Pushing Through the Pain: How the Steelers Will Get Big Ben Ready for Sunday

Dr. David ChaoFeatured ColumnistJanuary 15, 2016

CINCINNATI, OH - JANUARY 09:  Ben Roethlisberger #7 of the Pittsburgh Steelers is carted off the field after being injured in the third quarter against the Cincinnati Bengals during the AFC Wild Card Playoff game at Paul Brown Stadium on January 9, 2016 in Cincinnati, Ohio.  (Photo by Andy Lyons/Getty Images)
Andy Lyons/Getty Images

We all saw what happened to Ben Roethlisberger on Saturday, the sack from Bengals linebacker Vontaze Burfict that injured his throwing shoulder.

But what's happened since? What's Roethlisberger's day-to-day like right now, and what are the Steelers doing to get him ready to play Sunday in Denver, as he's expected to do?

First off, imagine waking up the next day. Your shoulder is throbbing. It's hard to even roll over, let alone push your way out of bed. You try to do the normal things you do on a daily basis, but everything is affected by the pain. The next day? Same thing.

That is what Roethlisberger is experiencing this week. That's what it's like to have an AC (acromioclavicular) joint sprain.

If you had this injury, you might consider it debilitating. You'd certainly avoid doing anything to aggravate it.

Roethlisberger, on the other hand, can't avoid aggravating it. He has to deal with it while preparing to play in an NFL playoff game.

As an orthopedic surgeon specializing in sports medicine who spent 17-plus years in the NFL, including time as a head team physician, I have treated dozens of AC sprains. I will try to give an inside look at how the Steelers medical staff might get their star quarterback ready to play.

Treating any injury starts with diagnosis. By video, Roethlisberger's injury was a classic AC joint sprain and not a clavicle fracture like Tony Romo suffered twice this season. Immediately after on-field evaluation, Big Ben was likely taken to get in-stadium X-rays to confirm the bone integrity and assess the degree of the AC joint injury.

An AC joint sprain is also called a shoulder separation. It has nothing to do with the "ball and socket" (glenohumeral) joint of the shoulder. The injury is to the junction of the outer (lateral) end of the collarbone (clavicle) as it meets the top of the shoulder (acromion). The coracoclavicular ligaments (conoid and trapezoid) that hold the end of the collarbone down in place are commonly part of the injury.

An AC joint injury is going to result in some general shoulder pain, loss of strength and motion and will cause a lot of discomfort when performing any activities that stress the AC joint (lifting, reaching). Imagine having to throw a football over and over again with this injury or even reaching to hand off the ball on a stretch play.

After diagnosis, treatment begins immediately. The Steelers medical staff focuses on ways to safely return their star quarterback to the game and make sure he is healthy for the next week. The key with mild AC joint injuries is pain and function, not stability.

Controlling the swelling is key. Several forms of oral or injectable medications could be used. Injections are often more powerful and act more quickly.

For the immediate, Toradol is a powerful injectable anti-inflammatory agent that also can help with pain. To help control swelling overnight and the first few days, a cortisone-type injection into the AC joint was likely also given. No brace is effective here, although a donut pad on top of the shoulder could help.

After the initial game, the days following involve rest, ice and modalities to continue with edema (swelling) control. Next, rehabilitation would consist of regaining range of motion and keeping the rotator cuff strong. Return to throwing comes later, after this initial rest period.

An MRI is routinely obtained after the game to confirm the diagnosis and rule out any additional injury. Although Roethlisberger spoke about ligament damage, that is really part of the original AC joint sprain. No additional damage was found. No repeat imaging is needed going forward.

What makes this injury an issue is that it involves Roethlisberger's throwing shoulder. A left-side AC sprain would have much less effect on his play. So far, Big Ben is on track to play. Having played the previous Saturday with the next game on Sunday gives him the advantage of an extra day's rest.

The Steelers will monitor Roethlisberger's swelling, range of motion and shoulder strength. They will know his status well ahead of the game. He is likely to have pain on follow-through, as that is when the AC joint is stressed. This may affect his ability to throw deep. A side benefit to playing in Denver is that the ball travels up to 10 percent further at altitude, which will help to counteract his weakness going long.

Come game day, Big Ben will likely be offered another Toradol intramuscular injection to help with inflammation and, to a smaller extent, lessen the pain.

Continuous use of Toradol four times a day for greater than five days is not recommended. However, despite its stigma, using it once a week throughout the season has proved to be safe, according to a study presented a decade ago at the NFL Physicians Society meeting.

It is also possible, safe and legal to receive an AC joint injection to numb the joint. Normally, it is a medical "no-no" to deaden a joint for fear of damage to the cartilage surface. In this case, the AC joint is not a weight-bearing joint.

Also, the treatment for an arthritic AC joint is resection (removal) of the joint, so there are no long-term consequences. A relief pad can be used to lessen direct contact, but there is no good way to brace the joint.

CINCINNATI, OH - JANUARY 09:  Ben Roethlisberger #7 of the Pittsburgh Steelers is helped off the field after being injured in the third quarter against the Cincinnati Bengals during the AFC Wild Card Playoff game at Paul Brown Stadium on January 9, 2016 i
Andy Lyons/Getty Images

In-game aggravation can be a risk, but outside of another similar fall onto the shoulder, re-injury is not a significant issue. There is no threat to nerves or other vital structures. This injury should not have any negative impact on Roethlisberger for the 2016 season or beyond. It really is a pain and function issue.

All of the treatment will be performed with full explanation and consent of the player. Since there is minimal future risk, the ethical issues of short-term gain versus long-term benefit do not really exist here. Of course, an informed consent discussion is always necessary before any treatment.

This will certainly be a long, painful week for Roethlisberger. Although he finished the Wild Card Game and is likely to play in the divisional round, he can only rely on more traditional anti-inflammatories and oral pain medicines during the week.

Simple tasks like pushing himself up out of bed or brushing his teeth are likely to irritate the AC joint and cause pain. This would create a frustrating week for any individual. Yet, as a NFL athlete, Roethlisberger is expected to be out there Sunday.

Big Ben is not being rushed back because it is the playoffs, however. The treatment regimen outlined is routine in the NFL, and quarterbacks I have treated have played through AC joint sprains with success.

In fact, this season, Tyrod Taylor played through such an injury in Week 11 and came back the following week to have a passer rating of 106.4.

Quarterbacks actually tolerate AC joint sprains better than many other positions, namely linemen, linebackers and running backs where players take constant contact to their shoulders. 

As we look forward to the divisional showdown in Denver, it will be the battle of two starting quarterbacks with throwing-arm issues: Big Ben with the acute AC joint injury and Peyton Manning with his chronic arm weakness resulting from neck surgeries.

With the appropriate medical support, I expect Roethlisberger to have the stronger arm Sunday.


David J. Chao, MD is a board-certified Orthopaedic Surgeon with a Subspecialty Certification in Sports Medicine, who has been engaged in an active San Diego practice since 1995. He is a member of the international ACL Study Group, the NFL Physicians Society, American Orthopaedic Society for Sports Medicine, American Academy of Orthopaedic Surgeons and is an Assistant Clinical Instructor at UCSD.

Dr. Chao is a former NFL head team physician with over 17 years of sideline experience.