Playing Hurt vs. Injured

In this episode:

-Hurt vs. injured. A sore rib means you're hurt but can still do the job at about 90%. A swollen, hyperextended knee that won't let you plant and pivot means you're injured. The team physician decides whether a player can play safely and what happens if something goes wrong. -
-When "it doesn't hurt" doesn't mean it's safe. For AC sprains, muscle injuries and ribs, pain is a reasonable guide. For a healing fracture like a clavicle, it isn't: the bone can feel fine and still be weak enough to break again on contact. The real question is whether playing could change the long-term outcome. Playing through a rib injury usually won't. Playing on a torn ACL can damage the meniscus and cartilage.
-Nick Bosa's calf. A calf strain matters for an edge rusher because pushing off is the whole job, and calf strains are linked to a higher risk of Achilles rupture. Early in a 4–0 season, it isn't worth the risk.
-Why sideline running isn't game-ready. Running in a straight line is very different from exploding off the line against a 300-pound lineman, changing direction, and still having the strength to protect yourself in the fourth quarter.
-Mike Evans' ribs. Rib fractures are stable and seldom cause further damage, but they are miserable to play with, especially for a receiver who twists to catch the ball. The episode covers flak jackets, numbing injections, and the rare risk of a collapsed lung (pneumothorax) from an injection, as happened to Tyrod Taylor.
-Trent Williams and stingers. A stinger is a stretch or direct hit to the nerves, usually brief. Sideline rules:
Symptoms should clear within minutes.
If weakness lasts, the player is out and gets neck imaging.
Symptoms in both arms are never a stinger and are a red flag.
Repeated stingers need a workup for an underlying problem in the neck.
-Dre Greenlaw's quad contusion. It's more than a bruise. Expect 5–10 days before he can plant and push off. Coming back too early risks heterotopic ossification (bone forming inside the muscle).
-Christian McCaffrey and load management. With his history of overuse injuries and heavy workload, managing his snaps with January and February in mind makes sense.
-Caleb Williams' hamstring. NFL data put grade 2 strains at about 22–28 days. Re-injury rates are high, and Chicago's cold weather is a reason to give him extra time.
-Lightning round: play or sit?
Wide receiver with a rib contusion, normal X-rays, 7/10 pain on contact: both play him.
Edge rusher with a mild calf strain who has pain at full acceleration: Brian plays him only in the playoffs, Drew sits him.
Offensive lineman whose arm went numb for 20 seconds and is normal 5 minutes later: plays, if it's his first stinger and his exam is normal.
Kicker who strains a hamstring mid-game in a snowy playoff game with no backup: test him on the sideline first, and go for it on fourth down if he looks bad.

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Patellar Instability: One Surgery, Two, or Three?

Dr. Brian Feeley and Dr. Drew Lansdown talk about patellar instability. They see it all the time in clinic, but it's one of the harder problems in sports medicine to sort out. They cover what happens when the kneecap dislocates and who does well without surgery. They also explain Dr. Dejour's "à la carte" approach, where the surgeon picks which problems in the leg to correct. And they discuss a new randomized trial from Norway on MPFL reconstruction.

In this episode:

-The Norwegian trial. Patients aged 12–30 with at least two dislocations were randomized to MPFL reconstruction or to arthroscopy plus rehab. At 3 years, the rehab group was about 5.8 times more likely to still be unstable (AJSM 2026).
-What happens in a dislocation. The kneecap almost always slips toward the outside. This can come from a direct hit or from a planting and twisting move, much like an ACL injury.
-Putting it back in. Straightening the knee usually lets the kneecap slide back into place. Brian has a story about a mattress-jumping sleepover.
-What tears. The medial patellofemoral ligament (MPFL), which normally holds the kneecap in place, is stretched or torn. Some patients also chip bone or damage cartilage.
-First-time dislocations. When the anatomy is normal, rehab usually works. Most athletes return in about 6 to 8 weeks. Patrick Mahomes returned in about 3.
-Bad luck or anatomy. Features that raise the risk include a rotated hip, a flat groove (trochlear dysplasia), a high-riding kneecap, a patellar tendon that attaches too far to the outside, a rotated lower leg, and being knock-kneed.
-Don't treat the X-ray or MRI. Surgeons don't operate on a knee that has never been unstable, even if it looks abnormal. A kneecap that "sits to the side" on an MRI means little, because the knee is straight during the scan.
-Measurements aren't perfect. Surgeons may not get the same result when they measure the same knee twice, or when two surgeons measure it.
-The à la carte approach:
MPFL reconstruction for almost everyone.
Tibial tubercle osteotomy (moving where the patellar tendon attaches) when the pull on the kneecap is off.
Trochleoplasty (deepening the groove) only occasionally.
Femoral derotation osteotomy for severe rotation.
For borderline anatomy, MPFL reconstruction alone works about 95% of the time.
-Recovery and outcomes. The first 6 weeks after an osteotomy are hard. Patients who are doing well at 6 months tend to still be doing well 10 to 15 years later. The knee doesn't have to be anatomically perfect, just good enough.
-A reminder. Most pain at the front of the knee is not instability. It usually gets better by improving how you do squats and lunges.

Hosts: Brian Feeley, MD, and Drew Lansdown, MD (UCSF)

Reference:

Straume-Næsheim TM, Randsborg PH, Nilsgård TL, Årøen A. Medial patellofemoral ligament reconstruction vs nonoperative treatment for recurrent lateral patellar dislocation: three-year results from a randomized controlled trial. Am J Sports Med. 2026;54(4).

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This podcast is for educational purposes and is not medical advice.

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