In a dismal Week Four road loss to the Texans, the worst news for the Steelers seemed to be a knee injury to quarterback Kenny Pickett. He was sacked escaping the pocket on a fourth-and-one play late in the third quarter. Assisted off the field by trainers, Pickett was initially hesitant to put weight on his left leg but was seen doing so by the time he reached the sideline. He was noted by reporters to walk independently to the training room. Pickett was quickly ruled out of the rest of the game but was seen without crutches or a brace after that.
Following the game, head coach Mike Tomlin told the media that Pickett had a knee injury and would undergo further testing, presumably an MRI, once the team returned to Pittsburgh. The Twitter doctors, including the very accurate Dr. David Chao, predicted an MCL injury. The following day, NFL insider Ian Rapoport reported Pickett’s injury was a bone bruise with an associated muscle strain, which was confirmed by Coach Mike Tomlin yesterday in his weekly press conference.
Tomlin added that Pickett is expected to practice today and his “functionality and comfort would be the guide” in terms of how much work he got in practice and that he has a chance to play against division rival Baltimore Ravens this coming Sunday.
So what exactly is a bone bruise? We have discussed this a few times over the years. The name can be misleading. A bone bruise is a microfracture of the inside of the bone, which results in bleeding.
Here is a quick rundown (courtesy of www.md-health.com):
- Subperiosteal hematoma– A bone has a thin covering called the periosteum, and a direct force can cause an injury with bleeding beneath this covering, resulting in a subperiosteal hematoma.
- Interosseous bruise– On the other hand, high compressive forces that are repetitively inflicted on a bone can cause bleeding inside the bone where the marrow is located, causing a bone bruise called interosseous bruising. This commonly occurs in the knees and ankles of professional basketball or football players.
- Subchondral bruise – Finally, there is the subchondral bruise, which occurs between a cartilage and the bone beneath it, causing the cartilage to separate from the bone with bleeding in between.
Bone bruises can only be seen on MRIs, not plain X-rays. Here’s a schematic image of the bone of the distal femur, or the lower end of the thigh bone:
[from the US National Library of Medicine]
[www.lermagazine.com]
The treatment for all of these is essentially the same – ice, anti-inflammatory medications (like Ibuprofen or Toradol, which has gotten so many NFL players through games and is commonly used for post-op pain as well) and light activity to keep the knee loose and prevent the stiffness that follows swelling. A stationary bike is the perfect therapy because it doesn’t require Pickett to bear weight, which is clearly painful, but allows him to work on range of motion and minimize tightening of his quadriceps muscle.
Pickett was also reported to have a muscle strain by Rapoport, although this part of the injury was not mentioned by Tomlin. Per Trib Live reporter Chris Adamski, Pickett was seen at the Steelers facility Monday walking without a limp and no brace on his knee. While we do not know which muscle was involved, it does not seem to be significant.
As far as recovery time, there is a fairly broad spectrum. A bone bruise does not cause knee instability, so it is primarily a pain issue. In his rookie year, Cincinnati Bengals wide receiver A.J. Green sustained a bone bruise playing against the Steelers on the only catch they allowed him. He missed the next game against the Baltimore Ravens but was able to return against the Cleveland Browns two weeks after the injury, catching three passes for 110 yards with a long of 51 yards. He was diagnosed with his second bone bruise after landing awkwardly on the first day of training camp in 2013 and missed two weeks of practice, including the first two preseason games. He went on to play the final two preseason games (back when the NFL played four of them) and the entire regular season.
Both Le’Veon Bell and Ben Roethlisberger have suffered bone bruise injuries as well. The running back was injured in the final game of the 2014 season and worked hard to recover in time for the playoff game against the Ravens the final week but never got a helmet. The Steelers’ season ended, so we will never know if Bell could have returned later in a theoretical playoff run. The quarterback sustained both an MCL sprain and a bone bruise against the St. Louis Rams in Week Three of the 2015 season. He missed four games, but the MCL sprain was probably the bigger issue there.
As far as other quarterbacks with a left knee bone bruise, the return to play is typically a week or two. In 2021 as the Chicago Bears’ starting quarterback, Andy Dalton suffered this injury in the second week of the season and missed two games. In 2018, Green Bay Packers quarterback Aaron Rodgers wore a left knee brace and played through what was reported to be a “deep bone bruise” without missing any time.
It sounds like Pickett’s injury is not too severe and that the team got lucky. If pain is the determining factor, I would expect the captain of the Steelers’ offense to push for the chance to face the Ravens. The coaches have a tough decision to make at that point. Last season, Pickett was ruled out of the first matchup against Baltimore early in the game with a concussion, and Mitch Trubisky had a rough outing in his place, throwing three interceptions in the 16-14 loss. When the Steelers played the Ravens for the second time, Pickett led a game-winning drive in a come-from-behind victory, throwing a touchdown to Najee Harris with 56 seconds left. Pickett had to scramble on third and eight to make that play. The question for this week is whether he will be capable of that.
The Ravens defense will no doubt apply pressure to whichever Steelers quarterback they face. The decision to start a healthy backup in Mitch Trubisky or an injured starter in Kenny Pickett will almost certainly come down to how mobile Pickett looks in practice because that is a tool he will likely need if he wants to avoid the pressure of the Baltimore pass rush.
It may be tempting for the Steelers coaching staff to play it safe and shut Pickett down this week, knowing that he will have the following bye week for further recovery. After such a rough outing against the Texans, though, this team needs a better result. If Pickett can play, he still gives the Steelers their best chance to win. My guess is he will get that shot.
“Melanie H. Friedlander, M.D., F.A.C.S. is a board-certified general surgeon at the Association of South Bay Surgeons in Torrance, California. She has developed and published many scientific studies in highly esteemed medical journals.”
