The Dynasty Doctor

Scott Peak Posted On August 24, 2013

doctor

Editor’s Note: Dr. Scott Peak is an ABPN board certified neurologist and neuro-oncologist. He is also a dynasty football addict and huge friend of Dynasty League Football. He’s excited to lend his expertise in medicine with hopes he may help the DLF Team and its followers better understand medical conditions and injuries that may impact NFL players and dynasty football owners. If you have a question for The Dynasty Doctor, just click here. Please remember The Dynasty Doctor is geared towards questions regarding medical science, injuries to players and their collective impact in fantasy football.

We asked him to make a special house call to describe the recent injuries and here’s what he had to say.

After the last installment of the Dynasty Doctor, we had two requests for a review on Le’Veon Bell and his mid-foot sprain. We will also discuss injuries to Randall Cobb and Arian Foster.

In the first start of Bell’s NFL career, he unfortunately sustained a mid-foot sprain against Washington and his inauspicious debut was capped at four carries for nine yards. Widespread panic ensued as dynasty owners hoping for a glimpse of his talents were instead left to worry how long he would be out. Since that time, reports have varied from a mild mid-foot sprain to a Lisfranc injury. I previously reviewed Lisfranc sprains, and I would recommend giving it a read here.

The Lisfranc ligament is important for stabilizing the first toe, and it connects the cuneiform bone to the second metatarsal bone (see figure 4 here). The ligament can be stretched or torn when a foot plants in the turf and a tackler lands on the back of it (see figure 5 here). The first toe is pushed into the ground and the force of impact can stretch or tear the Lisfranc ligament. The end result is an unstable first toe joint, and severe pain can result if pressure is placed on the foot.

Given Bell will not require surgery, this could be consistent with a stage 1 Lisfranc sprain. A stage 1 Lisfranc sprain is the least severe form of this injury, so that is good news. The ligament is not torn, but rather stretched, resulting in pain but no need for surgical correction. The treatment is immobilization with a boot to take pressure off the foot, and prevent worsening of the injury. It is possible that a stage 1 Lisfranc could become a stage 2 or 3 injury if immobilization is not used. In fact, x-rays are typically taken a few weeks after a stage 1 injury to make sure bones have not moved in a way typical of a more severe injury.

Outcomes for a stage 1 Lisfranc sprain are generally good. He would likely need at least six weeks to recover from this injury, and that is the most optimistic estimate. In the literature, there are stage 1 Lisfranc sprains in athletes that required three months or longer to return to sports. These injuries are unpredictable and resolution of pain with normal imaging of the foot are necessary before a return to play is generally allowed. The time it takes for this to happen can be variable. Hopefully Bell will return in six weeks, but that is not guaranteed. Literature supports excellent long-term outcomes for patients with stage 1 Lisfranc sprains diagnosed quickly and treated appropriately, so Bell’s value in dynasty should not be adversely impacted.

If Bell’s injury is a mild mid-foot sprain, a ligament other than the Lisfranc may have been stretched. Recovery from a mild mid-foot sprain can be two to six weeks, and more recent reports are now classifying his injury as ‘up to six weeks.’ In short, either nobody knows for sure, or Pittsburgh isn’t in a sharing mood. Notably, despite recent good news, neither head coach Mike Tomlin or Bell will say how long this injury will keep him out. If you recall the past two years, owners of Maurice Jones-Drew and Darren McFadden were told neither player had a Lisfranc sprain, and were ‘week to week.’ Dynasty owners were left hanging, since they couldn’t cut, trade or play McFadden or Jones-Drew. Heck, they couldn’t even put them on IR. Hopefully, Bell won’t repeat this cycle of frustration, but we will have to see how this plays out. Bottom line, the most optimistic estimate is that Bell will be out two to six weeks with a mild mid-foot sprain. I am still skeptical on the true nature of his injury, based on vague reports released in the media that seem to be constantly changing. One thing is for sure, Bell doesn’t need surgery right now, so that is good news. Whether he will be back in six weeks or less remains to be seen, and I remain skeptical until I see Bell on the practice field again. I am a buyer in dynasty leagues if you can get him at a discount.

There has been some consternation about Randall Cobb and Arian Foster, so I thought I would comment a bit on both now. We also discussed Cobb and Foster on the DLF Dynasty Podcast August 21, 2013.

Randall Cobb sustained a biceps injury to his right arm. The available information is vague and the specific nature of the injury remains a mystery. While speculating about injuries can be a gamble, it is necessary when NFL teams withhold injury details. As dynasty owners, we need to use available information to make an informed decision. The injury for Cobb has been described as on his right bicep, it is painful, he can play with it, but it may bother him all year. This sounds a lot like either biceps tendonitis or a torn biceps tendon. The biceps muscle has tendinous attachments at the shoulder and elbow. Biceps tendons at the shoulder have two separate attachments, a long and a short head. Here is an excellent diagram as a reference.

Tendonitis is inflammation in a tendon that can result in pain, and is usually caused by overuse or anatomical impingement. Treatment is initially with conservative measures, such as anti-inflammatory medication, steroid injections and physical therapy. Conservative treatment for biceps tendonitis is tried for three months, but if it fails, surgery is usually the next step.

The long head of the biceps can be torn, either from overuse or when an athlete uses their hands/arms to brace themselves from a fall. The short head is not commonly torn. As a result, even though the long head of the biceps tendon may be partially or completely torn, the short head enables the biceps muscle to work. There can be weakness, and this is expected given the long head is torn. The extent of weakness is a 15 to 20% reduction in strength with flexion of the forearm and supination (rotating the hand/forearm up, as if holding a bowl of soup).¹ If surgery were done, recovery would take three to six months, and that would likely be season-ending. Pain can be persistent, but may improve in three to six weeks. Cobb may have to deal with pain all year long and weakness in his right biceps. It is also noteworthy that a tear may be partial or complete. A partial tendon tear might actually be more painful, whereas a complete rupture resolves pain faster. That might sound weird, but the irritating focus is no longer present. If a tendon is partially torn, when the biceps pulls on it, that produces pain. If conservative measures fail, surgery is done. Surgery can be done after a trial of conservative treatment for 3 to 6 months, so it makes sense that Cobb is going to try playing with his injury. The likelihood of him rupturing the short head of the biceps tendon is low, and the main question will be whether he can play with pain and weakness in his right biceps or not. Time will tell. I do not think this injury will significantly impact Cobb’s long-term value in dynasty, but it could be a nagging issue for 2013. Cobb is a buy-low in dynasty leagues, and if you can get him cheap send out those offers.

Arian Foster reportedly had an epidural injection to treat back pain, and this has been a source of concern for his dynasty owners. Foster’s workload in 2012 has been well-documented, as has a decline in YPC and receptions every year since his dominant 2010 season. Naturally, back pain in any such player will create angst for dynasty players. Foster received epidural injections for back pain that spread into his legs. Radiculopathy is the medical term for back pain that spreads into the lower extremities. Radiculopathy occurs when a nerve is being compressed as it exits the spinal column. Nerves provide both movement and sensation to specific levels of the body, and if irritated, pain will be perceived along the path of the nerve. For example, if an elbow bangs against a wall, pain spreads down the forearm and hand. In Foster’s case, something is pressing on a nerve, resulting in pain spreading down his legs. A disc herniation, narrowing in the spinal canal (stenosis) or degenerative changes can be culprits for this type of pain. Treatment is typically conservative with rest, physical therapy to strengthen muscles that stabilize the spine (paraspinous muscles), and anti-inflammatory medications. If that fails, then epidural injections may be used. Epidural injections are placed by anesthesiologists or rehabilitation doctors. A needle is used to inject numbing medicine and/or steroids nearby the affected nerve, with hopes to reduce pain and inflammation, thereby accelerating recovery. Improvement of pain can occur in 50% or more of patients treated with epidural injections for back pain, but the result may be short-lived. American Academy of Neurology published guidelines on usage of epidural injections to treat back pain, and pain control lasted about three months. Epidural injections had no impact on need for surgery. The guidelines can be found here. Up to three epidural injections may be used in a year to manage back pain. There are retrospective studies that report 89% of NFL athletes with lumbar disc herniations and back pain, when treated with epidural injections, returned to play for an average of 2.8 seasons. NFL athletes in this study missed an average of 0.6 games (range 0 to 2).¹ There are, however, a lack of high-quality studies on this topic. Still, these results give dynasty players reason for optimism in Foster’s ability to play 2013 and beyond.

Foster reportedly did have pain after his epidural injections and this can occur if localized bleeding or pressure from the injected pain medication irritates the nerve. Longstanding nerve injury from an epidural injection is rare. Foster’s ability to return to play will depend on whether his pain is controlled. Weakness resulting from disc herniations is reported, as occurred with Peyton Manning. Still, pain is usually the most pressing issue. If Foster can tolerate the pain, he could return to play with it. Surgery in the future may be necessary if his pain is not controlled with conservative measures. NFL players with lumbar disc herniations have returned to play, such as Rob Gronkowksi, and it is possible Foster may be able to play with this condition. Foster’s long-term dynasty value is relatively intact, but caution should be applied by dynasty owners given Foster’s workload and unpredictability of back pain flaring up.

References:

Hsu SH, Miller SL and Curtis AS. Long Head of Biceps Tendon Pathology: Management Alternatives. Clin Sports Med. 2008;27:747-762.
Krych AJ, Richman D, Drakos M, et al. Epidural Steroid Injection for Lumbar Disc Herniation in NFL Athletes. Med Sci Sports Exerc. 2012;44(2):193-198.