Second Opinion - Medical Red Flags
By Jene Bramel
August 30th, 2011

One of the things we're always trying to do at Footballguys is leverage the assets we have in order to bring our subscribers every possible edge. In doing so, offered a new inseason column for 2010 called "Second Opinion" where I asked our long time Footballguys Staffer Dr. Jene Bramel to share with you his unique perspective on injuries. It was definitely popular, so we are bringing back for 2011. Dr. Bramel has a view I think you'll want to pay close attention to as he merges his extremely strong knowledge of Fantasy Football with his "real job" where he works as an urgent care physician and team physician. He will take his long-time interest in orthopedic injuries to try to read between the lines of the injury reports and coachspeak to provide insight into the most critical injury situations around the league.

In addition to the injury news we already release each week, this column will add a valuable second opinion for those looking for information about how effective their injured fantasy player might be in the coming week. It should be noted that Dr. Bramel won't have access to specific medical information and he's not an orthopedic surgeon or certified athletic trainer. What he is a guy lives and breathes NFL Football and also has a unique ability to translate injury news for a player into what we think it means to you as a Fantasy Football Owner.

Joe Bryant
Owner - Footballguys.com

Peyton Manning

Some of the worry over Manning's offseason neck surgery has settled after he was activated from the PUP list this week and cleared for a limited practice, but he continues to slip toward the bottom of the second tier of quarterbacks in many drafts. Will Carroll did his usual tremendous investigative work on the surgical procedure that Manning had done and the expected timetable for recovery. Carroll's consistent opinion for the past six weeks has been that Manning would play in Week 1. The Kerry Collins signing made for an interesting hedge by the Colts, but I agree that Manning will likely be under center next week, and I think he can be effective right away.

I've seen concerns that Manning's arm strength and accuracy were issues late last season and that his physical appearance on the sideline this summer suggests that he has begun to show signs of weakness in his throwing arm. With regard to the arm strength/accuracy issue, you need only look at this throw to Pierre Garcon during the wild card game against the Jets in Week 18 to see that Manning had plenty in the tank late last season. And, while it's reasonable to expect Manning to need some time to regain his arm strength and knock off the rust after his recent rehab, I'd be more than comfortable with him as my QB1 (and am not downgrading his receiving options either).

If you do assume the risk on draft day, watch Manning closely during the first weeks. The video above will provide a great comparison. If you don't see the same snap and velocity by Week 2, it's time to be concerned. If you see Manning fumble snaps or lose the ball when pressured, we should probably be worried. Both would be evidence that his grip strength and shoulder strength may not be all the way back. I'd also watch how the Colts approach defenses. Manning is a master at putting defenses to a decision before the snap. If you slide a fifth defender out in coverage, he'll check to a run. If Manning elects to run the ball against seven in the box, I might be nervous that he's not ready to challenge defenses. If you see the Colts' outside receivers running shallower routes and not the traditional vertical stretches (deep post, sideline routes outside, seam routes inside), a similar concern would be valid.

I'm on record in the tier series with Sigmund Bloom with a recommendation to take whichever second tier QB falls to a value draft slot. Not to say that it's without risk, but I'm still willing to bet on Manning anytime after the third round. If you can still get him in the fifth or sixth round this week, you're getting all of the possible rewards with little of the potential fantasy risk.

Arian Foster

I wrote multiple times last season that the first 7-10 days after a player returns to contact after a hamstring injury (of any severity) are critical. It takes time for the bleeding inside the muscle belly to resorb and for the associated inflammation to settle so that the muscle fibers can heal. Even a mild hamstring strain represents torn muscle fibers. Come back too soon and it's easy to re-aggravate the injury, and potentially suffer a more significant tear. One study of NFL players returning from hamstring injuries reported that at least a third re-aggravate the injury within two weeks of returning.

If you saw Foster's reaction after the play last week, you saw a player that knew something wasn't right. He may not have been in so much pain to limp while leaving the field and he may have been reassuring on Twitter (though, I'd argue that his frustration with the fantasy football community may belie his reassurance), but this injury should concern you. I wouldn't expect him to participate in any practices until the Wednesday before Week 1 at the earliest. Hopefully, this situation progresses similar to that of Darren McFadden (who recovered from last season's preseason hamstring injury without setbacks and had a tremendous season), but it's not an over-reaction to worry over Foster given his durability history.

I've dropped Foster to the bottom of my top tier of running backs (Rice, Peterson, Foster), but I'm not yet worried enough to downgrade him out of the first round. He's extremely talented (and will dominate the touches whenever he's on the active gameday roster), playing with a strong offensive line and balanced offense and a perfect fit for the zone running scheme in Houston. This isn't Maurice Jones-Drew with a balky knee that no amount of rehab will get to 100% on a questionable offense. If you're in the middle of the first round and Foster falls to you, his talent and statistical upside is worth the durability risk - even if he takes a week or two to get back to speed.

Maurice Jones-Drew

Something about this situation doesn't add up for me. All the available evidence seems to suggest that Jones-Drew had a problem with the meniscus in his left knee for well over a year, played through it last year (and very well at times) then had surgery to address the issue in January. Exactly what procedure he had and what his rehab and recovery was isn't as clear.

Here's what bugs me.

While MJD is a gamer and undoubtedly wanted to finish the season, it's fishy that a minor meniscal tear that may have required only a simple repair and 3-6 week rehab wasn't addressed at any point between 2009 and January 2011. It's fishy that he wasn't cleared to run, depending on who you believe, until sometime between April and June. All meniscal injuries are different, but it's fishy that a chronic condition that took an additional twelve plus months of pounding was a candidate for a simple meniscus repair, and has been referred to as "bone-on-bone" at times. It's fishy that MJD wasn't ready for camp (and is only now deemed ready for full contract and preseason games) eight months after his procedure.

You know where I'm going with this. The lockout kept us in the dark about lots of things and anything in the previous paragraph could be misinformation put out by MJD or others, but I don't think this was a simple meniscal repair. It smells like a more significant procedure, quite possibly microfracture surgery. If it was a simple repair, it's worrisome that the recovery and rehab extended to four months (or longer) until he was cleared to run and nearly eight months before he was ready for contact.

Reports are that MJD has his burst and acceleration back and is running without pain in limited contact drills. He's reportedly going to play in this week's preseason games. But, despite the improvements in run blocking in the interior line last season and MJD's ability to run through pain last year, he's an extreme medical risk and the team has two capable running backs behind him on the depth chart. The depth in the second and third tier of running backs is such that you need to be fully convinced that MJD can handle a 17-25 touch workload for 14-16 games before grabbing him in the second round. If you do decide that he's worth the risk, you must take Rashad Jennings a full round or two earlier than you might otherwise choose to handcuff your RB1 to protect the investment.

Antonio Gates

Gates has always been one of my favorite players. I bought into the hype extremely early, when my good friend and then RedEyeSports writer Bob Henry wasn't just behind the driver's seat of Gates' bandwagon before he earned the starting job in San Diego, he was attaching Dr. Seuss like noise makers to the side panels to draw attention to it. But he makes me nervous this year. Though we know he's as tough as they come and showed his willingness to play through his plantar fasciitis last year, Gates is in something of a no-win situation.

Despite no team-specific offseason activities, Gates acknowledged that he still has pain in his foot at times as camp began. That's seven months of added recovery and rehab time after the rest during the season last year (in missed practice time, then when he finally shut it down for the year). At some point this spring, Gates had two options. One, continue rest and rehab, knowing that all indications were that his condition was chronic and would never fully heal. Two, have surgery to release his plantar fascia, which would likely relieve much of his pain but change the way his body bore his weight on his feet, leaving him prone to other conditions and pain in other parts of his feet and lower body.

He chose option one.

While it's very reassuring that Gates has been able to hold up over multiple practices in a row this preseason (contrast that to MJD's preseason), it will unfortunately not take much for his condition to flare up again during the year. It's certainly possible that he'll put in a full 16 game season with Gates-like elite fantasy production. But I think it's more likely that the 31-year old warrior will miss lots of practice at some point this year and be forced to consider painkilling injections to suit up on Sunday. We know how that ended in 2011. It's enough that I've begrudgingly dropped Gates down with the rest of the mere mortals in the elite TE tier (TE3).

Austin Collie

Collie has fully recovered from the multiple concussions suffered in 2010. He has chosen a new helmet to help minimize the possibility of a recurrence this year. But no helmet will reduce his risk to near zero. The number of concussions he's suffered makes it more likely that he'll suffer another if he's hit in a way that's more likely to cause a concussion. And his role in the Indianapolis offense - quick slants over the middle, choice routes against zone coverage - put him in a position where he may take another (inadvertent) helmet-to-helmet hit or turn with the ball after the catch and take a hit that causes a significant rotational force on his head and neck.

On the Audible earlier this summer, I likened the situation to that of a boxer with a glass jaw. I'm not saying that Collie isn't tough enough to play football. In fact, I'm arguing the opposite. From an anatomic and physiologic sense, his head/neck/brain is (likely) no longer able to withstand the same trauma it once was. He may not take a hit at the right speed or angle necessary to cause concussion symptoms this year, but he's at a much higher than baseline risk.

Like everyone else I'm discussing in this feature, your risk tolerance must drive your fantasy decision-making process. When he's on the field, Collie is arguably a fantasy WR1, especially in PPR leagues. But should Collie suffer a concussion this year, he may well be observed for longer than one week. If the concussion is severe (any loss of consciousness or prolonged post-concussion symptoms), it may be a month or much longer. I still have Collie in my WR2 tiers, but I wouldn't argue with anyone who ranks him outside the top 35.

Marques Colston

Scopes and microfracture, swelling and irritation, pain and more pain. You have to feel for Colston and his knees. I wonder if the few cells of cartilage left in Colston's knees wake up every morning feeling like Sean Penn, waiting (and maybe even hoping) for the next camera to poke its way into their neck of the woods, and readying themselves to hurl another string of obscenities. Unfortunately, even that's probably old hat for them now.

Unlike the players above, this most recent surgery, despite it being Colston's fifth knee procedure and of the microfracture variety, doesn't bother me that much. Colston has played through knee pain and swelling for years. His game was never built on elite speed, explosiveness or change of direction. He's been successful because he knows how to run routes, use his body to separate in tight spaces, has elite hands, an offense that regularly schemes to get him in single coverage on linebackers and a hyper-accurate quarterback who trusts him explicitly. The loss of another fraction of a step is worrisome, but not nearly as worrisome as it would be for a downfield threat or less technical route runner. I think he's still a high floor, safe WR2.

Around the Training Table

The news that Jeremy Maclin's illness wasn't diagnosed as cancer or other life-changing illness was fantastic. From a purely football perspective, however, the fifteen pound weight loss and anemia that were part of the symptom cluster that prompted the medical workup are worrisome. Recent reports suggest that both issues are behind Maclin, but it shouldn't be surprising to see the Eagles ease him back to a full workload. Philadelphia has lots of receiving options, especially if Steve Smith returns to form, and will be able to work Maclin back into the offense at his own pace. As those who have had extended illnesses, regardless of the final diagnosis will attest, expect Maclin to be inconsistent if/when he is able to play 50-70 snaps as his body continues to recover.

The Panthers now have two players struggling with Achilles' issues. Jonathan Stewart's battles with a chronic Achilles' problem are well known. The recent flare in training camp puts yet another red flag on his medical file. With the re-signing of DeAngelo Williams and questionable passing offense already limiting his fantasy upside, Stewart remains the most disappointing mix of elite talent and poor opportunity in recent memory. He has the talent to be considered in the RB3 range, but I'd be much more comfortable with him as a risk-reward RB4. Joining Stewart in the training room is the face of Carolina's front seven, Jon Beason. He had a minor procedure on his own nagging Achilles' injury last week (likely to remove an inflamed bursa sac, shave down a bone spur or remove scar tissue) and can be expected to miss at least 2-3 weeks. If the procedure was successful, Beason should be able to play without pain. If he can avoid a conditioning injury in the first week or two back, he should be effective.

Like last year, I don't have anything but a nagging suspicion to support my speculation, but I'm skeptical that Percy Harvin makes it through a full season without a migraine. I'm worried that he'll have a recurrence if he takes a hard hit and I think it's highly unlikely that his current approach to preventing headaches will keep him from ever suffering another episode. Adding that medical concern to my concerns that he'll struggle to transition into a primary outside receiver role and I'm having trouble recommending him as a top 20 fantasy WR.

I was somewhat reassured by LaRon Landry's comments that his Achilles felt 100% and he was nearly ready for full contact, but the hamstring injury he suffered while sprinting during warmups last week underlines the issue with players who haven't been able to stay in football condition. The hamstring strain also raises concern that he's using an altered stride to take the pressure of his foot problem. Neither explanation bodes well for Landry making it through a full season without setbacks. His fantasy upside is such that he's worth considering in the elite DB tier, but he's no longer the unquestioned top overall DB and top ten overall IDP selection.

Every season, it seems that a promising rookie running back suffers a season ending injury during training camp. This year, there were two. Ryan Williams ruptured a patellar tendon. Mikel Leshoure ruptured his Achilles' tendon. Both players will have an uphill climb to regain their pre-injury explosiveness and change of direction skills. But I think it's a little early to shovel dirt on their graves, particularly in the case of Leshoure, who's already been written off by many as unrecoverable. Often, that opinion is backed by citing a study that reported that over a third of NFL players never return to the field after tearing their Achilles' tendon and those that have, on average, a 50% reduction in their power ratings. While the conclusion (that Leshoure will never be effective again) may prove correct, the study isn't a strong argument. It's limited (only 31 players, and few skill position players) and simplistic (the power rating measured only yards and touchdowns rather than any objective biomechanical measure) and makes no effort to distinguish between player talent or front office investment (contracts, draft round, etc). An easy counter argument might make note of the success of explosive edge rushers like Greg Ellis, Julian Peterson and Derrick Burgess or a safety who recovered with enough change of direction skill to succeed as a two way defender like Mike Brown and Yeremiah Bell. Leshoure (and Williams) have a long way to go, but it's not a foregone conclusion that neither will be able to return to a productive career.

James Harrison made plenty of news this offseason after making some pointed comments about his offensive teammates and, in the process, may have pushed discussion on a more important issue to the backburner. Two back surgeries to address a herniated disc later, Harrison is admittedly far less than 100% and doesn't expect to be for quite some time. The disc problem reportedly hindered him down the stretch last season, though his production (11 solo tackles, four sacks and two passes defended in three playoff games) didn't suffer much. Still, since Harrison's game is built on strength and leverage rather than speed, reports that he's been squatting less than two-thirds of his usual amount should have you worried. He didn't look comfortable last week and might be limited for some time. Buyer beware in all IDP setups.

Thanks for reading and best of luck in your drafts in the coming days.

Thanks as always for reading. Questions and comments are always welcome in the discussion section below or by e-mail and Twitter (@JeneBramel). Best of luck in your draft this month.

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