Many decisions in Sports Medicine boil down to one simple assessment: risk versus reward.
Aaron Rodgers' case is no different.
Rodgers went down with a broken collarbone Nov. 4 against the Chicago Bears. Since that night, despite wild speculation and countless rumors, only one group has really had a clue as to when he may return.
Physicians—in both sports and elsewhere—place tremendous value on risk-versus-benefit evaluations with almost every decision they make in patient care.
For Rodgers, the degree of bone-healing may reign supreme over all else—even important markers such as arm strength, range of motion and pain tolerance.
If Rodgers should return to the field before his collarbone fully heals, a second hit similar to the one that originally caused the injury could prove devastating—for both the rest of 2013 and potentially well beyond.
Let's take a closer look, courtesy of ESPN's Monday Night Football via @gifdsports.
When Bears lineman Shea McClellin planted the Packers' signal-caller onto his left shoulder back in Week 9, the combined force of McClellin's weight and the ground sent a gigantic amount of stress through Rodgers' shoulder. The blow overwhelmed his collarbone, causing a fracture.
Fortunately, Rodgers landed in such a way that the collarbone likely only minimally fractured—as the absence of a surgery implies.
In other words, the break is probably non-displaced.
For a better mental picture of a non-displaced fracture, picture a drinking straw. Now, bend it and restraighten it. The overall shape of the straw remains the same, but an obvious deformity exists at the site of the bend.
On the other hand, a displaced fracture more closely resembles a snapped toothpick. The toothpick is both broken and grossly distorted.
A non-displaced fracture will heal with rest and immobilization. Over time, the body reattaches the fracture in its proper alignment—takes the crease out of the straw, so to speak—and it's good as new.
The toothpick is a different story.
Frequently, a displaced fracture requires surgery for proper healing. If an orthopedic surgeon does not manually manipulate the broken bone back into place and secure it with metal hardware while it heals, a player runs the risk of two feared complications: malunion or nonunion.
Malunion means a bone heals together at an improper angle or some other abnormal alignment. Nonunion describes a bone that does not come together at all.
Why does this matter to Rodgers?
About four-and-a-half weeks post-injury, the superstar's collarbone is well into the healing process—but likely not yet near completion.
During the first week after a fracture, inflammatory cells group at the fracture site and clear the way for the body to lay new bone.
Two to three weeks out, a cartilaginous callus encompasses the break, laying the groundwork for the bone-to-bone connection. However, a callus is quite weak compared to healthy bone.
Over the next few weeks, the callus begins to harden and solidify, and the bone reaches clinical stability after an average of six to eight weeks. The exact time frame depends on the extent of the fracture, the specific bone involved and the player's innate healing ability.
Until the bone reaches that stability, however, it remains at higher risk of reinjury.
According to ESPN Milwaukee's Jason Wilde, doctors used CT scans earlier this week to gauge just where in the healing process Rodgers sits. Unfortunately, it might not be far enough:
According to Rodgers, there are three components to him being cleared to play—and the scan didn’t show what he’d hoped it would.
“There were three parts to it: The strength, the range of motion and the evidence that we see on the scan,” Rodgers said. “Two out of three are passed so far."
Wilde further explains that the quarterback practiced this week. Nevertheless, the decision to return to play is not an exact science. Rather, it comes down to a group discussion—one taking into account the experience, opinions and knowledge of the Packers' medical staff as well as the aforementioned imaging and functional status.
If Rodgers' collarbone is not sufficiently ready to take a large hit, a displaced fracture could result. The surgery to repair a displaced fracture can require up to three months of recovery time—and potentially much longer.
Furthermore, in some cases, a weak collarbone may also put the surrounding tissues of the shoulder—such as the acromioclavicular (AC), coracoclavicular (CC) and sternoclavicular (SC) ligaments—at risk.
When should Aaron Rodgers return?
In exceedingly rare cases, a displaced collarbone can threaten structures such as the major blood vessels or nerves within the neck and shoulder.
What's the bottom line?
Simple. Risk versus reward.
The strength may be there, and the range of motion may be there, too. Additionally, if the former MVP takes the field, the Packers become an instant threat to any team in the NFL.
Yet if one hit from a defensive lineman can still send Rodgers off to X-rays and eventually surgery, the question begs asking: Is it worth it?
Dr. Dave Siebert is a resident physician at the University of Washington. He plans to pursue fellowship training in Primary Care (non-operative) Sports Medicine.