A look at the most significant injuries that impact fantasy football.
By Jeff Stotts, MAT, ATC, PES, CES
This article is part of our fantasy football help series.
Injuries are a fact of life in football, but fantasy owners can use injuries to their advantage, especially during drafts. Injuries and offseason surgeries often drive down the cost of elite talent, creating opportunities for middle and late-round picks to outperform their draft slots. Opportunistic owners can bolster their lineups at a discounted rate if they make informed choices on ailing or still-recovering players.
To help you make those prudent decisions, we will look at some of the most common football injuries.
The spine of the back is divided into 33 individual vertebrae. Between each vertebra sits an intervertebral disc that serves as a shock absorber for both the daily and excessive stresses applied to and through the back. Each disc is made up of a rigid, outer ring of fibrocartilage called the annulus fibrosus that surrounds a softer, semifluid center known as the nucleus pulposus. For comparison sake, imagine a jelly or cream-filled donut. The baked dough of the pastry is the annulus fibrosus while the inner filling represents the pulposus. The dough surrounds and contains the filling, preventing it from spilling out. However, if enough pressure is applied to the donut, the dough is unable to hold back the filling and its contents will eventually burst out.
An intervertebral disc acts in a similar fashion if the back is violently or repetitively compressed or twisted. Stress forces the nucleus pulposus to bulge or stick out, causing a ruptured or herniated disc. The injury is worsened when the suddenly projecting area of the disc begins to pinch on any nearby nerve. As a result, these injuries can cause pain in the lower back as well as the corresponding extremities.
Surgery to fix a herniated disc often involves a microdiscectomy procedure in which the bulging disc fragments are removed. The surgery is common in athletes but adequate time to heal is necessary, especially if there is nerve involvement.
The ankle, the most commonly sprained area in the body, is comprised of four bones forming multiple joints. The primary joint associated with the ankle is the talocrural joint that is formed from the talus of the foot and the two lower leg bones, the tibia and the fibula. The talocrural joint is fortified by ligaments situated on the outside and the inside aspects of the foot. These ligaments stabilize the foot and lower leg during lateral or side-to-side motion. The inside ligament is a triangular band of connective tissue known as the deltoid ligament, designed to help prevent excessive eversion of the foot. The deltoid ligament can be sprained but a medial ankle injury is usually accompanied by an avulsion fracture.
On the outside or lateral area of the ankle sits three ligaments, the anterior and posterior talofibular ligaments and the calcaneofibular ligament. Together they help stabilize the ankle during inversion (moving the foot inward). However this positioning makes them susceptible to injury when the foot is violently twisted or forced inward, like when a player comes down another player's foot. A sprain to the lateral ligaments is the injury that most people think of when they hear ankle sprain. Like all sprains, they occur in varying degrees of severity.
A Grade I sprain is considered minor with partial or micro tearing of the involved ligaments. Grade I sprain are considered mild and often cause a player to miss little or no action. An ankle brace or a tape job can be utilized to help support the affected area. A Grade II sprain is considered moderate and often referred to as a partial tear. The injury is often accompanied by a considerable amount of swelling and requires more intensive treatment and rest. A loss of function also occurs, limiting the range of motion at the joint.
A Grade III sprain is considered a total tear or rupture and generally result in a complete loss of function and stability. They often require a long period of rest and rehabilitation and in some cases surgical intervention.
Grade II or III sprains are particularly problematic because the biomechanical properties of the ligament have been altered. In these sprains, the ligaments have passed their yield point and their strength and integrity remains forever altered. Think of a well-used rubber band. You can't ever get that rubber band back to what it was when it was fresh out of the package. It may still do its job but it isn't quite as effective.
The injury tends to be more problematic than your garden-variety lateral sprain, as the location of the sprain makes weight-bearing more difficult, thus prolonging the recovery timeline.
In a typical ankle sprain, the ligaments on the outside or lateral portion of the ankle are overstretched and damaged. However in a "high-ankle sprain," or syndesmotic sprain," the damage is located at the distal tibiofemoral joint. Here the distal ends of the lower legs bones, the tibia and fibula, form what is referred to as the ankle mortise. Multiple thick and strong ligaments, including the interosseous ligament and the anterior and posterior tibiofibular ligaments, stabilize the junction. However, this positioning leaves them vulnerable to injury when the ankle is twisted while being forced upward. When these ligaments are sprained or in come cases completely torn, it is classified as a high-ankle sprain. Treatment for these sprains is similar to that of a normal ankle sprain but high-ankle sprains often require additional time to heal.
A bunion is a bone-related bump that can develop when the big toe deviates from the joint line. It can be particularly painful and limit function. Bunions often involve the metatarsals, and intrinsic properties of the foot can lead to their development. Broken fifth metatarsal, an injury that can also be influenced by the structure of the foot, are increasingly common. The two injuries might not be directly linked, but a variance in a player's foot could be an underlying cause of recurring problems.
Fifth Metatarsal Fracture
Also known as a Jones fracture, the fifth metatarsal is located on the outside of the foot at the base of the pinkie toe and bridges the bones of the midfoot and toes. Recovery is often complicated, and the odds of a re-fracture are high. Follow-up procedures are often necessary to repair hardware-related problems, and bone grafts are regularly utilized to reinforce the injury site, lengthening the recovery process. Broken fifth metatarsal fractures are increasingly common, especially among wide receivers.
Anterior cruciate ligament injuries are common in the NFL – with more than 200 reported the last five seasons – and the success rate of reconstruction surgery is relatively high. Recovery usually takes eight to 12 months, but while a player might be cleared to return to action within this timeframe, the graft used to repair the damage could need a full year to display the same biomechanical properties as the original ligament. Thus, ACL injuries that occur late in the season, especially traumatic ones, often carry over into the following year, negatively impacting two seasons.
Furthermore, being cleared to play and playing at a high level are two different things, and players need time to prove the knee is a non-issue. Multiple factors, including age, type of graft utilized and injury history can influence the risk of re-injury. And players who undergo ACL surgery are more likely to develop osteoarthritis, a major concern for a player with both knees at risk.
The medial collateral ligament is one of the collateral ligaments of the knee, located on the inside aspect of the joint. It attaches to the medial meniscus and aids in stabilization during lateral or side-to-side movement.
If the sustained damage is minimal and limited to micro tearing of the MCL, the sprain is considered mild or a Grade 1 sprain. If the MCL partially tears, it's assigned a Grade 2 designation. A complete tear is considered severe and is referred to as a Grade 3 sprain.
It can heal without surgery, especially if the meniscus remains unscathed. However, if there is a tear to one of the menisci, the knee's shock-absorbers, the damaged cartilage tissue can be removed or repaired. A removal, or meniscectomy, is significantly more common, as the tear must occur in a very specific location to undergo a true repair. A meniscectomy allows for a quick return but increases the long-term risk of conditions like osteoarthritis.
When the meniscus is damaged the surgeon normally has two options: removal or repair. A removal, or meniscectomy, is the more common of the two procedures and has shorter recovery timeline. Following a meniscectomy, an athlete can usually return to activity within six weeks. Because the cartilage is removed, a meniscectomy can increase the risk for long-term issues like osteoarthritis and other complications including cysts.
A true meniscus repair is only an option if the tear is a specific type and in a certain location of the disc. Repairs are believed to have better long-term results than a partial or full meniscectomy. However, this security is accompanied by a much lengthier recovery, often three to six months.
Unfortunately, most meniscus surgeries are reported as a repair regardless of the surgical option performed. As a result, it's best to consider the estimated timeline provided by the team and not the medical terminology. If recovery following a meniscus surgery is measured in weeks and not months than it is likely the injured individual underwent a removal.
Patellar Tendon Tear
The patellar tendon attaches the quadriceps muscle group to the tibia and is responsible for straightening the leg and bending at the hip. The kneecap is embedded within the tendon, meaning this injury directly impacts the biomechanics of the knee. The injury has been historically problematic for wide receivers and cornerbacks, as these positions demand that players smoothly backpedal and make sudden starts and stops. As a result, patellar tendon ruptures have often been career-altering, impacting wide receivers like Mark Clayton and Victor Cruz.
The posterior cruciate ligament is the lesser known of the two cruciate ligaments. The PCL sits behind the ACL and acts as the central axis for knee rotation. Fortunately, the PCL is stronger than the ACL and is more difficult to tear on its own. If a player's injured knee does not responding well to treatment, surgery is used to fix the partial tear. Usually, isolated PCL injuries aren't quite as problematic.
Core Muscle Strain (Groin)
These types of injuries generally happen when repetitive forces normally directed through the body's midsection are rerouted into the groin and abdominal muscles. The transmitted force can then cause tiny muscle tears that leave the abdominal wall vulnerable to a hernia. Renowned surgeon Dr. William Meyers did extensive work in diagnosing and differentiating the various injuries in this area and was the first to move away from the term "sports hernia." Dr. Meyers, who has operated on countless NFL players, including Marshawn Lynch, Adrian Peterson and Arian Foster, prefers the term "core muscle injury" due to the high variety of issues that can occur in the area. The success rate of these procedures is exceptionally good, with players frequently returning to their previous level.
The fibula is the smaller of the two lower leg bones, extending from the outside aspect of the knee to the ankle, and does not bear as much weight as the tibia. The positioning of the fibula leaves it susceptible to fractures, especially when the ankle is violently forced a specific direction. The fibula acts as an anchor point for various ligaments of the ankle, including those that stabilize the area between the tibia and the fibula. A fracture is generally fixed using a surgical plate and screws. Like most bone injuries, recovery for a fibula fracture is dependent on multiple factors including mechanism of injury, the type of break, any other additional structures damaged and the necessary form of treatment.
Recovery time is also dictated by the amount of ligament damage involved. The distal end of the fibula is an anchor point for multiple ligaments of the ankle, including those that stabilize the syndesmosis of the ankle. The syndesmosis is the area of the ankle where the distal ends of the tibia and the fibula are united by connective tissue and is the area of the ankle injured in a "high" ankle sprain. Syndesmotic injuries often occur in conjunction with fibula fractures as the force of the injury breaks and displaces the bone, tearing the ligaments in the process. Surgery will involve an internal fixation using a plate and screws to help return the syndesmosis to its natural position.
The hamstring isn't a passive muscle or even a limited secondary synergist. It's a dynamic muscle group responsible for providing major movement at not one, but two different joints. The three hamstring muscles work to bend the knee (knee flexion) and straighten the hip (hip extension). The hamstring is the antagonist to the quadriceps muscle group, working in an opposite manner to the major muscle group on the flipside of the thigh. This complex relationship allows the two groups to accelerate and decelerate the knee. Given the sheer power and force generated between the two, it's not surprising that the hamstring remains vulnerable to strains.
Once a strain to the area has occurred, an intricate, multiphase healing process is initiated. Each phase is delicate, but it's the final few phases that often prove to be problematic for an injured athlete. As the initial inflammation phase begins to subside, tissue repair begins. Scar tissue, made up of complex proteins fibers like collagen and elastin, begins to develop at the injury site. This phase, known as the proliferative phase, often takes four to six weeks depending on the severity of the strain.
It's during this time that the final phase, known as the remodeling phase, starts. Collagen fibers within the scar tissue are repeatedly broken down and remade to increase strength by properly aligning the injured muscle fibers to resemble healthy tissue. Unfortunately, the body does this in a random fashion, creating scar tissue that may feel and appear healthy but does not possess the same strength as the preinjured muscle.
Athletic trainers or physical therapists can fight this predisposition by loading the injured muscle in a precise pattern during the rehab process. Still, newly formed tissue remains susceptible to reinjury, sometimes for as long as a year. This is a primary factor of why players may often experience recurrent hamstring injuries over a significant period. As a result, patience is key to ensure that the proper amount of healing has been carried out to allow the muscle to withstand the rigors of football.
The hip is a ball-and-socket joint with a labrum ring for added stability. It can tear in a variety of ways, compromising the integrity of the joint. A hip pointer occurs when an athlete has suffers a contusion to the crest of the ilium, one of the three bones that form the hip. Your iliac crest is what you rest your hands on when you place your hands on your hips. The injury itself can be extremely painful with trunk rotation as well as other activities including breathing, laughing and coughing. Nerve involvement with a specific nerve that runs along the iliac crest is the primary reason hip pointers elicit so much pain. To further complicate things, the hip flexor muscles attach along the iliac crest and are often injured as well.
The shoulder complex is comprised of four individual articulations. The sternoclavicular (SC) joint is the only connection between the arm and the trunk of the body and is located where the clavicle (collarbone) joins the manubrium of the sternum (breastbone). The collarbone continues along the shoulder until it meets the acromion of the shoulder blade, forming the acromioclavicular (AC) joint. Here the collarbone serves as a strut for the shoulder, creating a pivot point that allows for a high degree of motion.
If the fracture is an isolated injury then the nature of the break comes into play. If the bone did not shift and remains non-displaced, the play should avoid surgery and would simply need to let the bone heal. If a significant displacement occurs, a pin would likely be inserted to insure proper healing. This type of injury would require a longer recovery window.
The league's concussion protocol is broken down into five steps. For the most part, the steps are completed on a day-to-day progression, though players have advanced through multiple steps in single day.
Step One is the Rest and Recovery phase. To progress to step two, the injured athlete must be symptom-free while at rest and have the scores of advanced neurocognitive testing return to their individualized preseason baseline status. This test, known as ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is first carried out by each NFL player prior to the start of the season. The test is a computer-based program and analyzes the player's neurocognitive function by challenging their ability to correctly perform various tasks including shape and color recognition, delayed memory recall and matching. ImPACT testing allows for each player to be properly screened, an important step for an injury with a wide range of signs and symptoms.
Step Two is the introduction of Light Aerobic Exercise. Once symptom-free, the player can begin cardiovascular exercise under the supervision of a member of the team's medical staff. Other activities like balance training and dynamic stretching may be performed. If at any time the individual's symptoms return, the step stalls and the previous step restarts.
Step Three is "Continued Aerobic Exercise and Introduction of Strength Training." Players who reach this level may begin low level sports-specific exercises and incorporate strength training into their routine.
Step Four integrates Football Specific Activities into the previous step, although the drills must remain noncontact. Once the player is able to complete the first four steps without displaying any concussion-related symptoms, he enters the final step needed to return to play.
In Step Five, Full Football Activity/Clearance, a team physician followed by an independent neurologist will examine the player. The player can finally return to the team's next football-related activity if the Independent Neurological Consultant (INC) signs off on his health and determines the protocol has been properly completed.
The labrum is a fibrocartilaginous ring that helps fortify the shoulder's ball-and-socket joint by increasing the surface area of the socket, preventing excessive movement of the shoulder blade. The labrum can tear from an isolated incident or gradually with repetitive motion. It is a painful injury that diminishes shoulder stability. Fortunately, the success rate of labral repairs is high, and multiple quarterbacks, including Drew Brees, have bounced back nicely following the procedure. The typical recovery timeline is four to six months,
Rotator Cuff Tear
The rotator cuff is a group of muscles that work to complete dynamic movement of the shoulder while providing additional stability. They are vulnerable to injury, especially with repetitive overhead throwing. Studies show that arm strength post-surgery can remain diminished for up to a year. The precedent set by quarterbacks coming off rotator cuff surgery is discouraging, though Jay Fiedler and Tim Couch weren't exactly in the primes of their careers when they had surgery.
Shoulder Separation (AC Sprain)
A separated shoulder is simply a sprain of the ligaments of the AC joint. The severity of an AC sprain is assigned a grade based on the amount of damage to the involved ligaments and any other supporting structures. A Grade 1 sprain is considered mild and is marked by overstretching and microtearing of the ligaments. A Grade 2 sprain involves a tear of the AC ligament but minimal damage to the CC ligament and is often referred to as a moderate sprain. Injuries that receive a Grade 3 or higher are considered severe and are marked by a rupture of the stabilizing ligaments and an upward shift of the collarbone. These injuries generally include additional damage to the surrounding muscles and often require surgery.