Is Aaron Rodgers going back too soon?
As everyone in the great state of Wisconsin (my original home state!), with an interest in football, or with access to the internet knows, Aaron Rodgers is approaching a comeback. October 15th, he was tackled by Anthony Barr of my current home state Vikings and fractured his clavicle (collarbone). He underwent surgery October 20th. Per report, he had 13 screws and 2 plates applied. He is now 7.5 weeks (53 days) from surgery....so the question of the hour is: Can he play?
Important disclaimer: I haven't taken care of Aaron Rodgers, nor do I know surgical details beyond those of the linked article above. Opinions are my own!
Clavicle fractures are common, and treatment is controversial. Essentially, we have two options: nonsurgical management (let it heal the way it is). Or surgical management (plate and screws).
Advantages of nonsurgical management:
Healing is potentially quicker (believe it or not)
Avoid the risks of surgery (infection, nerve injury, bleeding, plate fracture, incision healing problems)
Advantages of surgery:
Lower risk of the bone not healing at all (called nonunion - no there won't be a quiz at the end of this)
More "anatomic" repair
For generations, clavicle fractures were treated without surgery, sometimes with complex slings (anyone remember figure of 8 slings?) or manipulation. None of this seemed to change outcomes. Then, an excellent study from Canada demonstrated improved functional outcomes with surgical fixation. This was demonstrated as a minor, but significant, improvement in overhead endurance with surgery. This led to a paradigm shift and renewed interest in fixing fractures surgically (which many argue can be dangerous if overdone!).
Recent literature has challenged the finding that shoulder function is improved with plate fixation, but most evidence continues to point to a small, but significant functional improvement with plate fixation. In addition, this makes sense when you consider the amount that these fractures can displace (see below)
As you can see, the bone is badly broken, with a small "butterfly" piece of bone. In addition, the alignment has changed - leaving the shoulder hanging lower and closer to the body. This makes the muscles of the shoulder less efficient.
For the average Joe, or even in the non-throwing arm of Aaron Rodgers, this is sometimes acceptable (he broke his left clavicle in 2013 and was treated without surgery...although his fracture likely didn't look as bad as the above picture!)
However with the current fracture being on his throwing side, and with a fracture that may have been more displaced (in worse alignment), the decision was made to go forward with surgery- certainly a reasonable conclusion on one of the most valuable arms in the world! This begs the original question: Is it healed enough to play?
While many options have been described to treat clavicle fractures, plate and screw fixation is by far the most common. An incision is made over the bone, and the muscle is divided to identify the clavicle and the fracture. The early healing tissue is removed, the clavicle ends are cleaned, and the bones are realigned. Typically, this is able to completed with an anatomic (or perfect) reduction. Large plates and screws are applied to the bone to hold it in position while it heals. This is all fairly standard. The muscle and skin are closed and the patient goes home.
As mundane as that sounds, the real battle is just beginning. There is now a race that is happening between two opposing forces: healing (good) and hardware failure (bad). If the bone heals before the hardware fails, the good guys win. If the hardware fails before the bone heals, it's bad news. The plates can fracture, the screws can cut out through the bone, and the clavicle will not heal. Fortunately, this only happens in about 2% of patients...in this battle, the good guys almost always win.
In most cases of plate failure, there is a slow, fatigue failure...the analogy to this is a paperclip that is bent back and forth too many times and snaps. In most cases, patients hardly know it has failed. Oftentimes, there is no real reinjury. This type of failure is much different than what we would be concerned for Aaron Rodgers about - a violent (and unpredictable) injury. While Aaron Rodgers is unlikely to fail by standard ways (with fatigue failure over time), the concern is that a violent hit could bend or break his plate.
Ultimately, ensuring that his bone is healed is the only reliable way to avoid his plates bending or breaking the first time he gets buried by a 350lb lineman. That being said, there are a few things the surgeon can do to make his clavicle as strong as possible early in his recovery:
Use a stainless steel plate (titanium plates are common and may help in healing of certain fractures, but are much easier to bend)
Use a thick plate (thinner plates are less prominent, but are weaker than thicker plates)
Use two plates (the surgeons did this here - this may make the fixation stronger)
Use a longer plate (the longer it is, the stronger the fixation is)
It is likely that the surgeons did their best to maximize the above...so the question remains - Is it healed?
While this question is the most critical to answer - it is actually much harder to know than one might think. Bone healing is a slow process of early healing followed by "remodeling" with time. Full bony remodeling can take months or even years. However, we use different terms to discuss healing.
Clinical union: when the patient has no pain in the fracture (by pressing on it or by using the arm)
Radiographic union: when the bone has healed completely on x-rays.
In most clavicle fractures, clinical union comes first - especially with strong plates in place. This can give a false sense of confidence though - if the bone hasn't healed on X-ray. Based on Aaron Rodgers throwing the ball 50 yards on TV a week ago - I think he's likely to be clinically healed.
The problem with radiographic union is that this is an inexact science. The bone is covered by the plate, which obstructs the view of the healing. Furthermore, if an anatomic reduction was completed at the time of surgery, the fracture is almost not visible after plate placement. Finally, in some cases there are small areas of bone that are "spot-welded" with healing, but the strength of the bone is still weak. Because of these factors, decisions about "return to play" for athletes like Aaron Rodgers, are very challenging. Why don't you try...here's 3 xrays of the above patient (after surgery):
Can you tell which is which? When is it healed? Give up? The top picture (A) is 2 weeks from surgery, (B) is 6 weeks from surgery, (C) is the day of surgery.
Feel like that one was too hard? Take a look at this one:
This clavicle was fixed with an anterior plate (another technique). You can see how hard it is to see if the fracture is healed now....with double plates (like Aaron Rodgers had), it's nearly impossible.
As you can see, x-rays, which are the standard of care for following clavicle fractures after surgery - don't provide as much clarity as you may believe. CT scans may allow a more 3-dimensional view of fracture healing. While this may provide value in the future, there aren't good studies to help us decide how much healing is needed for safe return to sports. Because of this, we have traditionally quoted a minimum "3 month" return to play. This allows a safety factor to ensure complete healing before return. We typically use this time to rehab the shoulder, and get back to full motion and strength.
What about for Aaron Rodgers though? He has already been seen throwing beautifully. His team needs him to compete for a wild card spot (and they are still in the mix). This is no easy decision. Certainly, the bone will be stronger 6 weeks from now. The season, however, will be done by then. If he refractures his bone, his recovery starts over, and he may have long term issues related to repeat surgery.
Ultimately, this is where the sacred relationship between doctor and patient (athlete) is most critical. A careful, and involved discussion between Aaron Rodgers and his surgeon will help make the right decision for him. All available information will be reviewed and discussed. I'm certain they will come to the correct conclusion for him. Either way, I look forward to seeing him back in action!
Jon Barlow, MD
Breaking on ESPN.com at the time of this writing, Aaron Rodgers has been cleared to return. We'll all look forward to seeing him back in action. The first week(s) back will be critical - if he can avoid a re-injury in the first few weeks - he's likely out of the woods. A risk/reward that he views to be worth it. Best of luck!