NFL Week 4 Injury Notebook

Talk of an injury epidemic in the NFL continues, and Week 3 certainly did not help stall the conversation.

I cannot deny the numbers—I wrote previously about the 15 Achilles tendon tears that already occurred in 2014, if you include the two from this week. However, I also caution against jumping to the conclusion that we are facing a true injury wildfire, but rather either a controlled-but-slightly-larger fire or a smoldering and slowly spreading flame.

Some food for thought: (I have a research-trained mind. I can't help it.)

1. Beware the "availability heuristic," a mental shortcut capturing the notion that if it is easy to recall a given event, it must occur frequently. Through Twitter and other outlets, the media and public now hear of just about every single injury—mild or serious. In fact, as I was writing this section, news of Kansas City Chiefs running back Joe McKnight's torn Achilles surfaced by way of ESPN's Adam Teicher. I soon received several Twitter questions about the injury's seemingly dramatically increasing toll. However, I did not change the thesis of this section, as one injury here or there does not a trend make.
2. The numbers suggest Achilles injuries are, indeed, increasing in frequency. Nevertheless, keep in mind that we are talking about a rare event to begin with, and the concept of relative vs. absolute increase is worth mentioning. For example, if 10 Achilles tears occur one year and 20 the next, we see a doubling of injuries in the absolute sense. However, the overall annual rate of Achilles injuries remains quite low when spread across the entire league.
3. It is very difficult to definitively prove trends in either direction when talking about rare events. This article from Discovery News claims an Achilles tendon rupture rate of about four to ten per season and one to three per preseason prior to 2011—or somewhere around 14 per year in the worst-case scenario. In 2011, though, a total of 30 tears occurred prior to the article's publish date in December. In 2014, even if one Achilles tendon gives way every week through December, we would see fewer tears this year than in 2011. However, that would not imply a trend downward since then.

What does all this mean? Simple: We don't really know just yet, but we might get there soon.

Are Achilles injuries trending up? Perhaps—or maybe this 15-to-25-per-season range represents the new level to expect since the 2011 lockout. I'm not arguing one way or the other (yet) because the publicly available data remains incomplete.

Furthermore, I won't even get into other variables that may affect Achilles injuries, such as practice schedule changes, preexisting Achilles tendinitis in players, individual player history of prior Achilles injuries or fluoroquinolone antibiotic use—my medical readers will get that seemingly random final reference.

Additionally, the relative significance of each variable is not clear, and the number of potential permutations large. That said, I do think that answers—ones that clarify the scope of the problem and come up with very real potential solutions—are out there somewhere.

Enough of that, though. Let's get to this week's injury notebook.

Sports Medicine Topic of the Week: The Hamstring Strain

Each week, we will look at a different Sports Medicine topic that may come into play during an NFL game. This week's topic: The hamstring strain.

 

In the above video, Dr. Luga Podesta of the renowned Kerlan-Jobe Orthopaedic Clinic in California gives an excellent overview of hamstring strains.

In the NFL, hamstring strains can tend to linger and carry a reasonable risk of reaggravation. They can also impose significant limitations on skill positions such as wide receivers.

Furthermore, a prior hamstring strain is a proven risk factor for future strains—look no further than Cleveland Browns wide receiver Miles Austin and Green Bay Packers defensive back Casey Hayward.

Generally speaking, it remains quite difficult to accurately predict when a player will return to play following a minor to moderate hamstring strain. While a player rehabs, medical staffs usually rely on his report of pain more than anything else, and MRI findings do not reliably predict the length of time a player will miss.

Mild to moderate hamstring strains will heal with relative rest and rehab. Complete tendon ruptures require surgery and can even represent a career-threatening injury.

Fantasy Football Injury Advice of the Week: Beware WRs with Hamstring Injuries

Chris Szagola/Associated Press

A new feature this week, this slide will look at a common fantasy football injury situation from a medical standpoint and offer some generalized advice.

A wide receiver playing through a minor hamstring strain represents a relatively common scenario in the NFL. However, it may leave fantasy owners with a tough decision.

Start or sit?

As a general rule of thumb, wide receivers and new hamstring injuries—or newly aggravated ones—do not go together well. A sore hamstring not only limits a receiver due to pain but may also shorten his stride length and lower his leg strength.

The end result? A potentially slower, less agile player in a position that demands top-end speed and cutting dozens of times per game.

Every situation is unique, of course, and elite wide receivers with hamstring strains may justifiably earn a fantasy lineup spot despite an injury. However, in general, think hard about starting wideouts with ongoing hamstring troubles, and weigh other options carefully—especially when it comes new injuries, where the chance the injured player plays as more of a decoy is very real.

Bye Week Recap

Elaine Thompson/Associated Press

Bye weeks start this week. Make sure players from the following teams are out of your fantasy football lineups:

1. Arizona Cardinals: Running back Andre Ellington will appreciate the extra rest as he continues to recover from a peroneus longus tendon injury.
2. Cincinnati Bengals: Wide receiver A.J. Green rewarded faithful fantasy owners with over 100 receiving yards Week 3, playing through a toe injury that will only get better before his team's next game.
3. Cleveland Browns: Look for tight end Jordan Cameron's shoulder to be less of an issue during practice leading up to Week 5.
4. Denver Broncos: Linebacker Danny Trevathan returned to practice last week. He could return to action Week 5 after suffering a leg fracture during training camp.
5. St. Louis Rams: Quarterback Shaun Hill may assume the starting role once again following his team's bye week. He is dealing with a thigh injury.
6. Seattle Seahawks: Running back Marshawn Lynch had a brief back scare last week but performed well Week 3. He will appreciate the week off.

Matt Cassel, QB, Minnesota Vikings (Red)

Rogelio Solis/Associated Press

Player: Matt Cassel, QB, Minnesota Vikings

Injury: Lisfranc injury and fracture

Latest News: NFL Network's Albert Breer announced the grim diagnosis shortly after the injury occurred. Fox Sports' Brian Hall later reported the Vikings placed the quarterback on injured reserve, ending his season.

Alert Level: Red

Relevant Medicine and Anatomy: Will Carroll, Bleacher Report's lead writer for Sports Medicine, told me Cassel did indeed suffer a Lisfranc injury.

The Lisfranc joint marks the point where the metatarsals—the long bones in the middle of the foot—meet the bones that make up the foot's arch. Lisfranc injuries occur as a result of a sharp plant and twist or direct trauma to the middle of the foot.

The anatomy and biomechanics of the Lisfranc joint can make recovering from a significant injury quite complicated. Any disruption of the joint, fracture or bone displacement necessitates surgery to stabilize the complex.

Possible On-Field Limitations and Considerations: Ongoing post-operative pain after surgery to stabilize a severe Lisfranc injury is not rare. Fortunately, Cassel is not a running quarterback.

Fantasy Advice: Rookie quarterback and first-round draft pick Teddy Bridgewater will take the reins of the Vikings offense Week 4. It's worth checking to see if he is available on waivers.

Follow-Up: Cartilage damage can occur with Lisfranc injuries. Even if Cassel does avoid such a complication, this injury will likely affect him well into the 2015 offseason—and perhaps longer.

Jake Locker, QB, Tennessee Titans (Red)

Associated Press

Player: Jake Locker, QB, Tennessee Titans

Injury: Wrist strain

Latest News: The Tennessean's Jim Wyatt believes Locker is "closer to doubtful/out" than his questionable tag suggests.

Alert Level: Red

Relevant Medicine and Anatomy: The muscles that make up the bulky part of the forearm control the wrist and fingers. Generally speaking, the muscles on the front of the forearm flex the wrist among other actions, while those on the back extend it.

A strain implies an injury to one of those muscles. Not only does a strain produce pain and swelling, it also leads to some degree of weakness of the muscle in question—and, therefore, it's action.

Possible On-Field Limitations and Considerations: NFL Network's Ian Rapoport points out that Locker's grip strength is of prime importance. Lower grip strength in a quarterback may lead to anything from inaccurate and wobbly passes to a higher risk of fumbles.

Fantasy Advice: It sounds unlikely that Locker will play. Even if he does, you can probably find someone on waivers with a higher chance of good fantasy production than the former University of Washington Husky.

Follow-Up: His wrist strain should heal well with enough time. That said, pay attention to recovery benchmarks such as passing accuracy and, as mentioned, grip strength in the days and weeks to come.

Jamaal Charles, RB, Kansas City Chiefs (Orange)

Jed Jacobsohn/Getty Images

Player: Jamaal Charles, RB, Kansas City Chiefs

Injury: Recurrent high-ankle sprain

Latest News: ESPN's Adam Teicher noted that Charles practiced Friday. According to the Chiefs injury report, he also practiced Thursday on a limited basis.

Alert Level: Orange

Relevant Medicine and Anatomy: Last week, a video of Charles warming up before kickoff surfaced via Chiefs writer/reporter B.J. Kissel. While reassuring in one sense, it does not show Charles twisting, planting and cutting—the real limitations of a high-ankle sprain. After all, the injured ligaments in a high-ankle sprain prevent the bones of the lower leg from rotating about one another. Without stressing them by recreating that movement, it's difficult to draw any conclusions.

Possible On-Field Limitations and Considerations: The ultimate test for Charles is stopping from full speed, planting his injured foot out to the side and turning in the opposite direction. If he can do so effectively and without significant pain, his ligaments are likely healing well.

Fantasy Advice: Even if Charles played last week, I strongly recommended against starting him in fantasy lineups. Another week of healing means Charles has a better chance to contribute, but do not be surprised if he and Knile Davis split work throughout the game on Monday. 10 to 15 carries seems likes a possible ceiling, and any lingering limitations of his cutting ability might lower his effectiveness.

Follow-Up: Regardless of how this week goes, Charles' story isn't done yet. High-ankle sprains tend to linger, and until the running back falls off the Chiefs injury report altogether, the sprain merits monitoring.

Arian Foster, RB, Houston Texans (Orange)

Associated Press

Player: Arian Foster, RB, Houston Texans

Injury: Hamstring strain

Latest News: Texans head coach Bill O'Brien—via Texans reporter Deepi Sidhu—called Foster a game-time decision this week. "Hamstring" pops up on Foster's KFFL.com injury history three times.

Alert Level: Orange

Relevant Medicine and Anatomy: As mentioned earlier, return-to-play time following a hamstring strain is notoriously difficult to predict. Often, it relies on a player's report of pain and tightness as well as clinically measured strength and range of motion.

Possible On-Field Limitations and Considerations: A tight hamstring may shorten a player's stride length, thereby lowering top-end speed. It also carries the reaggravation risk many athletes know all too well.

Doctors and athletic trainers will likely watch Foster warm up prior to this week's game, and if any pain or tightness return, he may find himself on the inactive list once again.

Fantasy Advice: Be careful, fantasy owners, and pay very close attention Sunday morning.

If you do decide to roll with Foster, be ready to pick up backup Alfred Blue at a moment's notice. If Foster plays, he may split work with Blue due to the injury. Do not expect vintage Foster.

Follow-Up: As mentioned multiple times in this column in past weeks, hamstring injuries can linger and recur. The Texans medical staff will surely exercise extreme caution to minimize that risk.

Brandon Marshall, WR, Chicago Bears (Yellow)

Michael Conroy/Associated Press

Player: Brandon Marshall, WR, Chicago Bears

Injury: Ankle sprains

Latest News: According to the Bears injury report, Marshall did not practice at all this week and remains questionable for a huge divisional matchup with the Green Bay Packers. Will Carroll, Bleacher Report's lead writer for Sports Medicine, tells me the wideout is actually dealing with two separate injuries to the same ankle.

Alert Level: Yellow (if active)

Relevant Medicine and Anatomy: The ankle houses a number of ligaments, each of which can stretch or tear. Injuries to these ligaments—sprains—usually eventually heal with rest, time and, if needed, immobilization. Carroll's information suggests Monday night's injury involved a different area of Marshall's ankle than his original sprain.

Possible On-Field Limitations and Considerations: If he plays, the Bears medical staff will likely apply quite a bit of supportive taping to Marshall's ankle prior to the game. Tape provides physical support to the joint, decreasing the chance of twisting the ankle further.

Fantasy Advice: For the past two weeks, I called Marshall a relatively safe fantasy start despite his ankle injury—barring an aggravation, of course. Then, he suffered that aggravation.

If he plays on Sunday, he remains a touchdown threat against the Packers below-average defense despite his painful ankle. Recall he caught a touchdown pass after his second injury last week that was called back.

In short, Marshall remains a viable fantasy start. However, do not expect triple-digit receiving yards.

Follow-Up: As long as Marshall's sprains are not of the high-ankle variety, they will likely heal relatively soon—if the wideout can avoid further setbacks, that is.

Roddy White, WR, Atlanta Falcons (Yellow)

Associated Press

Player: Roddy White, WR, Atlanta Falcons

Injury: Hamstring strain

Latest News: Via 92.9 The Game's Mike Conti, Atlanta Falcons head coach Mike Smith said White will "absolutely" start this week. Falcons writer Jay Adams said White himself feels "good to go" for Week 4. The Falcons injury report lists him as probable after limited practices on Wednesday and Thursday as well as full reps on Friday.

Alert Level: Yellow

Relevant Medicine and Anatomy: White's hamstring issue seems quite mild. His week off last week likely allowed his body's healing process to catch up with the damage. If the wideout is not experiencing any symptoms—possible, but not entirely clear based on the available information—the inflammation and healing within his leg are likely subsiding or gone.

Possible On-Field Limitations and Considerations: As mentioned previously, a recent hamstring injury always carries a re-aggravation risk.

Fantasy Advice: If there is a wide receiver to start with a hamstring injury this week—remember, not a great idea as a general rule—it's White. He sat out last week, thus receiving an extra week-and-a-half of rest and recovery. His practice status trended upward throughout the week, culminating in a full day of reps on Friday. These factors all work in his favor, and he is thus, relatively speaking, a safe fantasy start.

Follow-Up: If White suffers no setbacks this week (and avoids other injuries, of course) the smart money says his hamstring strain becomes a non-issue next week.

Vernon Davis, TE, San Francisco 49ers (Yellow)

Tim Sharp/Associated Press

Player: Vernon Davis, TE, San Francisco 49ers

Injury: Ankle bruise

Latest News: After sitting out Week 3, Davis feels his ankle is "way better," according to a tweet from the San Jose Mercury News' Cam Inman. However, as of Friday, CSN Bay Area's Matt Maiocco reports the tight end remains "day-to-day" and uncertain about his status this week. Earlier this month, Maiocco wrote an MRI did not show structural damage, revealing only a deep bruise.

Alert Level: Yellow (if active)

Relevant Medicine and Anatomy: Deep ankle bruises can lead to significant swelling in or around the joint. The swelling places pressure on surrounding tissue, thereby causing pain, and can also limit range of motion and strength.

It appears Davis' bruise is well on its way to resorbing, but the tight end's ongoing limitations suggest it still has a bit to go.

Possible On-Field Limitations and Considerations: Planting, cutting and twisting are the name of the game for Davis. If he can do so without significant pain, he can remain effective.

Fantasy Advice: One of the tougher fantasy football decisions this week, owners need to assess their tight end situations carefully. It seems likely Davis will not be 100 percent this week, and the 49ers play an afternoon game on Sunday. Limited work also seems like a strong possibility.

When active and healthy, Davis is a top-tier tight end and thus can justifiably earn a fantasy start despite the injury, but a good backup plan is a must.

Follow-Up: Usually, deep tissue bruises like Davis' resolve with enough time, icing and relative rest. If he does not play this week, his trend suggests he will return for Week 5.

 

Dennis Pitta, TE, Baltimore Ravens (Red)

Tony Dejak/Associated Press

Player: Dennis Pitta, TE, Baltimore Ravens

Injury: Dislocated hip

Latest News: According to The Baltimore Sun's Aaron Wilson, Pitta underwent surgery for a dislocated hip earlier this week.

"

Ravens veteran tight end Dennis Pitta's surgery to repair a fractured, dislocated right hip was "successful," according to a team source.

Pitta underwent the procedure at University Hospitals in Cleveland on Monday where he was transported Sunday after injured his right hip for the second time in the past year. Pitta will remain in the hospital this week as he recovers from the surgery and is expected to return to Baltimore within a week.

"

The Ravens placed the tight end on injured reserve this week, as well, ending his season.

Alert Level: Red

Relevant Medicine and Anatomy: The hip marks the location where the femur—the thigh bone—meets the pelvis. The femur's rounded end fits into a socket with the pelvis known as the acetabulum.

Most of the time, the ball-and-socket joint that is the hip is quite stable—relative to the shoulder's ball-and-socket joint, at least. If a golf ball on a tee represents the shoulder, a beach ball in an inner tube might depict the hip—similar, but more firmly in place.

A dislocation involves the head of the femur slipping out of the acetabulum as a result of trauma—or, in the case of Pitta's second dislocation, no contact whatsoever. Fractures and soft tissue damage often occur as a result.

Possible On-Field Limitations and Considerations: A history of multiple dislocations will put Pitta at higher risk of further injury if he returns to the field.

Fantasy Advice: Ravens tight end Owen Daniels fantasy value gets a huge boost as a result of Pitta's season-ending injury.

Follow-Up: The fact that a seemingly normal football move dislocated Pitta's hip without contact from another player suggests the joint is not nearly as stable as a healthy hip. His surgeons and medical team will give him the best shot possible to return to the field, but at this point, there are far more questions than answers.

Clay Matthews, LB, Green Bay Packers (Green-Yellow)

Jonathan Daniel/Getty Images

Player: Clay Matthews, LB, Green Bay Packers

Injury: Groin strain

Latest News: Matthews told ESPN's Rob Demovsky and other media that he'll "be out there" against the Bears this week.

Alert Level: Green-yellow

Relevant Medicine and Anatomy: Often, groin strains involve the hip adductors—muscles that bring the thigh inward from the side. Grade-1 strains involve mild muscle overstretching without much loss of strength. Grade-2 and Grade-3 injuries are partial and complete muscle tears, respectively, producing partial to complete loss of strength and function.

Possible On-Field Limitations and Considerations: Like hamstring injuries, groin strains can linger. Weather can also come into play with this particular type of injury. For example, rainy conditions can make outdoor fields—like Chicago's Soldier Field, where the Packers play this week—slippery. Less traction can increase the risk of a player's planted foot slipping out to the side, a very common mechanism of injury for a groin strain.

The fact that Matthews may not miss any time whatsoever suggests his injury is very mild. His reaggravation risk may be the only factor worth noting.

Fantasy Advice: With or without Matthews on the field, the Packers defense faces a potent Bears offense this week. Look elsewhere. There are likely better options available.

Follow-Up: As suggested, Matthews' recovery comes down to avoiding aggravations. Mild strains heal well with—you guessed it—time and relative rest.

Dee Milliner, DB, New York Jets (Red)

Bill Kostroun/Associated Press

Player: Dee Milliner, CB, New York Jets

Injury: Quadriceps strain

Latest News: Not only did Milliner suffer a recent high-ankle sprain, the New York Jets injury report lists him as doubtful this week with a quadriceps injury. NJ.com's Darryl Slater wrote this week that the cornerback pulled his quad before last week's game against the Chicago Bears. Slater also calls his high-ankle sprain "healed."

Alert Level: Red

Relevant Medicine and Anatomy: The quadriceps muscle group—four muscles in total—sit in the front of the thigh and primarily function to straighten the knee. They do so via the quadriceps and patellar tendons, the latter being the part of the knee a doctor hits with a reflex hammer.

Possible On-Field Limitations and Considerations: When a player drives forward or leaps into the air, he calls upon his quads in order to push into the ground. Strained or weak quads can limit a player's leg strength—and thus his ability to leap, a particularly troublesome problem for a cornerback.

Fantasy Advice: Expect Milliner to sit out this week. To make matters worse, the Detroit Lions, the Jets' Week 4 opponent, feature a wide receiver by the name of Calvin Johnson. Fantasy owners might entertain looking to the waiver wire for a plug-in defense this week.

Follow-Up: As long as Milliner did not suffer a tendon rupture, he should be able to return to the field in the coming weeks.

Fantasy Football Quick Hits

Ann Heisenfelt/Associated Press

Quarterbacks

• Michael Phillips of the Richmond-Times Dispatch reported earlier this week that the Washington Redskins medical staff removed quarterback Robert Griffin III's cast. More details are forthcoming after next week's re-evaluation.
• With Jake Locker ailing, the Tennessee Titans will likely turn to Charlie Whitehurst, according to The Tennessean's Jim Wyatt. Behind Whitehurst? Rookie quarterback Zach Mettenberger out of LSU, who is coming off an ACL/MCL tear combo from college.
• Tampa Bay Buccaneers quarterback Josh McCown did not practice all week with a thumb injury. The Bucs injury report lists him as "doubtful."
• According to ESPN's Ed Werder, Arizona Cardinals quarterback Carson Palmer is making progress as he tries to come back from a nerve problem in his shoulder. He expects to play Week 5.
• Though the Dallas Cowboys injury report lists quarterback Tony Romo as "probable" after he practiced in full on Thursday and Friday, the veteran did not practice at all on Wednesday. Expect quite a bit of these "maintenance days" throughout the season.

Running Backs

• Jacksonville Jaguars running back Toby Gerhart practiced in full all week with an ankle injury and earned a "probable" tag on the Jaguars injury report.
• According to the New Orleans Saints injury report, running back Mark Ingram remains out this week as he recovers from a broken hand.
• Oakland Raiders running back Maurice Jones-Drew is recovering from his broken hand. The Raiders injury report hints he will return to action this week, potentially eating into Darren McFadden's carries.
• Pro Football Talk's Mike Wilkening notes Tampa Bay Buccaneers running back Doug Martin is probable to play this week through his knee injury.
• Baltimore Ravens running back Bernard Pierce practiced through a quadriceps injury this week. The Ravens injury report lists him as "probable" to play, but he may split work with rookie Lorenzo Taliaferro.
• The Carolina Panthers injury report lists running back Jonathan Stewart as "questionable" with a knee injury. He practiced on a limited basis Friday. According to the Black and Blue Review, head coach Ron Rivera thought he did not look "as good as (they) had hoped." Don't expect much from Stewart for the time being.
• The Panthers injury report also lists running back DeAngelo Williams as "probable." He practiced in full all week with a thigh injury. Without Stewart available, Williams could be a interesting bye-week play on fantasy fosters.
• Will Carroll told me on Sunday that San Diego Chargers running back Danny Woodhead suffered a Maisonneuve fracture last week. These injuries are quite unstable and require surgery, and ESPN's Eric D. Williams noted this week that the fracture forced Woodhead to injured reserve. With Ryan Mathews still out, the Chargers will turn to Donald Brown.

Wide Receivers

• Last week, I warned against starting San Diego Chargers wide receiver Keenan Allen due to a new groin injury. Though he played throughout the game, he hauled in only two receptions for 17 yards, suggesting either excellent coverage or a decoy role. That said, the Chargers injury report notes he practiced in full this week. As such, he is a much safer fantasy start this week.
• Be very careful with New York Jets wide receiver Eric Decker this week. He suffered a hamstring setback against the Bears last week. On a short week, the wide receiver "hamstring rule" applies in full here.
• Chicago Bears wide receiver Alshon Jeffery, who battled a hamstring injury recently, did not show up on the Bears injury report at all this week.
• Detroit Lions writer Tim Twentyman reported Friday that superstar wide receiver Calvin Johnson returned to practice Friday but remains questionable to play. He is dealing with an ankle injury but remains a start-whenever-active player.

Tight Ends

• As a friendly reminder, start New England Patriots tight end Rob Gronkowski whenever he is active. He is a constant touchdown threat, and his workload will only increase as he continues to come back from an ACL/MCL tear combo last year.
• Washington Redskins Jordan Reed missed Thursday night's game. He continues to recover from a hamstring strain.
• The Associated Press reported this week—via Yahoo Sports—that Minnesota Vikings tight end Kyle Rudolph will miss about six weeks after undergoing sports hernia surgery on Tuesday.
• Tennessee Titans tight end Delanie Walker is questionable to play due to a shoulder injury, according to the team injury report. With Charlie Whitehurst likely under center, he is a tough fantasy start—even if active.

Others

• According to Fox Sports' Mike Garafolo, New York Giants linebacker Jon Beason missed Thursday night's game against the Washington Redskins. Beason continues to deal with a sesamoid fracture in his foot. Poor blood flow to the sesamoid can limit healing in some cases.

Dr. Dave Siebert is a second-year resident physician at the University of Washington and a member of the Professional Football Writers of America. He plans to pursue fellowship training in Primary Care (non-operative) Sports Medicine.

Stats were obtained from NFL.com official statistics.

Questions about players on this list? Not on this list? Send 'em to Dave on Twitter.

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