Microfracture in the NFL
Guest column by Kevin Pelton
Before his attempted return from microfracture surgery on his left knee was cut short (at least temporarily) by an ACL tear in his other knee, Seattle Seahawks defensive tackle Marcus Tubbs was asked during training camp about the history of the microfracture procedure.
"I know people in basketball that have had it," Tubbs answered. "I haven't heard of anybody in football getting it. I can't say it hasn't happened but I don't know of it."
As Tubbs' answer indicates, microfracture has had a higher profile in the NBA, where All-Stars Penny Hardaway, Chris Webber and Amare Stoudemire have all had highly visible surgeries. That isn't likely to change after No. 1 overall pick Greg Oden underwent a microfracture procedure two weeks ago, likely sidelining him for the entirety of his rookie season.
At the same time, microfracture continues to become important in the NFL. We have been reminded of that so far this season as Tubbs, Kellen Winslow, Jeremy Newberry, Amon Gordon and Matt Lepsis have all returned or attempted to return from the procedure. (Jacksonville's Marcus Stroud is another notable player returning from microfracture, though in this case the procedure was on his ankle, not on the knee as with the vast majority of patients.) Meanwhile, Dallas receiver Terry Glenn decided against a microfracture that would have ended his season and possibly his career, opting instead to try another arthroscopy on his right knee.
Earlier this year, I researched a comprehensive list of microfractures in the NBA that I drew upon to write a column featuring Stoudemire that ultimately argued the procedure has improved to the point where relatively full recovery is possible.
Inspired by the mystery that surrounds microfracture in the NFL, I decided to extend that same study to football. Tubbs might be surprised to learn that I found 61 surgeries I believe to have been microfractures in the NFL, dating as far back as 1986, when microfracture pioneer Dr. Richard Steadman was introducing the procedure. By contrast, I have identified only 30 microfracture procedures in the NBA in that span.
To truly understand the impact microfracture procedures have had, it's important to look at the entire population of players, not merely the cherry-picked examples that are trotted out whenever microfracture is brought up. It's also important to keep in mind the circumstances of each procedure. For example, 1998 NFL MVP Terrell Davis had microfracture surgery on his left knee in September 2002 after two other surgeries on that knee and suffering a torn right ACL. The microfracture was a last effort to return to the NFL and it was little surprise that Davis did not succeed. Many players who undergo microfracture procedures show signs of arthritis or, like Davis, have previously undergone multiple other procedures.
From studying the list and going through the process of researching it, I've drawn some tentative conclusions.
Two keys to returning from microfracture in the NBA, age and the progress made with the surgery, don't carry over to the NFL.
While the same microfracture procedure pioneered on NFL players quickly spread to the NBA, the two sports put very different demands on athletes. Football players must deal with an intensely physical sport that requires frequent contact, often between players much larger than all but the most behemoth basketball players. By contrast, NBA players are constantly in motion and put stress on their knees by jumping repeatedly. Because of the difference between the sports, I've had to throw out two of the key takeaways I've noted in the NBA: the importance of the age of the player and the improvement in recovery as the procedure has been perfected. Neither of these trends are nearly as strong in the NFL, if true at all.
Stunningly, some of the most successful microfracture patients seem to be some of the earliest. The available evidence points to Hall of Famer Dan Marino having microfracture in 1986, just three years into his Hall of Fame career. Though Marino had not missed a start the previous two seasons, he had undergone multiple operations on his left knee after injuring it at Pitt. More surgeries followed, but Marino was able to play on the knee for 17 seasons. Rod Woodson apparently underwent a microfracture procedure in April 1991. Despite rehab and a holdout that lasted until late August, he was in the starting lineup for the Steelers' opener and played 13 more years in the NFL.
The most successful 1990s return from microfracture might be much more obscure, however. Lepsis, a tight end at Colorado, suffered a knee injury in the 1997 Senior Bowl and underwent microfracture shortly thereafter. Lepsis hooked on with the hometown Broncos, was moved to tackle, and missed only one start between 1999 and 2005. (When Lepsis ran into knee problems last year, it was his other knee; he tore his ACL and underwent microfracture on that knee as well.)
Obviously age isn't a positive factor for returning from microfracture, but several players 30 or older have made successful comebacks, led by Bruce Smith. The long-time Bills defensive end had microfracture surgery in February 1998 at age 34. He returned to play six more seasons and earn his final trip to the Pro Bowl. Tom Nalen underwent the procedure in conjunction with repairing a torn ACL at age 31 in November 2002 and has started every Denver game since returning the following season.
Fifteen players have undergone a microfracture in their 30s. Five of them failed to return to the field, but eight of the 21 players to undergo a microfracture at 25 or younger have never returned. Younger players have averaged more games after surgery -- 33.7 to 26.3, not counting players who are just returning this season.
It is extremely rare for a non-established starter to successfully return from a microfracture.
While many starting-caliber players have been able to return to that role after undergoing a microfracture, reserves often see their career come to an end. Charlie Batch is the most notable exception to this rule. Younger players like Gordon, Lepsis and DeShaun Foster have also been able to improve after getting on to the field, but players who are established backups have not been so fortunate.
Microfracture procedures are overwhelmingly common for linemen.
Earlier, I referenced the 300-pound lineman caveat. As it turns out, linemen -- both offensive and defensive -- are overrepresented in the group that has had microfractures. The weight they put on their knees makes them particularly vulnerable to cartilage damage. Thirty-one of the 61 procedures I have identified were performed on linemen -- 15 on offensive linemen, 16 on defensive linemen. They are also surprisingly common for safeties (eight), while Patrick Jeffers is the only wide receiver to undergo a microfracture.
Despite this discrepancy, there doesn't seem to be a consistent relationship between player size and success in returning from a microfracture procedure.
Incidentally, I'm still trying to figure out how one-time NFL kicker Owen Pochman needed a microfracture on his non-kicking knee. You couldn't make that up.
The long-term impact of a microfracture remains somewhat uncertain.
One of the major question marks about microfracture is how long players can play on what is, essentially, "fake" cartilage -- not as strong as what the knee initially begins with. Only nine players have remained in the NFL for at least five seasons after undergoing a microfracture. It will be interesting to see how someone like Foster, who had a microfracture done at age 22, is able to hold up in the long term.
The Broncos have a lengthy microfracture history.
I probably shouldn't have been surprised to see Denver keep popping up on this list, given that Dr. Steadman practices in nearby Vail, and his partner, Dr. Richard Hawkins, has been the head team physician for the Broncos. Denver players account for 11 of the 61 procedures I have identified. It's possible that this could result from microfractures being more accurately identified due to the local media's familiarity with the procedure.
What might be more interesting is that the Broncos seem to be much more aggressive than other teams at signing free agents who are coming back from microfracture -- Lepsis (as an undrafted rookie), Gordon, Courtney Brown, Eddie Moore and Jacob Rogers have all signed with Denver; all but Brown first returned or attempted to return as Broncos. Lepsis has been a major success story for Denver, and Gordon has become a starter at defensive tackle this season.