Off-season Injuries to Monitor

Last week I covered the dreaded ACL injury and discussed the various factors that dictate return to sport timelines. This week, I will cover the rest of the season-ending injuries, as every year, there are numerous off-season injuries to monitor. Generally speaking, the ACL and the Achilles are the two most devastating injuries with the longest rehab processes. Each player on the list below has a realistic chance of being ready to go in week one, but that does not mean there aren’t implications of their injury.

Ankle Surgeries

To understand the impact of ankle surgery on an athlete, we must first discuss the ankle’s role in human function. The ankle functions as a shock absorber and a force transmitter via a spring-like mechanism. Bear with me if that sounded like a foreign language to you; I will explain. We all took physics once; let’s recall Newton’s 3rd law, where every action has an equal but opposite reaction. In football, Newton’s 3rd law presents that when the foot hits the ground, the ground strikes the foot back with the same exact force the foot hit the ground with. One role of the ankle is to absorb a portion of this force, similar to how the shocks in a car absorb the bumps from the road.

An ankle with a normal range of motion can bend into dorsiflexion (the foot bends up towards the shin), allowing the force from the ground to be absorbed over a more extended period. A stiff ankle, however, does not undergo the same dorsiflexion range of motion, meaning the total time the ankle has to absorb the force from the ground is less, making the impact from the ground more significant. When an ankle is not absorbing force well, the force from the ground goes up into the knees, hips, back, and sometimes up to the shoulder and neck. Therefore, a stiff ankle can make an athlete more susceptible to future injury.

Additionally, a stiff ankle causes changes in the lower body mechanics. Some (but not all) of the more common changes are listed below.

• Changes in walking and running mechanics: Most commonly, the entire leg will rotate outwards (see YouTube video below). This is seen when looking from behind and noticing two or more toes in your line of view when the person is walking or running away from your viewpoint. The problem is the rotation of the leg leads to tightness and weakness of the glute medius muscle, overuse of the groin muscles, and underuse of the calves. Does this compensation influence athletic performance? Perhaps not so much, but overuse of the groin muscles and weakness of the glute muscles can contribute to injuries.
• Impact on squat depth: When someone makes a squat motion, whether weight lifting or simply bending forward to pick something off the ground, the ankle must move into the dorsiflexion motion 10-20°. Many people, after ankle surgery, never regain this full range of motion. Compensations seen with a squat-like pattern include excessive forward bending through the back, rotating the leg outwards, and twisting to the stiff side. These compensations can lead to injury while working out and impact a player’s ability to get into a three-point stance (therefore, they would not impact QBs, RBs, or WRs as much).
• Glute weakness/inhibition: When we walk, the ankle must dorsiflexion roughly 10° for a normal gait pattern. This allows us to advance our leg over our feet properly. Compensation occurs when someone does not have 10° of dorsiflexion (usually the leg turning outward described above). This compensation also contributes to the gluteus medius muscle not activating routinely during the walking progress. This leads to significant weakness in the gluteus medius muscle. This muscle is designed to provide stability when on one leg and, thus, is highly involved in running and cutting.

As you can see, there is more to ankle surgery than meets the eye. The good news is the above-listed compensations do not always occur, and even in the presence of these compensations, fantasy football production is not necessarily impacted. The unfortunate consequence is an increased injury risk, but that does not guarantee future injury. Fantasy football players should use this information and make their own decisions when weighing risk vs. reward for the following players.

Cooper Kupp

Cooper Kupp has been one of fantasy football’s favorite players throughout his fantastic career. The Super Bowl MVP missed the last eight games of the 2022 season after suffering a severe high ankle sprain requiring tightrope surgery. While it was unfortunate to miss Kupp during the fantasy playoff push, the tight-rope procedure has fantastic outcomes, and fantasy players can expect Kupp to be at 100% next season.

Following this surgery, there is no reason to expect impaired performance. A possible concern would be the development of chronic ankle stiffness that commonly occurs after ankle surgery mentioned above. Kupp is a hard worker and gifted with one of the NFL’s best training staff, which should allow him to regain as much range of motion in his ankle as possible. This injury may contribute to future injuries, but his production level should not be impacted one bit.

Ryan Tannehill

Tannehill suffered a high ankle sprain to his right ankle in week 15, and ultimately missed the remainder of the season. Like Kupp, Tannehill underwent the tightrope procedure. Tannehill never returned in 2022, but will be full go for 2023.

Tannehill’s response to this surgery differs slightly from Kupp’s due to their positions. Tannehill is a quarterback, and while a fairly mobile quarterback, does not run nearly as much as Cooper Kupp does on a given day. Therefore the potential negative influence of a stiff ankle would not be as likely to present itself as it would a receiver or running back. One added challenge for Tannehill, however, is that it was his right ankle he injured. As a right-handed thrower, he pushes off his right foot and ankle to generate power. During the throwing motion, the push-off ankle needs to undergo rapid changes from supination (during the windup) to pronation (during the follow-through). In my experience treating ankles, these motions can be tricky to restore after surgery.

For a thrower, not having full supination and pronation leads to compensations in any of the joints above (knee, hip, low back, upper back, shoulder) to compensate for the lost range of motion at the ankle. This can lead to overuse injuries in any of the above-listed joints. Tannehill and his training staff must work diligently to restore his ankle’s full range of motion. At age 34, this can be challenging but not impossible.

Rashaad Penny

Penny suffered a fibula fracture with syndesmotic and deltoid ligament involvement in week five and missed the remainder of the season after undergoing surgery. This type of injury heals just fine; however, the consequences of ankle surgery mentioned above can present themselves.

Often after surgery, the patient is immobilized and non-weight bearing for up to 6 weeks. This will lead to stiffness and muscle atrophy. As mentioned throughout this article, stiffness can be a challenge to regain, strength is easy. After the initial six weeks of immobilization, regaining ROM will be the primary focus, as well as strength and balance. 

Return to running will begin around weeks 8-12, typically starting in a pool or alter-G treadmill. Sport-specific training and a gradual return to full activity occur over weeks 12-16 post-op. This timeline will allow him to be fully ready to go for camp. As mentioned many times above, future injury risk is a concern if he can’t regain full range of motion at the ankle, but productivity should not be hindered.

Penny enters 2023 in a fantastic situation for a running backs fantasy football prognosis. The Eagles boast one of the most prolific offensive lines and run games. Should Penny stay healthy, he is in line for a great season. However, in Penny’s career, he has suffered multiple hamstring injuries, an ACL tear, a hand fracture, a calf injury, and now this. Health has been a major issue as he has missed 38 games in five seasons, with multiple games missed each season.

Tony Pollard

Pollard suffered a fibula fracture with a high ankle sprain in the NFC divisional round. The fibula required surgery, which took place shortly after the injury. The same analysis for Penny above suits Pollard; however, the timelines are different. Pollard’s injury occurred on January 22nd, whereas Penny’s occurred on October 9th. Pollard won’t be cleared for full activity until 16 weeks after injury at best, which is May 22nd. Recovery from surgery will impact his ability to train early in the offseason, but he may be able to participate in OTA’s and should be full-go by camp. Pollard is now the lead back in Dallas with Ezekiel Elliot out of the picture and is in line for a monster season!

Trey Lance

In week two, Lance suffered a broken right fibula with ligament damage, both requiring surgery. The combination of the fibula fracture with ligament damage also increases the likelihood of developing chronic stiffness. This is Lance’s right ankle, which he pushes off for throw power. Additionally, Lance is a runner, further emphasizing the need to regain full range of motion to reduce the likelihood of future injury.

The above paragraph sounds pessimistic and does not accurately depict my outlook for Lance’s career. I acknowledge that his risk for future injury may be higher than if he did not have this injury, but the injury is not a guarantee. He is only 22 years old, so his potential to regain full range of motion is much better than that of a 30-year-old. Additionally, just because his ankle may be stiff does not mean it will impact his performance. He should still be able to run and throw just as he did pre-injury. However, the ankle’s shock absorption property may be affected, which could feed future injuries. Also, as mentioned above with Tannehill, with this being Lance’s right ankle, the one he pushes off, he will need to fully regain the supination and pronation motions to allow his body to naturally rotate during the throwing motion. Failure to regain these motions may result in compensation and overuse from joints higher up.

Foot Surgeries

Like ankle surgeries above, foot surgeries can be challenging to regain range of motion fully. The foot is a fascinating piece of genetic technology. When we walk or run, the foot has an incredible ability to change shape depending on the phase of walking/running. Remember Newton’s 3rd law described above; every action has an equal but opposite reaction. Again, this means that when a player’s foot strikes the ground, the ground strikes them back with the same force. Understanding the foot’s anatomy and mechanics helps explain how a normal, uninjured foot is very efficient, whereas a stiff foot is not. I’ll explain below.

When the foot hits the ground, it quickly pronates, where the inside arch drops slightly, making the arch flatter. Several muscles, including the tibialis posterior and friends, control this flattening of the arch. This pronation motion is very important, as it helps cushion the impact of the ground. As the foot prepares to push off and leave the ground, it supinates and recreates its arch. The supinated position of the foot makes the foot firm, therefore, capable of creating more force when pushing off the ground allowing a player to move faster and with more power.

Pronation and supination motions depend on an adequate range of motion and strength at various joints in the foot and ankle. Particularly the talocrural and subtalar joints (part of the ankle) and the mid-tarsal joints (mid-foot) are responsible for creating pronation and supination. Any of these joints can become stiff with a foot fracture and subsequent immobilization in a cast or boot. Foot fractures will make the midtarsal joint more prone to stiffness, whereas ankle injuries will make the talocrural and subtalor joints prone to stiffness. Stiffness in these joints will impact the foot’s ability to pronate and supinate, therefore impacting the ability to absorb force when the foot lands and create force when pushing off.

Jimmy Garoppolo

Jimmy Garoppolo broke his left foot in week 13 and missed the rest of the season. Fresh off a new contract to be the Raiders starting quarterback, Garoppolo has had more than enough time to fully recover from this injury. 

Yes, I wrote above how these injuries can chronically change mechanics that can influence future injury, but Garoppolo is a pocket passer; he doesn’t run much. A stiff foot or ankle is much less influential as a pocket passer. Additionally, this is Garoppolo’s left foot. As a right-handed QB, he pushes off his right foot for power. I see no reason for this injury to impact Garoppolo going forward.

Michael Thomas

Michael Thomas looked great in his first three games after missing all of 2021 with an ankle injury. Unfortunately, In week three, Thomas dislocated his second toe, resulting in season-ending surgery. As of late March, Thomas is still rehabbing.

This type of injury typically occurs due to the tearing of the ligaments on the underside of the toe; these can be referred to as the plantar plate. The role of the plantar plate is to prevent the toe from extending (moving upward) too far. Functionally, this is seen when pushing off to run or walk. If there is no restraint on the toe extending, the toe cannot provide any push-off. Below is a fascinating Youtube video explaining the surgery.

This is a rare injury, and data on the success of return is not present. Thomas should likely be near 100% by camp, but he will be one to continue to monitor during the offseason and into camp.

Rashod Bateman

Bateman sat out the second half of the season after undergoing surgery for a Lisfranc injury. While we do not have a large data set on players returning from a Lisfranc injury, it appears a trend is developing where young players are able to successfully return to a prolific career, whereas older players cannot. We saw this past season that athletes could return from this surgery and play at a high level. Travis Etienne produced a 1,000-yard rushing season and finished as RB 17 on the year after undergoing a similar procedure last season.  Bateman is only 23 and should be just fine next season. 

Devin Duverney

Duverney suffered a Jones (5th metatarsal) fracture. This is a fracture to the outside bone of the foot. With an offseason to heal, there is no reason this should impact his readiness for week one. 

Other Injuries

Brock Purdy

Purdy underwent surgery on March 10th to repair his torn Ulnar Collateral Ligament (UCL) with an internal brace, a fairly newer surgical procedure. The repair with an internal brace is advantageous to a UCL reconstruction (Tommy John) surgery as it cuts the return to play time in half (repair average of 5 months vs. reconstruction average of 11.6 months). 

Brock Purdy with right elbow injury. UCL sprain probable. If pain controlled and doctor feels joint stable return possible. pic.twitter.com/0SY3A0Zdkh

— Dr. Mark Adickes (@jocktodoc) January 29, 2023

The repair with an internal brace utilizes a collagen-treated brace to anchor the surgery, allowing the native tissue to heal. In contrast, the reconstruction requires harvesting tissue from other parts of the body and is a much more involved surgery. With the repair using the internal brace, the athlete can progress through rehab much quicker due to the increased stability of the surgery and fewer tissues healing overall. While advantageous to reconstruction, the repair is still a long rehab process. 

Purdy will not begin throwing until 12 weeks post-op. In the meantime, he will focus on regaining elbow range of motion and reducing muscle atrophy (weakness). Twelve weeks, however, is not when he will be cleared for full throwing activity.  Per the rehab protocol, Purdy will begin with a gentle progressive throwing program at week 12, typically starting with only throwing 45 feet initially. Over the next eight weeks, this will progress to full range, but slowly. Of importance is that prior to initiating the throwing protocol Purdy has full range of motion, no pain, no laxity into elbow valves (excess movement that should be restrained by an intact UCL), and demonstrates adequate strength at various upper extremity regions. By 20 weeks post-op, which in his case is July 28th, he should be at full strength for throwing.

 

While this timeline allows Purdy to be 100% by the start of week one, let’s consider his situation. He played great in relief of Trey Lance and Jimmy Garoppolo last season but did not command the starting role for the 2023 season. His competition, Lance, missed almost the entire 2022 season with an ankle fracture. Lance will have the entire offseason to train and prepare for the training camp battle vs. Purdy. Purdy, however, will not. Purdy won’t even begin throwing in any capacity until June 2nd. As it stands, I give Lance the leg up to win the job simply because he has much more time to train and prepare for camp. 

Lamar Jackson

Jackson missed the last five weeks of the season with a PCL injury. I wrote extensively every week after his injury about how this would likely end his season or at least significantly hamper his production. Fortunately, Jackson’s PCL injury was not severe enough to warrant surgery, and he should have most of the offseason to train at max capacity.

The PCL is tricky because it usually does not heal. The rehab process includes allowing the swelling to subside, which can take time (clearly), regaining the strength of the quad muscles, and regaining proprioception. Proprioception is a sense that I wrote quite a bit about during the season. Essentially proprioception is our body’s ability to understand where its limbs are in space without looking. For you video game players, think of it as how you know exactly where your thumbs are moving to strike the different buttons on the controller without looking down. This is a nice example; only for Jackson, proprioception works on a much larger scale by allowing him the awareness of where his legs are when running and cutting to enable him to quickly and confidently cut. 

By week one of next season, I expect no issue with Jackson’s knee. Where he plays is a different story that will continue to unfold over the next few weeks.

Kyle Pitts

Pitts suffered an MCL tear requiring surgery in week 11. This was actually a fortunate outcome for the second-year tight end, as the hit looked much worse. The rehab from this injury can take up to six months or longer. Early phases of rehab are highlighted by restrictions in range of motion and typically non-weight bearing for six weeks. Any time post-op there are restrictions in range of motion, stiffness becomes a concern. Additionally, any time post-op someone is non-weight-bearing for several weeks, significant muscle atrophy (loss of size and strength) becomes a concern.

Return to athletic activities (plyometrics, running, cutting, jumping) typically does not happen until 20+ weeks after surgery. For Pitts, that is mid-April. The return to these activities does not mean he has full clearance for football activities. For clearance for football activities, he needs to demonstrate that his surgical leg is within 90% performance of the non-surgical leg on various strength, balance, and hop tests. Pitts should easily have enough time to achieve this by week one, but we may see a slower start to the season. Even if Pitts starts slow, the tight-end landscape in fantasy football is awful, and he will likely finish as one of the top options.