This week, hundreds of draft prospects are descending onto Indianapolis to participate in the NFL Scouting Combine.
While the most famous part of the annual event may be the 40-yard dash, just as important—if not more so—is an athlete's medical examination.
The process is lengthy and comprehensive, but many athletes will come out of it with flying colors. They will carry the blessings of multiple medical professionals to participate in combine workouts—and hopefully move on to the NFL later in the year.
Yet for an athlete with NFL dreams with a known medical or injury concern—or an unknown one, for that matter—it may turn into the single most important medical exam of his life.
The Most In-Depth Doctor's Appointment Ever
According to Dr. Matt Matava—president of the NFL Physicians Society (NFLPS), Professor of Orthopedic Surgery and Sports Medicine at Washington University in St. Louis and head team physician for the Rams—the combine exam focuses on more than just knees and shoulders.
"We break down the medical evaluation into two distinct segments: internal medical examinations and orthopedic examinations," Matava explained. "During the internal medical exam, players are evaluated by team internists for cardiovascular, kidney, liver and pulmonary health. Part of this examination includes a battery of tests—such as blood work, EKGs and, for certain players, stress tests for their heart—in order to determine if there are any internal issues that might affect the player's ability to participate in the NFL."
An EKG—short for "electrocardiogram"—is a test that looks at the electrical activity within the heart. While automatic electrical impulses tightly regulate the heart rate under normal circumstances, abnormalities within the conduction system can sometimes predispose to life-threatening irregular heart beats, or "arrhythmias."
Stress tests, on the other hand, analyze the heart's function during exercise to tease out any underlying heart muscle oxygen supply problems that may only arise at high activity levels.
Internists will also ask about a player's known medical issues.
"If a player has a history of problems, such as (high blood pressure), sickle cell anemia, diabetes or asthma, those conditions will be noted," Matava continued. "We also make note of their current condition and any treatments they are receiving. Then, we make recommendations to the team regarding that player's ability to play at the NFL level with these medical issues."
He added that every internist receives the opportunity to see every player, but at least one internist evaluates every prospect.
"If a player is healthy, the evaluating internist will compile a general health report which is shared with the other teams. Once the medical evaluations are complete, each player is given an internal medicine grade that can be somewhat unique for each team. This grade then gets factored into their overall medical grade. This is given to the team's general manager and head coach to be used when they make draft decisions."
Bones, Muscles and Joints
When it comes to football, an orthopedic evaluation—focusing on bones, joints and the rest of the musculoskeletal system—frequently looms just as large as the internal medical exam.
"The orthopedic evaluations are performed in a similar fashion (as the internal medicine exams)," Matava noted. "There are six exam rooms, and each exam room has six teams represented within it. Players will go to each room and will undergo an orthopedic history and exam, have his X-rays and other imaging studies reviewed and have their information presented to the other doctors in the room."
Additionally, linemen receive an X-ray of their lumbar spine—the only mandatory X-ray—to make sure they do not have a vertebral stress fracture. As the lumbar spine houses and protects the lowest part of the spinal cord, stress fractures in the lumbar vertebrae can threaten the integrity of the cord and its nerves as they exit and travel to the lower body.
Similar to the medical exam, an orthopedic grade comes next.
"Each team compiles an orthopedist grade based on the players' history of injuries, previous surgeries, current physical examination and current X-ray(s) and MRI(s)," Matava clarified.
"Some players will have a very healthy orthopedic grade, but their internal medicine grade might be low because of a medical condition. However, it is more common that a player's internal medicine grade is very high, but they've had significant orthopedic problems that affect their overall medical grade."
Regrettably, numerous players will come into the combine on any given year with well-documented and widely-publicized injuries. For them, the process differs in a few respects.
"For players with a known injury concern, their medical history is obtained and recorded," Matava explained. "Team doctors review the player's medical history all the way back to grade school. For instance, if a player has a knee injury as part of their medical history, the doctors will do an examination to look at any current problems and view all past X-rays and MRIs. If necessary, they will order new imaging studies to further evaluate the nature of the knee at the present time."
As one might expect, documented injuries frequently affect a player's orthopedic grade.
"A player might have an injury that is completely healed with no lingering issues, but usually, if he has had a previous injury, his score is still slightly reduced."
Not Your Everyday Specialty Clinic
If needed, medical evaluations go beyond general internal medical and orthopedic exams.
"Amongst the NFLPS membership, there are general orthopedics that usually went through a fellowship in sports medicine, but there are also orthopedists that are trained in sports medicine sub-specialities," Matava went on. "For instance, there are hand specialists, spine surgeons and several foot and ankle surgeons."
Specific medical conditions may require the attention of internal medicine specialists, as well. Cardiologists, pulmonologists, endocrinologists and nephrologists are available to evaluate a player's heart, lungs, endocrine system and kidneys, respectively.
Teams will also bring rarer medical conditions to the attention of an appropriate NFLPS specialist when required. That specialist will share his or her opinion with all 32 NFL teams.
Failing the Medical Exam and Medical "Red Flags"
Unfortunately, the combine medical exam may uncover serious medical problems, the importance of which can extend far beyond football.
"There have been several malignancies (cancers) that have been found during combine medical exams," Matava recalled. "There have also been cases of sickle cell disease and undiagnosed heart problems, such as arrhythmias."
Severe medical problems can even preclude an athlete from receiving medical clearance to play in the NFL.
For a brief period of time in 2013, current Carolina Panthers defensive tackle Star Lotulelei could not participate in workouts due to concern over a low left ventricular ejection fraction—the percentage of blood ejected by the heart with each beat. Fortunately, it seems he suffered from only a temporary condition—as is sometimes the case with low ejection fractions.
Nevertheless, the precautions exist for a reason.
"An athlete can 'fail' the medical portion of the combine," Matava reinforced. "For example, a player who has a malignancy or a heart arrhythmia might fail because he is not physically able to play safely at the NFL level. If there is a player who has an unstable knee, we would likely fail them as well."
Luckily, these scenarios are few and far between.
"We very rarely fail players, but there are some who do not end up getting drafted based solely on their medical grades."
"Injury-prone": A Myth?
Whether or not a player can be truly "injury-prone" or merely unlucky is a very complicated question. That said, at times, a history of frequent injuries can come into play.
"There are players that have more injuries, and thus by common definition would be called 'injury prone,' but there is no set medical definition," Matava remarked. "But there are certainly players we will occasionally downgrade because they have had multiple small injuries that suggest they are frequently in the training room receiving treatment."
The Medical Grade: Sometimes an Inexact Science
When an athlete completes the evaluation process, medical staffs compile the results and discuss them with teams.
Sometimes, the interpretation of those results can vary from team to team.
Say your team has the chance to draft a highly regarded player at a needed position. What is the lowest medical grade you would be willing to accept for this player and still draft him?
"All the X-rays and test results are shared with all of the medical teams, and NFLPS members will occasionally communicate other findings," Matava explained. "However, each team has their own grading scale for players, and each medical team shares their grades with their general managers and coaches."
Dr. Matava added that a given team's head athletic trainer will compile a list of all combine participants—one that includes each athlete's name, position, school, relevant medical history, relevant orthopedic history, test results and overall medical grade. The general manager and coach will factor in the data into drafting decisions.
Some players, however, will merit additional discussion.
"The doctors will have a meeting with the GM and coaching staff closer to the draft where they will flag about 50 players that need to be discussed further from a medical perspective," Matava continued. "(The GM and coaching staff) will want to go over the grades we assigned because they may really like a player's ability but want to understand how significant of a risk he is based on his medical history. We do our best to explain why we gave one player a 'C' and another a 'B-.'"
Nevertheless, no medical decision is ever 100 percent certain, and the combine is no different.
"At the end of the day, the coaches know that this is not a hard science and more of a subjective assessment based on imperfect information."
The Medical Re-visit
As mentioned, every year, some players will come to Indianapolis soon after an injury or in the midst of a long rehabilitation. For these players, a second exam becomes extremely important to their NFL future.
"The medical re-visit is for the guys who are currently undergoing treatment, have a surgery scheduled for a condition or are not yet completely rehabilitated," Matava made clear. "For example, a player might have his ACL repaired a week before the combine, so he's going to be on crutches.
"At this stage in the recovery, we can't learn very much from an examination. We will order an X-ray to see how his graft was placed, but it's too soon to know much more than that about his recovery. These players will come back a month or two later–when they are off their crutches and are doing their rehabilitation—so we can have a better idea or how they are doing in their recuperation."
Not Just Clinical Work
NFLPS physicians do not just evaluate and treat athletes. They are also academics, teachers and leaders in their respective fields of medicine.
"During the combine, the NFLPS has an academic dinner meeting where we present interesting cases and medical research involving NFL health and safety topics," Matava noted. "This purely academic event is my favorite part of the combine.
"We then have business meetings on Saturday. The first half of the meeting includes the athletic trainers—where we discuss issues applicable to both the athletic trainers and doctors. Then, we have a physicians meeting that addresses non-medical aspects of being an NFL physician—such as those relevant to malpractice coverage—that affect your ability to do the job."
A Unique Opportunity
From a 50,000-foot view, the combine medical exam is truly one of a kind—and crucial for both athletes and NFL teams alike.
"I'm biased, but I think the medical side is the most important aspect of the combine because teams can't get this kind of information about a player at any other time in the pre-draft process," Matava offered.
"A team can always ask a guy to do extra bench presses, run the 40-yard dash or have more interviews with coaches, but you are never going to get all of these medical specialists in one room together with this type of comprehensive medical assessment again."
Dr. Dave Siebert is a resident physician at the University of Washington who plans to pursue fellowship training in Primary Care (non-operative) Sports Medicine. All quotes were obtained firsthand.