Sports Rehab Write-Up: QB Anthony Richardson
It’s the popular sentiment, the settled science, the conventional wisdom…
You’ve got to slide!
That’s what we were all thinking when we saw Colts Rookie QB Anthony Richardson go down in visible agony — desperately reaching for his throwing shoulder after a huge hit in the 2nd quarter of their matchup with the Tennessee Titans.
We all want our star QB to slide instead of taking those big, punishing hits, but some guys just can’t! We’ve got the guys who duck & dive, and then we’ve got the guys who embrace the contact -- that’s not always the best move long-term!
Richardson, the Number 4 pick from this year’s draft, has been making regular appearances on the injury report this season – suffering a knee injury in Week 1 & a concussion in Week 2. So, in 4 games played, we’ve seen 3 injuries; and, unfortunately, the latest is season-ending…
According to sources close to the team, the rookie QB suffered a Grade 3 AC joint sprain. Interestingly enough, Richardson suffered a lower grade AC sprain in that same right, throwing shoulder during his last season of high school football and treated it conservatively. So what’s so different this time around?
Diagram of the Shoulder Joint (Mall et. al; 2013)
AC, or Acromioclavicular, joint injuries are all unique & fairly variable, with six agreed upon grades, or types, based on the level of severity and structures involved.
The 6 classifications of AC Joint Injuries (Berthold et. al; 2022)
We see Richardson take off to his right during a designed run before he gets tackled from behind by a Titans defender, who falls on top of the QB, driving him shoulder-first into the turf. If we look more closely at the tackle, before his shoulder meets the ground, we can see Richardson’s elbow held close to his side & slammed down almost perfectly vertical, sending an upward force through the length of his arm that would definitely result in some damage to the connecting ligamentous & bony structures of the shoulder. This is actually a pretty textbook case -- most AC injuries occur in a similar fashion to Richardson’s!
“The highest prevalence of AC joint injuries have been reported in 20- to 30- year old male patients participating in high contact sports, with AC joint injuries generally accounting for 12% of all shoulder injuries in the overall population. The mechanism of most AC joint injuries is a direct fall on the superolateral aspect of the shoulder with the arm in an adducted position. In contrast, indirect injury occurs by falling on the outstretched arm, causing the humeral head to translocate superiorly and drive the humeral head into the acromion. ”
So that explains the mechanism, but Richardson suffered a Grade 3 sprain, specifically. What does that mean long-term?
Grade 3 AC joint sprains are actually the most controversial classification of the six possibilities!
Grades 1 & 2 are essentially always treated conservatively with a little shoulder strengthening & some time off of the field – more so a pain management situation for the pros. Conservative management strategies for low-grade AC injuries have shown better outcomes as far as return to sport & of course avoid the potential complications of surgery (Berthold et. al, 2022). On the other hand, any AC joint injury from a Grade 4 to 6 should be treated surgically as you’d see significant structural damage beyond what can be managed with muscular stabilization.
Grade 3’s are a bit trickier, though! To this point, when factoring in the potential pitfalls of an operative procedure, there hasn’t been any study to show a significant advantage for surgery over conservative treatment. There are studies that suggest that surgical intervention may result in less pain and better muscle endurance in the long run, specifically for those who participate in any significant overhead work which does include professional quarterbacks! So how do we decide?
Well, we’ve started breaking Grade 3 sprains down into two subgroups to better identify which patients would benefit from surgical intervention. According to the report by Beitzel et. al,
“ The findings of the ISAKOS Terminology Project resulted in a new suggestion for the Rockwood classification by further subdividing the type III AC joint injuries into type IIIA (stable) and type IIIB (unstable). The basis for the sub-classification is primarily functional rather than anatomic, but special radiographic views may provide the necessary objective information. Unstable type III lesions (type IIIB) will continue to cause pain, weakness during rotator cuff testing, decreased flexion and abduction range of motion, and demonstrable scapular dyskinesis on observation.”
So it seems like the Colts medical staff figured Richardson had the unstable type of grade 3 injury – either that or they figured it best not to risk long-term functional deficits! Wouldn’t be very surprised if Richardson had some lingering instability in that shoulder before this latest injury, as well — not only from that sprain in high school, but from the repetitive hits and constant power-throwing too!
With Richardson officially sidelined for the rest of the season, can we expect him to be good to go for next year?
We can pretty safely assume Richardson will be back better than ever! The average time to return to sport in the general athletic population is 4-months & 84-percent return to their prior level of function within that time (Verstift et. al; 2019). According to a 2013 study by Lynch et. al, looking retrospectively at NFL players that suffered AC injuries, those who required surgical management were sidelined for an average of 56.2 days. That’s a pretty quick turnaround from Lynch’s study, but the study also didn’t really differentiate between severity of injury or various surgical approaches! We’ve also got to consider that a quarterback rehabbing his throwing shoulder might need a bit more time off! The 4-month estimate seems much safer!
Richardson might not be able to win Rookie of the Year anymore, but with plenty of time off & a chance to really lock into his rehab, Comeback Player of the Year might very well be in the cards!
Works Cited & Further Reading
Mall, N. A., Foley, E., Chalmers, P. N., Cole, B. J., Romeo, A. A., & Bach, B. R., Jr (2013). Degenerative joint disease of the acromioclavicular joint: a review. The American journal of sports medicine, 41(11), 2684–2692. https://doi.org/10.1177/0363546513485359 (picture)
Berthold, D. P., Muench, L. N., Dyrna, F., Mazzocca, A. D., Garvin, P., Voss, A., Scheiderer, B., Siebenlist, S., Imhoff, A. B., & Beitzel, K. (2022). Current concepts in acromioclavicular joint (AC) instability - a proposed treatment algorithm for acute and chronic AC-joint surgery. BMC musculoskeletal disorders, 23(1), 1078. https://doi.org/10.1186/s12891-022-05935-0
Beitzel, K., Mazzocca, A. D., Bak, K., Itoi, E., Kibler, W. B., Mirzayan, R., Imhoff, A. B., Calvo, E., Arce, G., Shea, K., & Upper Extremity Committee of ISAKOS (2014). ISAKOS upper extremity committee consensus statement on the need for diversification of the Rockwood classification for acromioclavicular joint injuries. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 30(2), 271–278. https://doi.org/10.1016/j.arthro.2013.11.005
Verstift, D. E., Welsink, C. L., Spaans, A. J., & van den Bekerom, M. P. J. (2019). Return to sport after surgical treatment for high-grade (Rockwood III-VI) acromioclavicular dislocation. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 27(12), 3803–3812. https://doi.org/10.1007/s00167-019-05528-w
Lynch, T. S., Saltzman, M. D., Ghodasra, J. H., Bilimoria, K. Y., Bowen, M. K., & Nuber, G. W. (2013). Acromioclavicular joint injuries in the National Football League: epidemiology and management. The American journal of sports medicine, 41(12), 2904–2908. https://doi.org/10.1177/0363546513504284
