Why so many NFL injuries this season? One sports-medicine doctor thinks he knows why


Week 2 in the NFL was a bloodbath from an injury-standpoint.

Among the big-name players who went down included Carolina Panthers running back Christian McCaffrey (ankle), New York Giants running back Saquon Barkley (ACL), Seattle Seahawks defensive end Bruce Irvin (ACL) and Denver Broncos wide receiver Courtland Sutton (ACL).

In addition, the San Francisco 49ers were hit particularly hard that week. Quarterback Jimmy Garoppolo (high-ankle sprain), Pro Bowl defensive end Nick Bosa (ACL), running back Raheem Mostert (high-ankle sprain) and others in their victory over the New York Jets.

Injuries, of course, are an every-season occurrence. And early-season injuries — especially with specific types of injuries — are more common on an annual basis.

But the NFL’s unusual offseason, which was altered significantly because of the COVID-19 pandemic, has added a different layer to how injuries appear to be occurring during the 2020 NFL season. It wasn’t just because of the particularly wicked Week 2, either.

What we’ve seen through the course of this season is a sharp increase in soft-tissue injuries — and specific ones, such as ruptured Achilles tendons, appear to be registering at fairly alarming rates. There appears to be a direct correlation between the lack of a typical offseason program and the increased soft-tissue injury rate.

Nick Bosa's season-ending injury was part of an early-season rash of ailments that might be tied to an unusual NFL offseason. (Photo by Sarah Stier/Getty Images)
Nick Bosa's season-ending injury was part of an early-season rash of ailments that might be tied to an unusual NFL offseason. (Photo by Sarah Stier/Getty Images)

Dr. Lyle Cain, who is an orthopaedic surgeon and sports medicine specialist at the Andrews Sports Medicine & Orthopaedic Center in Alabama, has studied the data — in both college football and the NFL — to this point and believes there’s a clear connection.

“Back when COVID was getting started in March, April, May, most of us were worried about soft-tissue injuries — hamstrings, Achilles and things like that, where you have to have a certain amount of elasticity and tissue compensation built up in your system to be able to handle really quick, explosive movements,” Dr. Cain recently told Yahoo Sports.

“We’ve certainly seen that. There probably have been more soft-tissue injuries to date in college and NFL than we normally see this time of year.”

There have been several studies on the incidence of Achilles injuries over the years, and it has gone from a fairly rare occurrence to a surprisingly more common one.

One study showed that between the 1997 and 2002 NFL seasons, there were a mere 31 Achilles tendon ruptures — an average of 5.2 per year — with 35 percent of those occurring during the preseason. Another study looked at the 2009 through 2016 seasons and documented 101 cases, or roughly 12.6 per year, with a whopping 64 percent of those injuries happening during training camp or the preseason.

In 2020 alone, we’ve officially had 15 NFL players go down with Achilles-related injuries. Of those 15, only one — Baltimore Ravens cornerback Jimmy Smith — is not on injured reserve.

The list of Achilles sufferers includes Buccaneers tight end O.J. Howard, Raiders offensive guard Richie Incognito, Eagles guard Brandon Brooks, Giants pass rusher Lorenzo Carter, Colts running back Marlon Mack and safety Malik Hooker, Browns rookie safety Grant Delpit and Washington Football Team safety Landon Collins.

The absence of a standard run-up to the season appears to be a major contributing factor. The NFL closed all team facilities prior to training camps opening and canceled the entire preseason.

“Realistically, in the NFL and in college football, not having that spring and summer prep — for the NFL, the OTAs and minicamps — [losing] all that preparation time they have, I think it’s probably very detrimental for their injury risk,” Dr. Cain said.

“They just hadn’t done football-related activities for so long. It doesn’t matter how hard you train, you can try to simulate that as much as you want in a training room, but it’s really difficult to simulate football unless you’re playing football.”

Will the trend continue? In Dr. Cain’s experience, soft-tissue injuries almost always wane as the season goes on.

But there’s a fear that players, in general, might not yet be out of the woods yet.

The preseason debate rages on

Some people would like to see the preseason eliminated. Some, mainly coaches, feel four preseason games remains best. Others feel a two-game exhibition season would be just right.

Dr. Cain doesn’t want to wade too far into that debate, even though he certainly understands the purpose for preseason games. For players, it’s a chance to acclimate their bodies for the season to come. For the teams, it’s their dry-run opportunity to grade players’ performances in game-like situations and help craft their rosters.

But what Dr. Cain knows from his own experience is that soft-tissue injuries tend to occur more often early in the season than later.

“Even going down to the high school level, for years we’ve noticed that a lot of the injuries happen early in the season,” he said. “We have a Friday night injury clinic in our offices for football injuries for a lot of high-school teams across Alabama. The first two, three or four weeks of the season, we’ll have 25 kids in on a Friday night.

“By midseason, that number is down to four or five kids [per week] on average.”

In 2011, the NFL endured a four-month lockout as the NFL Players Association and the league’s owners fought tooth and nail over a new labor agreement. A deal finally was struck on July 25 of that year, and players headed back to work shortly thereafter.

There was joy all over the NFL then. But reality sunk in soon after when the effects of a missed offseason program were felt.

Landon Collins of the Washington Football Team is one of an unusually high number of players who have suffered Achilles injuries in 2020. (Photo by Patrick McDermott/Getty Images)
Landon Collins of the Washington Football Team is one of an unusually high number of players who have suffered Achilles injuries in 2020. (Photo by Patrick McDermott/Getty Images)

In only the first 12 days of camps opening that year, there were a reported 10 Achilles tendon injuries — a stunningly high rate. Two additional Achilles injuries were reported over the following 17 days, which included the first two weeks of preseason action, according to a report in Journal of Orthopaedic & Sports Physical Therapy.

“If you look back to the 2011 data, it was about double the normal incidence than before, and they were mostly early in the season,” Dr. Cain said. “Very rarely do they happen at that rate later in the season.”

This has been the working theory in sports medicine circles: that the 2011 season was the closest comparable to what we’ve seen this year in the NFL. The one major difference? No preseason.

The good news? In Dr. Cain’s experience, the high rate of Achilles injuries isn’t likely to keep going.

“Generally, you don’t see nearly as many Achilles injuries mid-to-late season,” he said. “They’re almost always early-season injuries. Probably because the Achilles is just not used to that caliber of load that early in the year.”

The bad news? If we consider that the first four weeks of the regular season are, in essence, replacing this year’s preseason to a certain degree, then there still might be players who are in that early-year risk window.

A separate study showed that Achilles injury risks were highest in the first four weeks of the regular season, followed by the second group of four games, where it was still relatively high, before a significant dropoff occurred.

But as the NFL enters Week 8, in a year with no preseason, it appears some players remain in a danger zone.

Are turf fields to blame?

The Journal of Orthopaedic & Sports Physical Therapy report, studying the 2009 through 2016 studies, showed that 56.8 percent of Achilles injuries occurred on turf surfaces, versus 43.2 on grass. And yet by the end of that time period, 18 of the NFL’s 31 stadiums were played on natural grass.

It’s clear that turf surfaces — even with advances to make them safer — have generated a higher rate of injury, especially when it comes to Achilles ruptures.

“I think there’s no question, from a medical standpoint, that turf is harder on the body than natural grass,” Dr. Cain said.

The 49ers certainly are likely to accept that as gospel. It was on New York’s MetLife Stadium surface in Week 2 against the Jets where they lost five starters, including two who suffered ACL tears in a three-play span.

Prior to playing back on that same field against the crosstown Giants the following week, 49ers head coach Kyle Shanahan expressed concern about the “stickiness” of that field’s surface.

“You’re talking about stuff gripping ... too much,” Shanahan said. “I would think the only thing you could do is take off cleats [and use turf shoes], which isn’t fun either.”

Previously, MetLife had UBU Sports Speed Series S5-M Synthetic Turf — a surface that had been hailed as one of the safest during previous years’ studies. But in June, MetLife was switched to FieldTurf Classic HD, which is also used at Detroit’s Ford Field.

“Hopefully we’ll get something from the NFL that makes us feel better about that, but I know the players and our equipment guys will be looking at everything possible to help us with that turf,” Shanahan said.

Thankfully, the 49ers escaped that next game nearly injury-free. But the turf debate rages on.

Cleveland Browns center J.C. Tretter, the president of the National Football League Players Association, wrote a letter earlier on the NFLPA site this month explaining why he thinks turf is so dangerous.

“As a rookie learning the ins and outs of being a professional football player, I remember the collective groan that my older teammates made whenever it was announced that we’d be practicing indoors on artificial turf instead of the usual outdoor grass field. I played almost exclusively on synthetic turf in college.

“Once I started experiencing both surfaces interchangeably, I began to understand exactly why my teammates disliked the practices on turf. Whenever I practiced on an artificial field surface, my joints felt noticeably stiffer the next day. The unforgiving nature of artificial turf compounds the grind on the body we already bear from playing a contact sport.”

Cleveland Browns center JC Tretter believes turf fields are a major contributor to NFL injuries. (AP Photo/Rick Scuteri)
Cleveland Browns center JC Tretter believes turf fields are a major contributor to NFL injuries. (AP Photo/Rick Scuteri)

But with the Los Angeles Chargers and Los Angeles Rams having opened SoFi Stadium, almost half of the NFL’s 32 teams now play on some kind of artificial surface. Tretter and other players are not fond of this development, citing the NFLPA studies that have shown a direct correlation between turf and higher injury rates.

It shows that NFL players have a 28 percent higher rate of non-contact, lower-extremity injuries on artificial turf, based on NFL injury data collected from 2012 to 2018. And among those non-contact injuries, players endured 32 percent more non-contact knee injuries and a 69 percent rate increase of non-contact foot and ankle injuries on turf compared to grass.

Dr. Cain explains why.

“The thought process is that certain types of turf and certain types of cleats do result in a sticky surface, almost like velcro,” Dr. Cain said. “So when you have velcro on the bottom of your foot and it doesn’t release when you twist or turn, it can cause a lot of injuries. That has been the downside of turf going back to the 1980s, when turf really first came out.”

Turf, however, isn’t going away. You can’t grow grass in indoor stadiums readily, and certain outdoor stadiums in poorer-weather cities are forced to use synthetic or hybrid surfaces.

But Dr. Cain believes the NFL’s advances with turf-field study, along with matching each specific surface with the proper footwear, should help level things off a bit.

Typically, players are informed which shoes to wear for games with a “traffic light” indicator. Teams will post signs in locker rooms with three types of recommendations — “green” shoes are most recommended for whatever surface they’re on that day, “yellow” represents a wear-with-caution recommendation, and “red” means that a certain type of shoe is not recommended for that particular surface.

In addition, the NFL has implemented something called “The Beast” (which stands for “Biocore Elite Athlete Shoe Turf Tester’). It’s a device that was created to mimic the type of powerful loads and torque that NFL players generate when hitting the ground, how much force it takes to release cleats from different surfaces and whether players’ bodies typically will fall below the tensile-strength threshold before significant injuries such as torn ACLs, ruptures Achilles and sprained or rolled ankles occur more frequently.

It’s not foolproof, but it’s believed to have helped mitigate some of the injury incidence.

“The NFL has really done an outstanding job testing their turf,” Dr. Cain said. “[NFL chief medical officer Dr.] Allen Sills and the NFL were showing us some of the advances in this area at a meeting we attended last spring.

“It’s a whole vast science, really, and what they’ve found is that certain cleats on certain turf can be really dangerous. And it gets down to the little details of the different turfs — the weave, thread count, depth of crushed rubber in there. They’ve even studied how it changes throughout a season.”

In addition to field conditions changing as players trod on fields continually, moving the small rubber granules around, which requires regular field maintenance, there also are atmospheric effects based on the time of year, with temperature, humidity and wind acting as compounding factors.

“Even with maintenance and moving those granules around, it’s a real science and pretty exacting how it’s supposed to be done properly,” Dr. Cain said.

There’s also the length of the turf surfaces that appear to have a notable effect.

“Having half an inch of rubber, compared to three-quarters of an inch of rubber, what they’ve found is that there’s a vast difference in how it performs,” he said.

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