Dr. Flynn's Mailbag: On the possible/impossible returns of Hayward, Edelman, Hightower and turf toe

Hi everyone, hope you had a great week! I asked for a few good…or even mediocre questions this week and you all did NOT disappoint. Clearly, mediocrity is not in the BSJ vocabulary! If you didn’t contribute a question this week, I’d love to hear from you for future editions, so make sure you check out the contact information at the bottom of the page.

Quite a few Patriots questions this week: is it possible that some high-profile, early-season injuries potentially make a late-season return? And Gordon Hayward’s wife posted a photo on Instagram of him out of his boot! Is he ahead of schedule and ready to return sooner than planned? You’ll have to read to find out. But first, a question from a loyal reader about…the Chicago Cubs??

Jason Heyward has been seen out of his walking boot. Many speculate he could return to the team THIS year, is this smart? Is his injury one that would be better served with more rest and rehab or is healed? (Murph, @TMurph207)

Clearly, Murph has baseball on the brain — I think the Cubs’ right fielder Jason Heyward is happily not in a walking boot and, coincidentally, the Celtics’ Gordon Hayward is working out of his as well! (Murph’s son is a young superstar pitcher, so he’s completely immersed in red clay and knee-high socks). Hayward’s injury, a tibiotalar fracture-dislocation, generally takes 4-6 months to heal. Athletes with this injury are often bearing full weight by 6-8 weeks in a boot, walking without a boot by 3 months, and return to practice by 4-6 months. This puts Gordon Hayward right on track for a 4-6 month return to practice, somewhere around late March/early April.

Ankle fracture-dislocations are difficult to work back from, especially for basketball players. Tremendous amounts of force and torque are transmitted through the relatively small ankle joint. Often, the ankle is stiffer than prior to the injury and it can take many months to fully retrain the tiny nerves in the joint responsible for reflexive fine balance (called proprioception). While Hayward sounds to be doing a great job keeping active, even shooting from a chair a few weeks after surgery, it will take some time to get him feeling physically and mentally confident with his “new” ankle. I am hesitant to even say this because I don’t want it to be interpreted as “Gordon Hayward didn’t work hard enough to be back sooner, or Hayward isn’t physically or mentally gifted enough to be the fastest to return from an injury like this.” Everyone wants to be Adrian Peterson, they want to defy the odds and return for a record-breaking season before any athlete ever has before him or her. But sometimes that results in bad outcomes — stress fractures, other injuries. The Celtics organization has done an impressive job at managing expectations for Gordon Hayward’s return — stating many times that they do not expect him back this season. Yes, the door is open for a playoff return, but I am not expecting one. If he does come back this season, it will likely be on a significant play-count at less than 100%. And that will not be because of lack of effort, will, natural gift, physical or mental toughness. The guy’s a star. Can’t wait to see him play.

Could you apply the same level analysis to the Gordon Hayward injury as you did to Julian Edelman’s ACL injury? Is it not likely that his jumping (and perhaps cutting) ability will be affected? (Paul Solman)

Hi Paul! I have written a lot about Hayward’s injury, including an immediate video analysis on BSJ. With an ankle fracture-dislocation like his, I expect a gradual return to basketball. Ankles with this injury are very stiff and need to be slowly worked back into play. Athletes often experience minor setbacks along the way with swelling and soreness, so he will need limited minutes and recovery days at first. By next season, I anticipate that, if all goes well, Hayward should be much closer to his normal self. He will feel much more confident in his ankle and even challenging movements and jumping should be back to normal. In the long-term (10-20 years down the road), he does have an increased risk of post-traumatic arthritis in his ankle. The great news from his surgery was that there was reportedly no injury to his articular cartilage/joint surface. That makes the risk of arthritis a lot further down the road.

What is turf toe? (Brian Foley, @BFoley82)

Turf toe is an injury to the first metatarsi-phalangeal  (MTP) joint of the foot. English translation: an injury to the joint where the big toe meets the foot. Several structures stabilize that joint, including collateral ligaments on either side, the plantar plate (a thick fibrous band of tissue on the bottom of the joint which prevents it from bending up too far), the flexor hallucis brevis tendon, and two tiny bones called “sesmoids” that act like tiny kneecaps (but on the bottom of the joint). Why on earth is such a tiny joint so complex? Because it’s super important. An athlete’s ability to push-off, when starting to run or pivoting for change of direction or lunging to grab something quickly, is very dependent on the function of the big toe MTP joint. Relatively high levels of force are transferred through the tiny joint, so it needs lots of stabilizers to keep in intact.

Turf toe is an injury of the structures supporting the bottom of the first MTP joint, ranging from a slight stretch to a tear. It is common in football athletes and it’s incidence increased with the introduction of artificial turf. Synthetic surfaces are more grippy and less shock-absorbing and cleats are very flexible, leading to higher risk of toe injury.

Most cases of turf toe are treated non-operatively with rehab and rest. Occasionally surgery is required to repair a significantly unstable or chronically painful joint.

Read something suggesting Edelman could be back for the playoffs. Not sure he’s even eligible since he wasn’t on the opening day roster. But hypothetically, is there any chance he could play on say 2/4/18? (Jeremy Kay, @jeremylkay)

You’re right, Julian Edelman was placed on season-ending IR during the pre-season for an ACL tear, making him ineligible to return this season. But I’m happy to play the hypothetical game. Hypothetically, after an ACL reconstruction at the end of September, there is very little chance of a return for the randomly-chosen date of February 4, 2018 (in Minneapolis). Even if Edelman feels back to full form, the actual cells in his knee will not be. No matter how relentless the star is, the fact that he is human is hard to out-smart. Every athlete wants to get back as soon as possible and star athletes tend to want to out-do the record for fastest recovery. As athletes return sooner and sooner to play we are seeing a rise in complications from that rushed recovery — patellar stress fractures, re-tearing, swelling and pain. Even a year after ACL reconstruction, NFL athletes are not quite back to their true selves. Look at Dion Lewis, for example. After a modest return last season and early season discussion about him possibly being traded (I won’t name any names…you know who you are), he has now broken through as the shifty star running back of the team. Eighteen months after an ACL reconstruction is around the time these athletes get back to 100 percent, so it was no surprise to me that it happened for Lewis when it did.

Per the PatsCap mailbag, Hightower is eligible to return from IR on January 2nd. What is the typical recovery time for a torn pectoral muscle? Do you think it is possible for a player to return from this injury within the same season? Or is there additional time required to build back strength? Deer-antler spray? :) (Derek Bates)

The recovery time for a surgically repaired pectoralis tear is approximately 4-6 months. We will not see Dont’a Hightower back in a Patriots uniform this season. Even if the injury had occurred early in the season, Hightower would have been pressed to get back to full contact in the event of a deep post-season run. Pectoralis injuries, especially chronic ones, involve a long rehabilitation process and generally a very gradual return to full play. I do anticipate that he will be able to participate in off-season activities and will be ready for next year’s training camp.

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.

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