Peyton Manning’s Plantar Fascia Tear…Is this the End?

Fantasy Football Injury of the Week:  Peyton Manning and his Plantar Fascia

Yesterday we learned that Peyton Manning has a tear in his plantar fascia and will miss at least this week’s game against Chicago.  The fantasy implications of Manning missing time might be minimal (Manning is ranked 30th in my leagues this year for QBs), but as a Denver resident and Broncos fan, this is some serious news.

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This week I want to focus on what exactly is a tear of the plantar fascia, what can be done to treat it, and will Manning play again this season or ever again?

What is the plantar fascia and why is a tear career threatening?

The plantar fascia is a thick band of connective tissue that supports the arch of the foot. In the physical therapy clinic, we most commonly see an acute inflammation or micro-tearing of the fascia near the heel bone, known as plantar fasciitis.  We also see very chronic cases in which there is a buildup of scar tissue at the same location from repetitive micro-tearing followed by healing.  Plantar fascia injuries are one of the more common diagnoses that we see in PT but also one of the hardest to treat, especially the chronic cases.  Even though this band is thick and tough, it’s job is to maintain your arch while supporting all of your body weight.  When the plantar fascia becomes irritated, inflamed or weakened by chronic injury, every step can be painfully perpetuating the injury.

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Manning’s situation is much more severe than the common plantar fasciitis diagnosis we see at Therapydia.  In his case, he has sustained a partial rupture or larger tearing of the plantar fascia.  For any of you who have experienced the pain of plantar fasciitis yourself, that pain is magnified significantly with a partial rupture.  Imagine having a cut on the knuckle of your finger.  Every time you use or bend that finger, the cut painfully reopens and the healing has to start over.  The finger is easy to keep from moving, just buddy tape it or use a splint from the drugstore to keep it from bending.  The foot on the other hand is very difficult to immobilize so the time it takes to heal can be painfully long…..and therein lies the major problem with Peyton Manning’s foot issue.  Will there be enough time for him to return and be effective this year or will this be the end of Manning’s illustrious career?

When will Manning be back and is there anything that can be done to speed up his return?  

Unfortunately, I am not privy to all the details about Manning’s injury.  I can only speculate on what I’ve read or seen on Sportscenter.  The typical time frame for a non-operative recovery of a partial tear of most soft tissue injuries is 12 weeks or more.  This is when we often consider the injured tissue to be back to or near full strength.  However, at 4-6 weeks, the injury could be 80% healed which may be sufficient enough to allow an athlete to return to their sport.  Returning too early though can increase the likelihood of reinjury or lead to another serious problem.  See Arian Foster.

Manning has a few options that may get him back on the field quickly.  Platelet rich plasma (PRP) injections are being used more often these days to speed up the healing process.  Injecting the injured tissue with PRP provides an instant proliferation of growth factors that can quickly stimulate healing. Tenex is a minimally invasive procedure that removes the damaged or injured tissue, allowing the healthy tissue to regenerate and thrive.  Finally, Manning and his doctors may decide to do a plantar fascia release or surgical cutting of the the partially torn fascia.  By fully releasing the partially torn section of the plantar fascia, tension is released and inflamed nerve endings are no longer sending painful signals to the brain.  However, the long term risk factors of this procedure are much greater than other options including nerve damage, instability in the joint of the feet, loss of normal biomechanics of foot and ankle.  The expected recovery from these procedures is 3-6 weeks versus the 8-12 weeks or more of conservative treatment.

Again, I have very limited information on the severity of Manning’s plantar fascia injury.  He is also dealing with injuries to his throwing shoulder and ribs.  As the Denver Post points out, there are also a number of scenarios that could occur in the next several weeks that impact Manning’s return.  Nonetheless, we are here to predict when or if Manning returns from his plantar fascia tear, so here it is….

Prediction: Peyton Manning misses 4 games.  The tear is either mild enough to return in four weeks or he undergoes a minimally invasive treatment that allows him to return for an important Week 15 matchup against the Pittsburgh Steelers.  

Arian Foster, Achilles Tendon Rupture

Arian Foster, Houston Texans Running Back

Arian Foster is reported to have sustained an achilles tendon rupture in the Texans’ 44 to 26 loss to the Miami Dolphins on Sunday (video of injury here).  It has already been announced that Foster will miss the remainder of the season.  The real questions is if he will ever return to playing in the NFL and if so, at what level.  When healthy, Foster is a fantasy football team owner’s dream.  If you are playing in a keeper league,  given his past numbers and high fantasy draft stock, it is quite possible that he is on you our your opponent’s team for years to come.  

How severe is Arian Foster’s injury?

Achilles tendon injuries are classified from Grade I to Grade III.  Foster is reported to have sustained a grade III strain, also known as a complete rupture.  More information about the grading system below:

AchilleTendon-Injury-LG

Grade I: Mild strain, disruption of a few fibers. Mild to moderate pain, tenderness, swelling, stiffness. Expected to heal normally with conservative management.

Grade II: Moderate strain, disruption of several fibers. Moderate pain, swelling, difficulty walking normally. Expected to heal normally with conservative management.

Grade III: Complete rupture, often characterized by a “pop,” immediate pain, inability to bear weight. Typically requires surgery to repair.

©http://www.moveforwardpt.com/

What is next for Foster?

Foster will likely undergo a surgical procedure to repair his achilles tendon within the next week or so.  Immediately following the surgery he will be in a cast and using crutches to avoid putting any weight on the operative limb for 2-4 weeks.  After that he will be wearing a walking boot and slowly increasing the amount of weight he is putting through his leg during walking activities.  He will likely go through a therapy protocol lasting roughly 6 months before he is able to resume athletic activities (sample rehab protocol here).  

His rehab will include pain and swelling management using modalities such as the Gameready ice machine.  He will also likely undergo hands-on therapy including joint mobilization and trigger point dry needling to decrease pain and increase mobility.  His exercise program will be geared towards strengthening and stabilization of his core and entire lower extremity to decrease the likelihood that he will suffer another season-ending injury.  Proprioceptive training is extremely important in recovering from and protecting against injury.  Here’s an example of a proprioceptive training progression:

 

Will Arian Foster ever be the same?

Possibly.  A study published in 2009 investigated achilles tendon ruptures in the NFL and their impact on player performance.  The researchers found that on average, players experienced a greater than 50% decrease in power ratings following an achilles tendon rupture.  Furthermore, roughly 32% of players that sustained an achilles tendon rupture never returned to play in the NFL.  

Given recent data on achilles tendon ruptures and Foster’s explosive style of play, The Therapydia PTs feel that if Foster was your first pick in a keeper league, it may be time to look for a different league.  
Prediction: Arian Foster returns next season as a much less productive back, if he returns at all.  

Will Blake Bortles miss Week 6 with an AC Sprain?

Fantasy Football Injury of the Week:  How bad is Blake Bortles Grade I AC Sprain?

Blake Bortles has not typically been on the radar of many fantasy players since he joined the league in 2014.  However in 2015 he has had a sneaky good start to the season despite Jacksonville’s 1-4 record.  In my Yahoo league, he is currently the 7th best QB.  He has better numbers this year than our very own Peyton Manning (by a longshot) and fantasy studs like Drew Brees and Matt Ryan.

Unfortunately, Bortles may suffer a bit of a setback if he is forced to miss Week 6 against Houston.  Bortles suffered a Grade/Type 1 acromioclavicular (AC) joint sprain of his throwing shoulder at some point during Jacksonville’s week 5 loss to the Buccaneers.  Anytime a quarterback sustains an injury to the throwing shoulder it can be a scary situation.  Fortunately for Bortles, a grade one AC sprain leaves us optimistic that he will be able to play this week and here’s why.

What’s the difference between Grade 1, 2, and 3 AC Sprains?

An AC sprain is typically graded in its severity from a one to a three.  It easy to visualize the severity of an AC sprain in the graphic below:

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A grade/type 1 sprain is mild or partial injury to the joint ligaments or capsule.  In this grade there is a slight tear or sprain of the acromioclavicular ligament.  This ligament helps to stabilize the AC joint and ultimately the shoulder itself.  Bortles likely will rest the shoulder this week and participate in physical therapy everyday to retain his range of motion, strength, and help control the pain with modalities like the Gameready ice machine:

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A grade/type 2 sprain is a more significant tear of the acromioclavicular ligament as well the ligament below the clavicle called the coracoclavicular ligament.  

A grade/type 3 sprain is a severe injury to the shoulder.  In this situation, both acromioclavicular and coracoclavicular ligaments are completely torn.  The shoulder is very unstable and an athlete will often choose to have surgery to stabilize the joint by placing a screw or looped suture into the collar bone to anchor it back down.  This grade of injury will mean the player misses weeks or months of their sport.

So What’s the Prognosis?

Fortunately for Bortles he has been diagnosed with the most mild form of an AC sprain, a grade one.  Early in the week his shoulder probably felt sore and a little weak or unstable  He may have had some difficulty reaching overhead or across his body and lifting activities might have been uncomfortable.  Kinesiotaping can be helpful in giving stability and pain relief during this phase of recovery.

 

With daily physical therapy rehab, Bortles’ symptoms will likely improve significantly or resolve completely by Sunday.  

Prediction: Blake Bortles is able to play in Week 6 against Houston

 

Injury Revisited: Dez Bryant, Jones Fracture

With no high-profile injuries to players at skilled positions this week, we bring you an update on the status and likely return to play for Dallas Cowboys wide receiver Dez Bryant.  Dez suffered a right 5th metatarsal fracture, commonly referred to as a Jones fracture, during the Cowboys’ week 1 win over the New York Giants (video and more information here).

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Jones fracture (not Dez Bryant’s)

The base of the 5th metatarsal can be a particularly difficult bone to heal.  This is due to the area’s poor blood supply as well as the huge amount of force transmitted through the area, especially with running, jumping and cutting.  The day after the injury he underwent a surgical procedure that was reported to include internal fixation with hardware as well as a bone graft.  Given current surgical procedures, the graft was most likely a marrow aspirate with demineralized bone matrix injected at the fracture site.  This is essentially used to speed up healing and increase the likelihood that the fracture with heal completely.  In most cases, a bone graft is used when a fracture has been recurrent or chronic in nature.  However, it is very likely that they are treating this as aggressively as possible to allow for the quickest return to play possible. 

 

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Jones Fracture Repair (Not Dez Bryant’s)

A recently published study followed 25 NFL players from their surgery through return to play.  The study found that 100% of players returned to full participation and 12% of them ultimately refractured their 5th metatarsal and required a revision surgery.  The time from surgery to return to play was between 6 and 14 weeks, with the average being 8.7 weeks.  

Dez is undoubtedly receiving excellent care as he rehabilitates this injury.  He is likely undergoing joint mobilization, stretching, strengthening, stability and balance training and quite possibly trigger point dry needling in an effort to regain range of motion and full function.  

Given recent data on Jones fractures amongst NFL players, along with the demands put on the foot of a wide receiver such as Dez Bryant,  The Therapydia PTs believe this will be a fairly lengthy recovery.  

Prediction: Dez Bryant misses just over 10 weeks and returns to face the Carolina Panthers on Thursday, November 26th.  

 

Hamstring Strains for Lynch and McCoy (9-28-15 Fantasy Football Injury of the Week)

 

This week we saw two key running backs leave the game early with hamstring strains.  Marshawn Lynch left the game at halftime and never returned.  The diagnosis at this time is a mild hamstring strain after an MRI was performed yesterday.  Typically you get a little more detail from these MRIs but the news has been vague and sparse.  What is interesting about Lynch’s injury is that he entered week 3 questionable to play with a calf strain.   As physical therapists that work in sports medicine rehab, it is not uncommon for us to see this type of situation where one injury quickly leads to another if an athlete tries to return to their sport too quickly.  In this case, a calf strain followed by a hamstring strain is not surprising in the least, especially for a powerful runner like Lynch.  The calf muscle (gastrocnemius and soleus) primarily acts to point the foot downward like in a heel raise A woman running in her bright colored shoes showing off her calf musclestype exercise or pushing off when running.  However, it also assists the hamstrings in bending the knee (flexion).  It makes sense that if you strain the calf muscle and it’s not contributing as much to knee flexion, then your hamstrings (the primary knee flexor) may take on the extra load and potentially lead to injury.

LeSean McCoy also left last Sunday’s game with a hamstring strain.  Unfortunately, this is the second time he has strained his hamstring since training camp.  The fact that he has now had two significant injuries to the same hamstring likely means he is going to miss some extra time.  This time around, if he doesn’t allow for adequate rest to allow the muscle to heal completely, this could be a lingering problem for the entire season.

Knowing the severity of these injuries would be helpful in determining how much time will be missed but unfortunately it is difficult to find this information.  We are going to speculate that Lynch has a Grade 1 hamstring strain and McCoy is dealing with a strain closer to a Grade 2 since this is the second time it has happened.  The image below gives a good visual of the difference between a Grade 1 vs a Grade 2 hamstring strain.

blood cell types

blood cell types

If you ever wondered what the rehab looked like for a hamstring strain, here is an excellent video of a typical exercise protocol starting from very basic strengthening exercises and progressing over time to sport specific drills.  At Therapydia Denver, Josh and I would also incorporate various type of hands on manual therapy including myofascial release, trigger point dry needling, stretching, and joint mobilizations as needed.

Prediction: LeSean McCoy misses weeks 4 and 5.  Returns week 6 against Bengals

Prediction: Marshawn Lynch misses week 4.  Returns week 5 against Bengals

Prevent Winter Sports Injuries With FMS and Never Miss a Powder Day

FMS denver

One of the main reasons so many people who love to ski, snowshoe and ice skate move to Colorado is for our amazing winters. These winter sports are thrilling, relaxing and everything in between, but lower body muscle weakness, balance issues on slippery surfaces and poor flexibility can cause injuries and most commonly we tend to see a significant number of knee and shoulder injuries. Treatment for these injuries tends to be costly both from a financial and time perspective. It is not unusual for someone to miss the entire winter sports season from one injury, but these injuries can be prevented. The Functional Movement Screen (FMS) can help those who are at risk of injury know what their weaknesses are to improve them.

Functional Movement Screen 101

FMS was developed in 1995 by physical therapist Gray Cook and his colleague Dr Lee Burton, a certified athletic trainer with a doctorate in health performance and wellness. The screen looks at 7 integral human movement patterns to identify dysfunctions or imbalances between right and left side of the body. Weakness, asymmetry and limited flexibility of muscles are common sources of musculoskeletal injury. Each of these seven movements are graded on a 0-3 scale with 0 indicating pain during the movement and 3 being a normal/non-dysfunctional movement pattern. The highest score you can get is 21, and the key benchmark is 14. Some examples of the movements are shown below.

FMS Therapydia Denver functional movement screen denver  

14 or Below Scorers Are 50% More Likely To Be Injured

Several studies have shown that if a person scores 14 or lower, they have a 50% higher chance of suffering an injury. One study looked at 38 female collegiate athletes at the start of their fall or winter sport and found that 69% of the athletes that scored 14 or less suffered an injury during the season. A 2nd study looked at an entire professional football team and again 14 was the magic number that indicated who was most likely to get injured during their season. The likelihood increased from a pre-test probability of injury of 15% to just over 50% when the player scored 14 or less .

Taking Action Based On Your FMS Results

A big reason why we like to use the FMS is because they have a software program that let’s us tailor a specific home exercise program that is individualized to you based on your specific score and movement dysfunctions. You will be emailed directly with your results along with descriptive pictures and videos of each exercise.

FMS results

Most FMS clients make a one-on-one physical therapy appointment to review the exercises and address any pain or dysfunction that was encountered during the FMS. Our PTs use the information from FMS, along with a PT evaluation, to create a custom workout that is specific to your winter sport. Schedule your FMS appointment today to stop injuries before they can happen!