Dr. Flynn's Mailbag: QB's non-throwing shoulder, concussions, ACL recovery, turf, knee braces & diverticulitis

Hi everyone! Great questions this week! Would love to hear from you for future editions, so make sure you check out the contact information at the bottom of the page.

It is an eclectic mailbag this week - brain health, sports hernias, knee braces in the NFL, turf concerns, Brady’s shoulder injury and….diverticulitis?! What’s the saying? Is it “age before beauty?” Well, Tom Brady is both, so let’s start with him…

When a QB has an injury to non-throwing arm, why would he miss practice? It’s non-contact, so he isn’t at risk of aggravating the injury. (Kevin Duffy, MassLive @KevinRDuffy)

Hmm…is this a hypothetical question? Tom Brady missed practice Wednesday with what is reportedly a sprain of his left AC joint. Read more about the injury on BSJ here. The truth is, even a non-throwing shoulder injury is painful during the throwing motion. Brady isn’t just tossing a ball lightly for a couple of yards. He uses his core and both shoulders to throw the football to his intended target. He also uses his non-throwing shoulder to dodge and move in the pocket. Another reason why athletes may miss parts or the entirety of practice with an injury like Brady’s is to get therapy - time on the field is time away from treatment.

While we’re at it, here’s a question from…errr….me.

Have you ever seen this degree of specificity on a Patriots’ injury report? (Doc Flynn)



I don’t know what to say about this one, but I do find it interesting that the team is sharing so much information on Brady’s injury. Maybe you guy have an opinion on this one?

Re: Tom Brady and the beating he’s been taking coupled with his “he said/she said” countless concussions. I worry for his “rest of life” quality. The brain health is not something remedied with his and Gisele’s $$$$$. What say you? I say this is his last year! (Phil Olsen)

My opinion is that it would be naive to think that there are many professional NFL athletes out there who have not had a concussion. I don’t know if I would go as far as to say that Brady has had “countless” concussions, but it is clearly concerning that his wife shares that information you. Brain injuries in the NFL are a serious matter and I was just watching testimony from former players, wives, and TBI experts in front of the US House Judiciary Committee this morning. Research is still emerging, but when I listen to former NFL athletes tell their stories it complicates my feelings about a game that I love and re-solidifies our family rule that my boys will kick if they want to play tackle football. I don’t know the answer, but I will tell you that I’m a lot less worried about a seasoned quarterback like Tom Brady than I am about some of the quick slot receivers. Those guys are at significantly bigger risk of head injury. I hope Brady can play as long as he wants to and I suspect it will be more a performance and overall wear-and-tear decision rather than a head injury risk one.

(Phil’s son is a third-year medical student - best wishes to him! He has many sleepless nights ahead of him, but they’ll all be worth it when learns the true privilege of becoming part of the lives of strangers and being entrusted with such responsibility to keep them healthy.)

Always hear FB players love quickness/never the same after ACL reconstruction. Is there science that backs that up? Hope not for @Edelman11 et al! (Loren Maloney, @LorenTMaloney)

Yes and no. During the first one-to-two years after an ACL reconstruction, two major things are happening. The first, is that the graft (a tendon) is microscopically starting to change into tissue that more closely resembles a ligament. This process takes about 15-24 months. The second thing that happens in the first season back after ACL reconstruction is that the athlete is getting accustomed to the “new normal.” A reconstructed knee isn’t exactly the same as the original model. It may be slightly stiffer, still slightly weaker, and the brain’s use of that knee is still altered. Over time, athletes get more used to it. Take Dion Lewis, for example. Doesn’t he look much quicker/explosive/jitterbuggy than he did his first season back after ACL?

Level of performance after ACL reconstruction has been shown in studies to be position-dependent. Quarterbacks tend to return to the field and perform at their previous level at a higher rate than running backs and receivers. For example, 64.3% of NFL linemen return to play with no significant decrease in performance. 92% of NFL quarterbacks return to play, also with no appreciable decrease in performance. Receivers and running backs, on the other hand, have been shown to have poorer performance after ACL reconstruction. A study from 2006 showed that these athletes experience a 33% decrease in performance after ACL surgery. The data from this study is old; 1998-2002. It should probably be repeated to reflect advances in ACL reconstruction technique (eg tunnel placement) and rehabilitation protocols. Newer data from the NFL Combine looked at athletes who had ACL reconstructions and attended the Combine from 2010-2014. They found no statistical difference in performance on events including shuttle drill and 3-cone drill compared to non-ACL controls. Those results may be more indicative of what we think we’re seeing now.

Overall, I’m not worried about the gritty JE11. A couple of years of dealing with a chronic fifth metatarsal foot fracture must have been tough. It’s awful that he has to deal with another long recovery. But I would expect that his first year back may show a slight decline in performance while the knee continues to heal and he gets used to his “new normal.”

I brought up this issue once before, and you've touched on it, but I remain curious. I keep seeing this evergreen contention that artificial turf can be a causal factor in injuries, especially knee injuries. The belief is out there, among both some athletes and some fans. And I know you've stated that in general, the older harder surfaces are more demanding and so less than ideal on an ongoing basis. But I am specifically curious about what the experts' speculation is on whether artificial turf can be a cause of things like knee injuries. I've heard claims that injured players in some cases experiencing the turf grabbing and catching their foot. But I don't know if it's true, or confirmed, or if it has been tested. As a layman, it seems plausible. And it seems obvious that in the case of knee injuries, you want the foot to be able to release from the turf in cases where you want to avoid high-stress twisting . . . so many joint injuries seem to come from things twisting and bending in ways they aren't able to do. What's the speculation of yourself and say, others in the field on this matter? (Brian Keegan)

There is a lot of debate about injury rates on artificial turf versus natural grass fields. Early studies of first-generation turf fields seemed to indicate higher injury rates, while newer studies disputed those findings. There are a lot of variables at play, including the hardness of the turf or grass/dirt, the amount of friction generated by the surface (ie how much it grabs the cleat), and the actual shoe that the athlete wears. The hardness and friction are further complicated by things like cold weather (which hardens the soil, particularly seen in northern stadiums), wet weather (which can decrease the friction on any field surface), and ability to maintain even/safe field conditions which can be a concern where grass does not grow well or turf pellets are mounding up.

Newer turf fields tend to be softer (ie more forgiving when a head strikes it) and less grippy (generating less surface friction) than first-generation Astroturf. Every field is tested for GMax (a measure of hardness) and fields that are too hard will not pass. The “stickiness” of the turf is variable from field to field and therefore difficult to assess.

If I had to make a very broad generalization, then I would say that we see more injuries on turf fields. That being said, a poor-condition, frozen grass field at Foxboro in January isn’t a great surface either.

Here’s a link if you want a deeper dive… https://www.hss.edu/conditions_artificial-turf-sports-injury-prevention.asp

Do you see the advancement in knee braces as a big potential breakthrough with all the knee injuries in the NFL? (Ben Hoffman, @BenjiTuna88)

Not yet. Many linemen wear knee braces to prevent knee injuries. However, there is surprisingly scant/NO data to support this. Many colleges require both knee braces and ankle taping for linemen, but studies have actually shown that bracing might have the opposite effect - it may increase risk of injury. NFL teams have a harder time selling the use of prophylactic bracing to their players because of the collective bargaining agreement. Players often refuse to wear prophylactic braces because they find them cumbersome, slow them down, and they SMELL NASTY after a few weeks!

I suspect Dont’a Hightower wasn’t wearing a prophylactic brace on his right knee prior to his most recent injury because it felt like it was getting in his way. However, given his history of chronic issues with that knee, I was not at all surprised that someone (with the initials BB) suggested that start wearing one after the injury. You may not have noticed, but Hightower did wear a hinged right knee brace, which can protect the MCL, in last week’s game against Tampa Bay.

Can you give us all a good primer on Diverticulitis? Is it a recurring affliction? What are the usual symptoms? How is it treated? I know people with IBD and Crohn’s, is it similar to those? (Adam Crane)

Bruins center David Backes has missed some time while he is being treated for diverticulitis. Diverticulitis is an acute condition where the tiny outpouchings (diverticula) in the wall of the large intestine get inflamed or infected. We don’t really know why the little pouches form (some people have them - diverticulosis - and some people don’t). Doctors think it may be related to a low-fiber diet. The colon has to work harder to push the harder stool out causing the little pouches to form (I can’t believe I’m writing about this in a sports injury mailbag).

Acute (or sudden…not going on for years) diverticulitis is very painful and treated with antibiotics and hydration. Everyone responds to treatment differently, so it’s not clear when Backes will be back to normal. Crohn’s disease and IBD are different characters altogether, much more chronic and totally different pathology which I won’t get into here.

With Rajon Rondo the most recent athlete to be diagnosed with a “sports hernia,” I’m wondering if you can explain what that is and how it’s different from any other type. (Dan Shapiro)

A hernia is a “condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it (often involving the intestine at a weak point in the abdominal wall).” Typical hernias are seen in the inguinal (groin) area or around the belly button and occur because a weakened area of tissue allows parts of organs such as the intestines or fat can protrude through either the abdominal wall or groin. They’re dangerous only in cases where the organ can get stuck there and lose blood supply/die and make the patient very sick.

Sports hernias, on the other hand, are sort of a misnomer. They can be accompanied by a subjective bulge that’s higher than a typical inguinal hernia. Many sports doctors actually consider sports hernias to be more of a chronic overuse injury to the hip adductor (groin) tendons and the abdominal muscles. They are seen more in athletes who twist their core a lot - basketball, hockey, skilled position football players. Treatment for sports hernias includes rest, physical therapy, or surgery.

Dr. Jessica Flynn is a sports medicine physician at Lahey Hospital and Medical Center in Burlington, MA. She writes about injuries in professional sports on her blog, DocFlynn.com. You can follow her on Twitter @jessdeede.

Have a question for a future Dr. Flynn Mailbag? You can send those to her at any time via email (docflynn@bostonsportsjournal.com), or you can Tweet them to her here.