jason Pierre-Paul's operating room schedule entry and surgical scars. But that's a story for another article.)

Eifert returning in 3-4 months is a reasonable expectation. It's the usual recovery timetable given by orthopedic surgeons and fits the waited-to-have-surgery-until-last-possible-week-and-still-be-ready-for-Week 1 narrative. But this expectation presumes Eifert will have no delays in the late stages of his rehab. The Bengals will not clear Eifert to return to full contact until he has full strength and near full range of motion in that ankle.

There are three ankle ligaments on the outside of the foot. Eifert's chances of returning at the more optimistic 12-week end of his timetable will depend on which and how many required "tightening." For comparison, Cam Newton had a similar procedure in March 2014. He returned at the early end of his timetable and was ready for camp and the regular season, but admitted he was given more of a 4-6 month estimate and didn't feel himself until nearly 6-7 months after his procedure.

Expect Eifert to start on the PUP list as camp begins. Like Le'Veon Bell and Donte Moncrief and every player returning from fifth metatarsal surgeries, watch his progress and effectiveness carefully once he's cleared to return.

JIMMY GRAHAM | RIGHT PATELLAR TENDON TEAR

There's not much new on Graham. He's recovering from what's been a devastating injury with few examples of complete recovery within 12 months. The Seahawks remain cautiously optimistic he'll return in time for the regular season. Like Cruz, I'm rooting hard for Graham to give us a strong example of an elite skill position player returning to full form after this injury. But that's a tough ask.

One other tangential but major point with Graham. The Seahawks traded for him last March and had four months to work him into their offensive game plan. Graham's usage in the offense was inconsistent last year, though, While he had at least eight targets in six of his eleven games, the Seahawks kept him to a tight 45-55 snaps after Week 1. Without knowing whether he'll be available early in the season and without another offseason to build chemistry with Russell Wilson, it's hard to see Graham step forward this season even if he proves to be an outlier on the patellar tendon recovery curve.

jared cook | foot surgery

The Packers called Cook's May foot surgery preventative. That raises suspicion for an injury similar to Sammy Watkins -- a slow-healing stress fracture in the fifth metatarsal. Early estimates have Cook likely to return for training camp, which is in line with the 8-10 weeks most players need to recover from fifth metatarsal surgery. I'll be watching for more details as the summer progresses.