Monday Injury Rounds: Week 2

Making rounds on this weekend's injuries, with updates on Dez Bryant, Andre Ellington, T.Y. Hilton, C.J. Anderson, and others

NOTE: This column is a living document. I'll be updating as needed after team press conferences, imaging reports, Monday Night Football injuries, etc. Major changes to the content will be noted in red. I'll also be retweeting any key pieces of news and my own reaction and analysis, so make sure you're following @JeneBramel and checking my timeline on Twitter throughout the week.

INJURY ROUNDS

There are three important components to injury diagnosis.

First, it's very helpful if you are able to see the injury happen. Injuries follow the laws of physics and biomechanics. If you can see how the body was stressed, you can often narrow the list of possibilities. An athlete can sometimes tell you what the mechanism was, but injuries often happen too quickly for them to accurately report what happened.

Second, a good examination is critical. Broken bones and tendon ruptures and ligament injuries can often be diagnosed on the field or sideline. Sometimes, the clinical picture won't be clear, but a combination of an accurate player report of the injury and good physical exam usually leads you to the correct diagnosis.

Third, imaging studies (x-ray, MRI, etc.) help to confirm the suspected diagnosis and help to determine severity and any associated injuries which may not be clear on exam.

With ever-improving high definition images and multiple camera angles, I'm often able to get a very good look at the mechanism of injury. You'll often see me incorporate slow motion moving images and still frames showing the physics of player injury in this article. But, unless the television broadcast catches the medical staff exam of a player, I'm working with incomplete information. Even then, those exams only show us which areas the medical staff is concerned about. Eventually, we'll also hear about the results of imaging studies. But teams can be misleading or give out so few details that imaging reports may not be useful either.

So, much of what I write on Monday is my own speculation. I try not to stray too far and I'll only include what I think are the most likely diagnoses.

dez bryant | foot fracture | month-to-month

Bryant limped off the field in the fourth quarter and would not bear weight on the ball of his foot while hobbling back to the locker room. After the game, the Cowboys reported that Bryant suffered a broken bone in his foot, would need a screw fixation, and would miss 4-6 weeks.

I'm not so sure. Please note that the following is my speculation. As I write this, GamePass does not have the television broadcast of this game up for review, but I'm basing what follows on probability.

The most common foot fractures, especially when an athlete refuses to bear weight on the front of the foot, are metatarsal fractures, i.e. the long bones of the midfoot. If the first or second metatarsal bones were involved, the Lisfranc complex would likely be involved. That's a much longer recovery than 4-6 weeks. If the third or fourth metatarsal were involved, it's unlikely Bryant would need a screw fixation.

Fifth metatarsal fractures are by far the most common metatarsal fracture in athletes and almost exclusively fixed with screws. Again, it's my speculation and hasn't been confirmed, but I think this is Bryant's most likely injury.

If my speculation is accurate, 4-6 weeks is a very optimistic timeframe and expectation. Dr. Robert Anderson -- who you may well hear mentioned with Bryant in the next 48 hours -- does the large majority of screw fixations for these fractures in NFL players. His literature routinely quotes 6-8 weeks as a reasonable time frame, with 6-10+ weeks as a range of potential outcomes. 

The Cowboys have a bye in Week 6. I think it would take a miracle recovery for Bryant to make it back before Week 7. The most optimistic comp for Bryant is Marvin Jones, who worked to return from a similar injury in 6-7 weeks only to fight through multiple compensatory injuries. 

On the positive side, players recover from fifth metatarsal fractures well. There are multiple instances of wide receivers -- most recently Julio Jones and Devante Parker -- returning to full form. Many players have needed a screw revision procedure later in their careers, but those players -- including Jones and Parker -- had their first procedure before Anderson modified his technique to include a bigger screw and bone grafts.

Hopefully, we'll get confirmation of the location of the fracture and/or the surgeon by tomorrow afternoon. Both will be critical in firming up Bryant's return to play expectation. Also, I'll update this blurb with video of the injury if the television broadcast provides a clear look.

1230ET: The Cowboys have now confirmed Bryant has a fractured fifth metatarsal. Shortly afterward, Ian Rapoport tweeted the Cowboys are immediately sending Bryant for surgery and still feel four weeks is a possible recovery date.

Don't believe it.

As noted above, the surgeon who performs these procedures most often on athletes says otherwise. His most recent study, published just this month, continues to quote an average of 8-9 weeks for a return to play. The most aggressive return was 5.9 weeks.

It's possible the Cowboys could rush Bryant back before their Week 6 bye with a perfect rehab. But I think we'll hear as we get closer to that date they've decided it's just not realistic to push him and risk aggravation and additional injury.

andre ellington | pcl sprain | week-to-week

I didn't see a clear mechanism of injury on Ellington, but the usual concern with a non-contact knee injury is an ACL tear. Bruce Arians told the media right after the game that the Arizona medical staff had suffered a PCL sprain. Usually, that's happens when a player is hit on the front of the knee with his foot planted on the ground -- a hyperextension mechanism without any rotation. Ellington clearly didn't have that occur. 

After some additional research, it's notable that some PCL injuries can occur without contact when a player plants with his foot pointed down and his knee deeply flexed.

As you can see in the GIF to the right, that's exactly what happened to Ellington shortly before he went to the ground.

This won't be a season-ending injury, but it won't be a quick recovery either. It's difficult to pin down a recovery timetable on a PCL sprain. It's a major stabilizing ligament of the knee and players oftentimes feel only slow improvement with these sprains. Breshad Perriman is just the latest example of a slow to recover PCL injury. We could see Ellington return as soon as 3-4 weeks, but it won't be surprising if this recovery stretches to 4-6 weeks.

T.Y. Hilton | knee contusion | week-to-week

Hilton went down to the ground on a catch late in the third quarter and hit his left knee hard on the turf. He remained in the game briefly, then left for treatment and x-rays. Those x-rays reportedly showed no fracture.

Interestingly, Jim Irsay told the media after the games Hilton would "miss a few games." While bone bruises are difficult injuries, particularly around the knee, it's way too early to put an extended timetable on Hilton's recovery.

The Colts will have a much better idea of what to expect after Hilton has an MRI tomorrow. Assuming the more detailed imaging study does not show a subtle fracture the x-ray missed, the amount of swelling inside the bone and how Hilton feels by mid-week will better guide the Colts.

For now, consider Hilton week-to-week and questionable at best for Week 2. But I wouldn't rule Hilton out for Week 3 and beyond until we get more detailed information or see Hilton not practice by the middle of next week.

c.j. anderson | toe sprain | day-to-day

I'm worried about this injury. It may well be only a toe sprain but there's a hint of a midfoot mechanism in the frame-by-frame video. Anderson may have gotten his foot turned in time, but here's a still frame showing his foot flexed and a defender about to land on it. That's how a midfoot injury occurs.

If Anderson has a toe sprain, it may be difficult for Anderson to recover in time for this week's road game on Thursday night. If it's more midfoot than toe, Anderson may be dealing with a multi-week injury.

Cecil Lammey and others in Denver are reporting Anderson's injury is minor. If he's practicing on Tuesday, there's little reason for concern.

To be clear, this is just my speculation. But if you hear rumblings of a concerning MRI, second opinion, Dr. Robert Anderson, Charlotte, or midfoot this week, it's time to get concerned.

demaryius thomas | hand | day-to-day

Thomas hurt his hand late in the fourth quarter. He was in pain, but returned to the game. Beat writers in Denver believe Thomas will have an x-ray to evaluate the injury. There doesn't appear to be a real concern here, but with the Broncos on a short week, hope for a quiet news day on Thomas on Monday.

desean jackson | hamstring strain | week-to-week

Jackson grabbed his hamstring after stretching for a ball on a deep sideline route. Washington ruled him out very early in the game, raising the possibility of a mid-grade strain and a multi-week absence. We'll know more after Jackson has a MRI on Monday.

delanie walker | hand | day-to-day

Walker hit his hand on a helmet yesterday and was in significant pain and had his hand supported by a member of Tennessee's medical staff as he walked off the field. Walker's x-ray reportedly showed no broken bones but he left the locker room wearing a cast. Teams immobilize lots of body parts to help limit swelling and pain overnight. If Walker is still in a cast early this week or requires a MRI to better define his injury, it's time to be more concerned about his Week 2 status.

derek carr | hand | day-to-day

Carr needed x-rays on his throwing hand after hitting it on a defender's face mask. Images didn't show a fracture, but pain and swelling prevented Carr from gripping and throwing the ball. After the game, Jack Del Rio said Carr had a sore thumb. Pain management and finding a way to limit the swelling early this week will be critical, but Carr has a chance to play in Week 2.


FOLLOW-UP APPOINTMENTS

Randall Cobb was limited by his shoulder sprain but appeared to finish yesterday's game without a setback. Expect him to be limited in practice as the Packers prevent him from taking contact that would aggravate his sprain again this week. Alshon Jeffery didn't have his usual explosiveness and lift but showed he was healthy enough to separate off the line and when breaking off routes. He should be even healthier in Week 2 and is less at risk of an aggravation with each passing practice.

arian foster | core abdominal surgery / groin strain | week-to-week

Foster is running and cutting as he advances deeper into his rehab protocol. Bill O'Brien ruled him out for Week 2 in his post-game press conference on Sunday. But we're nearly inside the Week 2 - Week 4 window that fits a reasonable timetable for his recovery from surgery, i.e. 6-8 weeks from the procedure. Expect to see Foster begin working back to football-related activity this week and next. Week 4 is still in play here.

mike evans | hamstring strain | day-to-day

Evans insisted he felt "really good" after Friday's practice but his return to play in Week 1 was never realistic. Assuming Evans had no setback after his limited Friday practice, we'll see him do more this week. With three limited practices (or better), he should be on the active roster in Week 2. Until he fully reconditions, however, he'll be at risk of aggravating what's clearly been a mid-grade hamstring strain.

c.j. spiller | knee surgery | week-to-week

Spiller was ruled out on Wednesday, according to Ian Rapoport, and didn't practice at all this week. I still think Rapoport's note that Spiller would be good to go this week is overly optimistic. We're nearly four weeks into Spiller's recovery and he's yet to practice. It's possible the plan all along has been to return to a full practice schedule leading into Week 2, but if Spiller misses practice on Wednesday, he may still be at least a week away from returning.

todd gurley | acl tear | week-to-week

The Rams stuck to their plan to bring Gurley back slowly despite losing Tre Mason to a hamstring injury this preseason. Gurley was cleared for contact last week and is in the final stages of his reconditioning process. There continue to be reports Gurley won't be on the active roster until Week 4 or 5, but watch his practice participation closely.

victor cruz | calf strain | week-to-week

Cruz hasn't practiced in nearly a month. His calf strain is clearly a mid-grade injury. Generally, once a player has missed more than two weeks with a muscle strain, it takes at least 1-2 weeks of slow reconditioning before a return. Week 3 is the earliest we'll see Cruz and it could well be longer.

julius thomas | fractured hand / tendon repair | week-to-week

Thomas is not expected to return to action until at least Week 4. But that may prove to be optimistic. He may not be able to practice for at least two more weeks. Tendon repairs must be carefully managed in the first four weeks to ensure the healing process isn't disrupted. 

tre mason | hamstring strain | week-to-week

Mason continues to recover from an aggravated hamstring strain. Reports last weekend hinted he was close to returning, but he needs to return to practice and make it through consecutive workouts before I'll feel comfortable projecting him to return to the gameday roster.


AROUND THE TRAINING TABLE

Breshad Perriman (PCL) and Geno Smith (jaw) should be nearing a return to practice. Josh McCown and Dion Sims are both in the concussion protocol. Eugene Monroe (concussion) has a chance to return for Week 2, but D.J. Fluker (ankle) is likely to miss multiple weeks with a high ankle sprain after having his leg rolled up on.

Terrell Suggs is out for the season with a torn left Achilles. He partially tore his right Achilles in 2012. Luke Kuechly is in the concussion protocol. His mechanism of injury was also concerning for a neck sprain. Consider Kuechly questionable for Week 2. Reshad Jones has a hamstring strain. Sam Barrington has an ankle injury. Duke Ihenacho (fractured wrist) and Antonio Cromartie (likely ACL+) will probably be ruled out for the season on Monday.

I'll be updating this feature throughout the day. Footballguys Insiders will get a full update with additional fantasy perspectives on Wednesday, with analysis of the week's game-time decisions early Sunday morning. Follow me on Twitter @JeneBramel for breaking injury news and analysis throughout the week.