My immediate thought after seeing Tony Romo's injury against the Seahawks was that Romo was done, and not just for that one game. At the time, I thought that the awkward twisting motion, combined with the pressure on the spine, would have invariably led to some kind of disc trauma in his back.
Two days later, we were informed by the team that Tony Romo had suffered a fractured vertebra. But I was still mulling the herniated disc option and exchanged some initial thoughts on the topic with a friend of mine who's also a Cowboys fan, and is a medical professional in real life.
So far on BTB, you've read the informed opinion of Dr. David Chao, and if you've listened to our latest podcast, you've heard Dr. Jene Bramel discuss the details of Tony Romo's injury with Joey Ickes and Landon McCool. Both doctors tried to remain as matter-of-fact about Romo's injury as they could, and studiously avoided any type of speculation.
My friend, who prefers to remain anonymous, had no such qualms. And since NFL reporters regularly pass off their friends and acquaintances as "sources," I'll follow suit and call my friend a source, first name Medical, last name Source. Here's an edited version of the thoughts and information Medical Source provided me with.
Q: What's the earliest you think Romo can return to action?
Medical Source: I think that he may return after the Redskins game. Here are half a dozen reasons why:
- Former Texans and Giants QB David Carr, who suffered the exact same injury to the exact same vertebra, called it a two-week injury on NFL.com
- Witten says Tony will return sooner than expected
- Bryan Broaddus of DallasCowboys.com has been hearing 4-6 weeks
- Mickey Spagnola, also of Dallascowboys.com, has stated that Romo’s X-rays were negative, but that an MRI showed the fracture
- Romo felt well enough to return during the second series
- Tony is a tough SOB
Number four may be the most interesting of the bunch. When I saw the injury, I thought, "Wow! That could be a compression fracture." The medical staff acted appropriately when they had Romo take an X-ray. And when that came up negative, the team may have thought they had gotten away with a bad scare.
But when Romo continued to complain of discomfort, I bet the first thought was, "Oh crap, the flexion load probably caused a disc herniation." The proper test to determine that is an MRI.
When the MRI showed a fracture (and it could have also shown disc herniation(s), but the Cowboys are not discussing those) that was missed by the X-ray, my instinct is that it must have been a small, hairline fracture to the lip of the anterior aspect of the L1 vertebrae. That Romo was able to move freely minutes after the hit and wanted to return to the game, supports that it was not a debilitating fracture that left the vertebrae unstable or deformed.
Q: Is this injury the final confirmation that Tony Romo injury prone?
Medical Source: I do not understand the people that believe that the hit was not that hard. When Romo’s butt hit the ground, he had a 270 lb (or so) man jumping on his back. Physics would dictate that there was nowhere for that force to be distributed longitudinally, so a lateral force displacement occurred, placing excessive force on the anterior aspect of the L1 vertebra. Think of taking a piece of wood and compressing it long-ways: it will bend, then crack.
The lumbar discs could have been ruptured by such a force: except that the energy never reached that level of pressure. Discs are filled with a slow moving jelly, so it takes time for it to displace posteriorly. The purpose of the watery cartilage, called the nucleus pulposis, is to act as a shock absorber for the spine. The fibrous outside annulus of the disc acts as a ligament to keep the segments from shearing apart during motion.
Since the nucleus moves slowly, it did its job, transferring the pressure throughout the spine, and not to the annulus – which would have caused another herniation. The weakest area (or weakest link of the spinal chain) of the back that is under the greatest load is the transitional zone between the T12 and L1 vertebrae. Since the longitudinal force exerted through the segments of the spine was still too much for the physiology of the bone to take, the weakest bone fractured.
From a medical perspective, the body acted perfectly. There is nothing abnormal about the trauma. It was a freakish hit that caused the cascade that led to the L1 fracture.
Romo is NOT injury prone. He might have been right when he said that someone that had not been strengthening their core may not have been able to survive that hit. An athlete with less than ideal stability would not have been able to absorb as much of the hit as Tony, and suffered multiple fractures, or worse.
Q: What do we know about Romo's L1 fracture?
Medical Source: Here is an image that may help you get a better idea of a small fracture.
Note that this is an X-ray image that almost certainly shows a bigger fracture than what Romo may have suffered. After all, the Cowboys doctors didn't see the fracture on their X-rays, while the fracture is clearly visible in the image above.
A few more notes:
There is very little chance that bone fragments enter the spinal canal and cause paralysis with a compression fracture. There's been some speculation about that being possible: it is not. The vertebral body is almost always fractured on the anterior side with a compression fracture, and the canal is on the posterior side of the bone.
About 1/3 of all compression fractures are estimated to be found and diagnosed. Most go under the generic back pain diagnosis and improve in a month or two. Romo's was diagnosed because he had an MRI for fear that he had a soft tissue injury (possibly a disc).
Even if a small fracture to the anterior aspect of the L1 vertebra never heals, the pain will dissipate after several weeks and the individual will have no functional limitations. Most old fractures accidentally discovered on CT or MRI are asymptomatic for the fracture.
Q: What's next for Tony Romo?
Medical Source: I watched David Carr on the NFL Network this morning, and he made a good point: the fracture will likely not get any worse. I also remembered that there was precedent for Romo’s bone to heal closer to four weeks: in 2008 he missed four weeks while his throwing hand healed. He returned after the bye the fourth week, so he missed three games.
If the hairline fracture is on the front edge of the L1 body (the most likely location due to the mechanism of injury), that is where the bone is most dense. That area is biomechanically engineered to take a beating. It is also the area that heals the fastest and is the most difficult to re-fracture.
At the beginning of the regular season, Romo will probably have a CT (or another MRI since it would be easier to compare the first finding to the second; but I would not be surprised if Romo already had a CT to confirm the fracture). If the CT shows that the bone is healing, pain will be the only limiting factor after the Redskins game.
Everybody recognizes how tough Romo is. If given the choice to play, he will take it. The chances of aggravating that injury are very, very small. If Dallas thinks Romo can play with an infinitesimal chance for re-injury, I suspect Tony will.
Q: Give us your take on how the season starts for the Cowboys.
Medical Source With The Gift Of Prophecy: I think the Dak-led Cowboys will beat the Giants opening day. The Giants look like a mess. I believe that they underestimated how much Coughlin motivated those players. Eli has yet to score ANY points in the preseason and the offense with him at quarterback has amassed 88 yards total in about four quarters of action. The Giants offense also started slowly last season in the opener, and only scored after Cowboys’ turnovers.
Playing in Washington in Week 2 will be a little harder. I would not be surprised if the Cowboys lose that game. People forget that Russell Wilson’s first regular season game resulted in a 62.5 passer rating and a loss.
Like New York, Chicago is also a dumpster fire. Adam Gase made Cutler look decent last season: now the quarterback looks like hot garbage. If Dallas wants to start Dak in this game, Dallas may win. Starting Tony against a punch-less Bears team would be a good way to ease him in before traveling to San Francisco in Week 4 to face a better defense, but a team with quarterback issues of their own. By the time the tough Bengals visit Cowboys Stadium in Week 5, Romo will have had enough snaps to work out the kinks.
And you know Tony wants to play at Green Bay in Week 6.