Thoughts on RG3's knee rehabilitation, the blame game, and what to expect when he returns

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A week has passed since Robert Griffin III’s knee surgery, enough time for the enormity of the injury to sink in. Here’s what I’m thinking:

It seems ambitious to expect Griffin to be at full strength by Sept. 8, 2013, the opening Sunday of next season. Ambitious, but not impossible. That’s my sense after speaking to three orthopedic surgeons (none of whom have examined Griffin), several players who have had ACL reconstruction surgery and one player who had the same ACL reconstruction revision surgery as Griffin did.

Griffin had surgery on Jan. 9, so he has one day shorter than eight months to be ready for the first game. Some athletes have returned to activity from ACL reconstruction revision surgery in six months, orthopedists said, but “returning to activity” is different than playing quarterback at a Pro Bowl level.

I’ve heard different opinions from orthopedists about how Griffin’s lateral collateral ligament repair might affect the timetable of his recovery. One said it could delay the short end of the timetable to eight months instead of six. But we know orthopedist James Andrews, who operated on Griffin last week, expects Griffin to be ready for the start of the season, so that tells us what Andrews believes about the impact of the LCL repair.

Ultimately, it’s impossible to know at this point whether Griffin will be on the field for the Redskins’ first game, and, if he does play, whether he’ll be his explosive, electrifying self. The many variables, according to orthopedists, include the expertise with which Griffin’s original ACL reconstruction was performed by Dr. Mark Adickes, the expertise with which Andrews revised that reconstruction and repaired Griffin’s medial meniscus last Wednesday, whether Griffin’s bone structure was damaged as part of the injury and how smoothly his rehabilitation progresses.

One thing I’m certain of: I would not bet against Robert Griffin III. He is incredibly determined and motivated. He embraces hard work. He does not shy away from challenges. He is strong mentally. He went through an ACL reconstruction rehab in 2009-10, so he should understand when to push his body and when it’s best to back off.

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I don’t find much value in assigning blame for Griffin’s injury, but I do think it’s important to understand who and what enabled it to happen. For me, that’s essential to accepting the hardships ahead of Griffin and the uncertainty that presents for the franchise, and to understanding the elements involved in future cases of Redskins playing hurt.

There were many contributing factors to this collective failure, as my colleague John Keim at the Washington Examiner aptly called it: sideline evaluations by team trainers and doctors; Griffin’s stubbornness and insistence on playing; the tough-guy culture of football that fostered Griffin’s mentality and coach Mike Shanahan’s willingness to acquiesce to it all.

Keeping Griffin out of the game was akin to stopping a freight train without brakes. Dan Le Batardsummed it up brilliantly in his must-read column Sunday in the Miami Herald. His commentary on the macho, cutthroat culture of pro football provided chilling detail about what former Miami Dolphins and Redskins DE Jason Taylor went through to play in his illustrious career. Le Batard wrote:

“Everything is lined up to get the unhealthy player back on the field — the desire of the player, the guy behind you willing to endure more for the paycheck, the urging of the coaches and teammates, the culture that mocks and eradicates the weak and the doctor whose job it is not necessarily to keep the player healthy but healthy enough to be valuable to the team, which isn’t the same thing at all. The doctor gives the player the diagnosis and the consequences on the sidelines with in-game injuries, without the benefit of an MRI, and then the player makes a choice with the information…and the choice is always to play.”

Over the last week, my thought process has centered on Redskins team doctors and athletic trainers, not Shanahan. I keep coming back to the question: how in the heck could the medical staff have continued to clear Griffin throughout the Seattle game?

Let’s start with the head coach, though. If team doctors/trainers told Shanahan that Griffin was cleared to play, and Griffin told Shanahan he felt OK to play, then why would Shanahan keep Griffin on the sideline after Griffin aggravated his knee injury on the second drive? That’s a no-brainer for Shanahan to send Griffin back in.

From that point, it was up to Shanahan to watch Griffin closely for signs of injury and ineffectiveness, both of which I (and many other analysts and fans) believe Griffin showed by the fourth quarter. Shanahan, however, deserves the credibility and benefit of the doubt that comes with 38 years of coaching experience. I respect that, even though I believe he should have been more skeptical of Griffin’s insistence on playing and the medical staff’s clearance of Griffin. At the very least, the months-long rehabilitation ahead of Griffin proves that.

I understand the difficulty in recognizing signs of Griffin’s injury from Shanahan’s vantage point on the sideline, but Shanahan after re-watching the game film said he was comfortable with his decision making. I’d love to re-watch the game with Shanahan and ask him what he’s seeing as Griffin limps to the Seahawks sideline or underthrows a deep pass that was intercepted. I’m genuinely curious because I do believe Shanahan could have reached the point of removing Griffin from the game.

Just keep in mind this is the same Mike Shanahan who nearly died because of his insistence to push through a ruptured kidney he suffered while playing football at Eastern Illinois. It’s the same head coach who famously convinced Denver RB Terrell Davis to re-enter Super Bowl XXXII in order to sell a play-action pass even though Davis couldn’t see because of migraine headaches (see the 2:00 mark of this clip). Davis’ injury was different than Griffin’s, but it’s an indication of the mentality and culture involved in such instances. That clip is full of coaches and players praising Davis’ guts and courage. That’s the NFL culture. I’m not saying it’s right or wrong; that’s just the way it is.

But as I said, I find myself thinking less about Shanahan and more about how the Redskins medical staff continued to clear Griffin to go back on the field throughout that game. And with that focus comes several questions to which we’ll likely never know the answers because team doctors, head athletic trainer Larry Hess and his staff do not speak to the media. And even if we reporters did get the opportunity to ask our questions, how could we be sure the answers were truthful?

Among my unanswered questions: Who evaluated Griffin during the Seattle game? What tests did they perform on him? How did the testing evolve as the game progressed? How did Griffin’s insistence on playing affect the medical staff in any way? Who reported to Shanahan during the game and what was said? What were trainers thinking and seeing as Griffin limped around the field, especially after he was sacked in the fourth quarter by Seattle DE Bruce Irvin, the play on which Shanahan believes Griffin suffered the ACL injury, according to the NFL Network?

From there we could discuss the competency of the Redskins medical staff, but I don’t think that’s productive. You won’t hear players such as RT Jammal Brown and former SS LaRon Landry singing its praises, but that same staff helped WR Pierre Garcon, LT Trent Williams and ILB London Fletcher stay on the field to help the team win the division this season.

All we can say for sure about the medical staff in Griffin’s case is that the staff cleared Griffin and now Griffin faces a months-long rehabilitation that jeopardizes his availability for the start of 2013. Somewhere in there exists either a critical breakdown or some terrible, terrible misfortune.

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Use caution when invoking Minnesota Vikings RB Adrian Peterson as an example of how quickly and strongly Griffin might return from knee ligament surgery. Dr. James Andrews operated on Peterson and Griffin, but two critical differences exist between their situations.

1. They suffered different injuries. Griffin tore the patellar tendon graft that was serving as the ACL in his right knee, his LCL and suffered medial meniscus damage. Peterson tore his ACL, medical collateral ligament and damaged both medial and lateral meniscus.

2. This is Griffin’s second ACL reconstruction (known as a “revision”). Remember that he tore the ACL in the same knee in 2009 while at Baylor. In contrast, Peterson’s ACL reconstruction was his first.

In this NFL.com article published on Nov. 15, Peterson’s father recalled how Andrews marveled at the pristine condition of Peterson’s knee. Griffin’s knee surely isn’t in the same condition, given his previous ACL reconstruction.

“The Adrian Petersons of the world are unusual, who perform at that high of a level starting at eight months after surgery,” said Rick Wright, professor in the department of orthopedic surgery at Washington University’s School of Medicine and the head team physician for the NHL’s St. Louis Blues. He is the principal investigator of a leading ACL revision study that’s funded by the National Institutes of Health.

“The athletes will tell you that they really kind of feel back to normal and stop thinking about their knee so much at about 12 months,” said Wright, who has not examined Griffin.

Look at former Redskins RB Tim Hightower. His injury was less severe than Peterson’s – Hightower tore only his ACL and meniscus – AND James Andrews performed his surgery, yet he still is unemployed 16 months after his injury. He required a second surgery to repair his meniscus after the Redskins released him last Aug. 31.

And take Redskins LG Kory Lichtensteiger. It took him nine months to return to practice after surgery to repair his torn ACL, MCL and meniscus in late Oct. 2011. And yet he required another surgery soon after returning and missed all of training camp. And Lichtensteiger, like Hightower, had not previously torn his ACL.

All of that proves Griffin’s six-to-nine-month timetable is not guaranteed. It’s a framework based on precedents.  

Fans should begin making friends with the concept of Kirk Cousins starting the 2013 season as the Redskins’ starting quarterback. It would a bonus if Griffin returned in time.

Considering Griffin’s value to the franchise and its investment in him, it’s easy to see the prudence in placing Griffin on the reserve/physically-unable-to-perform list at the start of training camp and keeping him there through the start of the regular season. That would force him to rehab for at least an extra six weeks and render inconsequential any desire (or, knowing Griffin, insistence) he and/or coaches might have to rush him back. Of course, that’s getting too far ahead of ourselves. That decision must wait for Griffin’s rehab to progress. Just something to keep in mind, though.

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Whenever Griffin returns, he’ll face some unnerving statistics regarding the probability that his third ACL lasts. 

Dr. Wright, the principal investigator of the ACL revision study, says the failure rate of ACL revisions is 13-15 percent, compared to a 5-8 percent failure rate of primary ACL reconstructions.

“You don’t know why that is,” said Wright, whose study is attempting to determine reasons and should near completion in about six months. “Is it because it’s just one of those people that are prone to failure? Is it because the people that fail are the ones that went back to the highest level of activity? You don’t really know, but the people that fail are more likely to fail again.”

Wright reiterated that the increased likelihood of failure doesn’t necessarily mean Griffin is doomed.

“We’re still talking about relatively decent numbers of the graft holding a second time,” he said. “When you look at big groups, they just don’t do as well as they did after their first one. We don’t know why that is. It doesn’t mean that any individual patient won’t have a great outcome, but in general if you look at 100 re-dos, they don’t do as well as 100 first-timers.”

That leads to more questions about Griffin’s return, including: Will he ever feel the way he did before this injury? If he doesn’t, will that affect his performance? Will he wear a brace and suffer the accompanying limitations?

The list of NFL players playing on their third (or fourth) ACLs is short: Carolina Panthers LB Thomas Davis, Pittsburgh Steelers NT Casey Hampton and New York Giants WR Domenik Hixon are the only ones I know of.

Former Redskins LB Jonathan Goff required ACL revision surgery in August after he re-tore the ligament during the Redskins’ first training camp practice in pads. Like Griffin, Dr. James Andrews revised his ACL reconstruction using a patellar tendon graft from his left (healthy) knee). The rehab and recovery is “a little bit different” than that from his first ACL reconstruction, Goff said.

“Since the graft does come from your other leg, it does take a little bit more time,” he said. “You have to pay a little bit more attention to that leg, too.

“They’re just taking out a chunk from your knee, so it’s not the best feeling in the world. But since the beginning, it has been strong and sturdy. It’s just that there’s a fair amount of pain management and soft-tissue work that you go to do to keep it moving.”

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Dr. Wright is not convinced Griffin would benefit from platelet-rich plasma therapy. That’s the process of spinning one’s blood to separate a high concentration of platelets, a type of blood cell, and then injecting it back into one’s body to promote healing.

“There’s not been any strong evidence the PRP treatments enhance the ACL graft or the ACL recovery,” Wright said. “I’m not saying we won’t know that in 10 years, but so far there’s been no studies that have shown that that’s what we should all be doing.”

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If the Redskins really want to preserve Griffin’s health going forward, they would demand that he throw the ball away when pressured or when his receivers are covered. The issue isn’t the amount of designed runs Mike and Kyle Shanahan call for him. Griffin’s serious injuries this season occurred on passing plays when he scrambled.

The problem there is that Griffin’s ability to extend plays with his legs, and in some cases run for positive yards, is a big part of why he’s so effective. How could coaches tell him to ignore his instincts and work away from what makes him a great player?

Griffin completed 65.6 percent of his passes, second most ever for a rookie. A big reason why: he rarely throws the ball away.

“I think the day I think about throwing the ball away at the beginning of a play, I should stop playing,” Griffin said on Dec. 19, the Wednesday between the Cleveland game he missed and his return against Philadelphia. “I just think that’s a faulty approach to the game, but I get where everyone is coming from.”

That mindset is evidence Griffin might have difficulty changing to a safer style behind the line of scrimmage.

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Designed runs do expose Griffin to contact, though, so they’re a factor in preserving his health. If the Redskins want to reduce the number of quarterback runs and have Griffin throw it more, they better have offensive linemen who can pass protect.

It has been the Redskins’ plan all along, even before the injury, to rely less on Griffin’s designed runs and more on his arm as he develops as an NFL passer. Those runs, however, served another purpose: to compensate for an offensive line that does not excel when the quarterback has to drop back to pass all game.

Keeping defenses off-balance this season using Griffin’s quarterback runs helped the offensive line immensely. The hesitation the option game created among defenders enabled Redskins linemen to get favorable leverage on blocks, and it kept defenders guessing between run/pass and who had the ball.

The zone running game remained the core of the Redskins’ offense. That’s how coaches like it and that’s how it will remain. The Redskins could, if they believe Griffin is capable as a passer, reduce the quarterback runs and operate the offense QB Rex Grossman ran in 2011 (and QB Kirk Cousins ran against Cleveland) – with tons of play-action passes on bootlegs and keepers. We’ll get an idea of their intentions from how they address the offensive line in free agency and the draft.

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Let’s end on a positive note, shall we?

QB Rex Grossmandoesn’t believe Griffin will suffer from missing the Redskins’ offseason program. In fact, Griffin will find ways to improve as a quarterback if his response to this injury is anything like how he handled himself at Baylor in 2009 after tearing his ACL.

When I went to Baylor for Griffin’s Pro Day last March, coach Art Briles and offensive coordinator Philip Montgomery described to me how Griffin matured and grew as a passer during his rehabilitation, which cost him most of the 2009 season.

“Something was taken away from him that he loved – football,” Briles said. “He got to see how much he missed it. He got to look at it from a different perspective – from the sideline with the headphones and in the press box, watching practice, watching tape from a different perspective. He wasn’t watching himself as much as he watching schemes and understanding the intricacies of why they should work in this situation. That part of it was a natural maturing process that he handled extremely well.”

Added Montgomery: “It was rough on him. He had never been hurt. It allowed him, No. 1, to physically develop a little bit more. He got to put on some good weight, get a little bit stronger. He worked his tail off, now. It also let him sit back and watch the game and see things and how things were happening on the field. It was like that redshirt year that he didn’t have. But he already had a taste of it and knew what he was looking for and what he could do if he was in that situation, so it was an even better scenario from that standpoint of, OK, it’s been taken away from me. When he came back, he worked every day like it was the last because it had been taken away. When you have something like that that you love and then you finally get it back, it was special.”

So the next time we see Griffin, and I’m not sure when that will be, it’s safe to assume he will have watched a ton of game film.

…If you’re reading this, you made it to the end! Thank you for your time. I know this was a long one.

If you’d like to share your thoughts or have feedback about mine, please leave a comment, email me at rcampbell@washingtontimes.com or hit me on Twitter @Rich_Campbell.

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