The Winning Edge in the NFL - Orthopedics!

It’s that time of year. The earth’s celestial alignment to the sun starts its 90-day shift. The great annual migration of several species from northern latitudes to southern climates begins—including that sub-specie of homo sapiens known as the pale, retired snowbird. It is also that time of year when millions of otherwise sober men (and women) assemble for weekends of football. 

Saturday afternoon is college football. Sunday is the NFL. In the United States weekends between September and February are ruled by football. Sociologists have long known and measured the city-wide decline in water pressure in every major city during football half times (toilets flushing). 

As these passionate fans watch their home team battle for that all important “W”, how many realize that the winning edge for their team is not the franchise quarterback, not the grouchy old coach, not the juking, end zone dancing, bling-drenched wide receiver. No, it is that bespectacled guy at the far end of the sideline bench who is probably catching a nap after his 66 hours of seeing patients that week.

Yup, what’s the winning edge in the NFL? Orthopedics. And who among those Packer Backers, Eagle Maniacs, Colt Crazies or Ram Rousers have any idea that their weekend highs and lows are shaped by this great and amazing community we all belong to? 

Wait, do you doubt the power of orthopedics to alter, for better or worse, a football’s won and loss record? Oh ye of little faith. Simply by looking down the team rosters the answer quickly becomes evident—orthopedic injuries.

Those “bone crushing” hits, among other insults, have made football and orthopedics as inseparable as, well, peanut butter and jelly. And this year, perhaps atypically, orthopedic injuries have taken center stage as the professional season unfolds. One particular area of the body, the knee, is shaping the misfortunes and, yes, fortunes of several teams in 2008-2009. 

Sixty days ago, Las Vegas declared yet another coronation of two long dominating teams—the New England Patriots and the Indianapolis Colts. But how fast the best laid plans of coaches and general managers can change. One day, one play, two ticks of the second hand and the season for both teams changed unexpectedly and dramatically. Kansas City Chiefs’ safety Bernard Pollard came locomoting to Patriot’s quarterback Tom Brady’s blind side blocking him in the leg as he stepped forward to pass. Brady crumpled to the turf with two torn ligaments—the medial collateral ligament (MCL) and the anterior cruciate ligament (ACL). 

Later that same day the Indianapolis Colts faced the Chicago Bears and the Colts’ remarkable quarterback Peyton Manning entered to play his first game since having surgery to remove an infected prepatellar bursa sac from his left knee. Noticeably absent was Jeff Saturday, the three-time pro-bowl center who had torn his MCL in a preseason match. Further contributing to the Colts’ woes was the injury to starting tight end Dallas Clark, who tore his MCLduring the second quarter. To aficionados of the game, star quarterback Manning played listlessly. His team mirrored Manning’s sub-par performance. Indeed, the combination of knee injuries to its multi-million dollar players left the Colts looking like a shadow of the Super Bowl team they once were. The Chicago Bears had, as it were, a leg up on the Colts that day.   

Reviewing the first day of U.S. professional football for 2008-2009 season, what are the ramifications of such injuries to franchise quarterbacks like Tom Brady or Peyton Manning? Further, what do these orthopedic traumas mean to the teams themselves and the fans who, ultimately, suffer the cost of disappointment?

Quarterback Tom Brady’s prognosis is mixed. He most likely will play again, but not this year. The ACL and MCL are two of four major ligaments within the knee. The ACL attaches to the femur and the tibia, and functions to stabilize the knee by restraining excessive forward movement of the tibia and limiting the knee’s rotation. The MCL is positioned on the inner side of the knee joint and functions as a restraint to inward force upon the knee.

When the only ligament torn is the ACL, the primary goal is reduced swelling prior to performing an ACL reconstruction procedure. In the case of Tom Brady, the situation is somewhat different because the MCL was also torn. Because of this, the surgeon has elected to wait four to six weeks to perform any ACL reconstruction, giving time for the MCL to heal. Then, once the reconstruction procedure is completed, the healing and rehabilitation process will begin. This process typically takes six to nine months—well beyond the limits of even the longest NFL season. 

The Colts’ injury woes may prove substantially more short term than the problems the Patriots are facing. While MCL injuries are painful and extremely difficult to play with, they rarely require surgery or the long-term level of rehabilitation required after an ACL tear. MCL injuries are broken down to three grades of severity, I, II, or III. The symptoms of a grade I injury may include some tenderness and slight pain. Treatment for a grade I injury includes ice, rest, and possibly some anti-inflammatory medication. For an athlete, these only mean sitting out for one to two weeks. Grade II injuries include an increased level of pain along with some swelling, and even more importantly include noticeable looseness within the knee joint. Athletes experiencing a grade II tear will sit out three to four weeks. A grade III tear includes severe pain, an increased level of joint instability, and is commonly accompanied with an ACL tear. The rehabilitation involved in this scenario can take up to three or four months. In any one of these scenarios, surgery is very rarely considered necessary. According to data from the PearlDiver Patient Records Database, only 1% of patients with an MCL tear will have surgery to repair the damage, so it is not likely any of the Colt’s injuries will be season killers.

As shown below in Table 1, MCL tears are anything but rare in the U.S. However, what is interesting is that through the PearlDiver Patient Records Database we can see just how many of these tears also include an ACL tear, the fate suffered by Tom Brady. As it turns out, between 15% and 18% of all MCL tears are accompanied by an ACL tear, or conversely, between 9% and 11% of all ACL tears are accompanied by an MCL tear. 

Table 1: Number of U.S. Medial Collateral Tears

But football is a high-level contact sport and just breezing through the injury reports can quickly fill a half page to a page of players listed with injuries to their ACL, MCL, or both. According to the article Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies printed in the Journal of the Academy of Orthopedic Surgeons, 70% of ACL injuries occur in non-contact situations. Quick math then would suggest 30% of ACL injuries occur in contact situations prevalent in football. On a national level, as shown in Table 2, we are seeing almost 200,000 ACL tears each year.

Table 2: Number of U.S. Anterior Cruciate Ligament Repairs  

These injuries include patients of all ages; however the vast majority of both ACL and MCL tears come in patients under the age of 65. According to PearlDiver data, the age group hit hardest includes patients between the ages of 15 and 19, who through 2004 through 2007 comprise 18.4% of all ACL patients under the age of 65. Patients age 20 through 29 then make up another 17.5% of the total patients. The total patients age 15 through 29 comprise 35.9%.

Much less common is the ailment suffered by Peyton Manning of the Colts. Diagnosed with prepatellar bursitis, Manning’s knee was becoming painfully inflamed and filled with fluid. The condition is caused by continually exerting pressure upon the knee. The ailment is not unique to football players, or even athletes. Anyone who is required to kneel for extended periods of time such as carpenters or roofers, patients with rheumatoid arthritis, gout, or anyone who could receive a direct blow to the knee is susceptible to the condition.

The prepatellar bursa sac provides lubrication just under the knee cap and allows the kneecap to move smoothly under the skin. However, if the bursa becomes inflamed, the result is swelling and collection of fluid around the knee. Normal treatment for bursitis is to let the accumulated fluid be reabsorbed by the body or in more severe cases drain the fluid. Rarely does prepatellar bursitis require any further procedures. However once the bursa sac becomes infected, removal may become necessary as was the case for Peyton Manning. From a sample of 4,691 patients within the PearlDiver Patient Records Database from 2004 through the second quarter of 2007, only 6.3% of patients diagnosed with prepatellar bursitis required a procedure to have the bursa sac removed.

Typical recovery for such a surgery would be expected to require several weeks before resuming normal activities. Yet professional football can hardly be considered normal activities. With the high physical demands it may still take a number of weeks before we see Manning at 100%. 

Each of these injuries has had an impact on the players and can have a serious impact on the teams. So to rewinding a little bit, what do these numbers mean to these two pro football teams? Since the opening day for the Colts, they have a record of one win and two losses, and since the Patriots season opener, the team which nearly achieved a perfect season in 2007 has already fallen to the Miami Dolphins, a team with one of the poorest records in the league through the 2007-2008 season. 

For fans, the problems of one team can be the benefit of another. As a fan of any team it’s easy to say, “maybe this year is the year.” But all too often that hope is crushed as the season gets under way. But there is a silver lining. For every fan out there rooting for a team other than the Patriots or the Colts, the football season just got interesting. The playing field just became a little more level. There is now very good reason to pull your team’s jersey out of the bottom of the drawer and watch the game rather than mowing the yard. Talk around the office water cooler is no longer about the dread of watching a team play one of the juggernauts of professional football.

Giving a clearer picture of potential reinvigoration of fans around the country, are the Sunday Night Football Nielsen ratings. On Sunday, September 21, according to tvbythenumbers.com, Nielsen estimated 17 million viewers tuned in to watch the Dallas Cowboys take on the Green Bay Packers. The week prior to this, 17.8 million viewers tuned in Sunday evening to watch the Cleveland Browns host the Pittsburgh Steelers.

Excluding postseason games, the last game with a larger viewing audience during the 2007-2008 season was when the New England Patriots hosted the Philadelphia Eagles on November 25, 2007, a game in which 21.8 million viewers tuned in to watch. Prior to that Sunday night football game, the next previous Sunday night game to reach 17 million viewers took place on November 11, 2007, when the San Diego Chargers hosted the Indianapolis Colts. 

This is an interesting effect orthopedics has had on football, but the story isn’t only about football on Sundays. Saturday afternoons also hold a special place in the hearts of football fans around the country. That’s when college football is in full swing as well, and much like the pros, orthopedics has played a role in the 2008-2009 season on this level of play as well. According to Selected Issues in Injury and Illness Prevention and the Team Physician: A Consensus Statement, American Academy of Orthopedic Surgeons, 2007, ACL injuries at the collegiate level of play are most common in the sport of football, which accounts for only 3% of all sports injuries. However, when these injuries occur, just as in pros, the effects can be season ending and team devastating.

Examples of this include; Purdue running back Jaycen Taylor, who tore his ACL in August during practice, Georgia Bulldogs defensive tackle Jeff Owens, Florida State running back Tavares Pressley. Even Notre Dame coach Charlie Weis was wounded in the line of duty as players crossed the sideline during a punt, resulting in a collision that would lead to both a torn ACL and MCL.

One team in particular has seen a string of ACL tears among its players. There must be something in the water down in Gainesville, Florida. Since July 2008, five members of the Florida Gators football team have torn their ACL. These include:

• Cornelius Ingram TE
• Brandon Beal LB
• Dorian Munroe S
• John Curtis S
• Jim Barrie OG