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Buffalo Bills linebacker Matt Milano updates his injury rehab schedule

We take a look at Milano’s specific type of injury to provide a baseline gauge for his return to action.

NFL: New York Jets at Buffalo Bills Rich Barnes-USA TODAY Sports

Good news everyone!! Buffalo Bills linebacker Matt Milano has been spotted running and working out this offseason, indicating that his rehab is progressing and that he appears ready to return to full form this upcoming season. The former fifth-round pick has been a stalwart for the Bills defense and was well on his way to a possible Pro Bowl selection before suffering a rather gruesome injury late in the loss to the New York Jets on December 9th.

Reviewing the injury, Milano suffered an ankle dislocation and fracture on a goal-line stand during the fourth quarter of the Bills’ Week 10 home game against the New York Jets. This was the result of quarterback Sam Darnold attempting to dive into the end zone, landing on the back of Milano’s heel, and firmly planting the foot in the turf. As the foot is planted, Milano is hit from behind by S Jordan Poyer and Darnold’s body on his foot prevented Milano from falling naturally, instead twisting to the left and snapping his fibula, which is the outer portion of the ankle. I will not place the picture in the article today due to the graphic nature, please view at your own risk.

Thankfully, the tibia—which is the shin bone—was spared due to twisting to the left instead of the right. While it is not a given that the tibia would have fractured if the foot got twisted inward, Milano still avoided a more serious injury—the type Washington quarterback Alex Smith suffered in 2018. Irrespective, there was a fracture with dislocation due to the foot turning in the manner as it did. The ankle broke on what appeared to be the lower portion of the fibula, which is the outside bone of the lower leg and the lower portion makes up part of the ankle complex. There is fairly significant ligament damage based on the dislocation but these ligaments will heal up due to the ankle being reduced or put back into place on the field. The ligaments will heal as the tissues most likely weren’t totally torn, which allows them to heal back together with scar tissue assisting in completing the new connections. While he will heal up, the ligaments are never quite as strong as they were prior to the injury, but this is common for all ligament injuries and he shouldn’t be at any higher risk for re-injury as this was more traumatic in nature. Proper tissue healing in this area will be aided as the ankle will be immobilized for some time after due to surgery.

An example of an ORIF (Open Reduction Internal Fixation)

Milano had surgery shortly after the injury, which gives us a rough timeline to go off of when evaluating his recovery. He had surgery on the ankle to stabilize it for long-term healing, which required a plate and screws with several different techniques available. I am not privy to the exact procedure; this comes down to surgeon preference and what imaging states in how they proceeded. After surgery, Milano would have been placed in a walking boot but ordered to remain non-weightbearing. I have seen various protocols regarding how long he would be limited anywhere from 2-6 weeks, Personally I would prefer the protocols that are more conservative to ensure that the repaired bone is able to form a bony callus and begin the natural healing with the hardware ensuring proper alignment. During this time, cold therapy and range of motion exercises are initiated to prevent ROM limitations of the joint and manage swelling.

Once the ortho surgeon is satisfied with the beginning stages of healing, weight bearing is progressed with a walking boot as the patient is able to tolerate with the use of crutches or walker to increase strength through the bone required for walking. As activity increases, external support moves from a walking boot to a stirrup brace or air cast to provide lateral support to the ankle. Weight-bearing exercises are increased and ROM/resistive activities are increased as tolerated. Proprioceptive exercises are also started to help Milano relearn where his body is at in space and regain control in various planes of motion. These activities are performed on BAPS board, Bosu balls, trampoline, uneven surfaces—anything to challenge the patient away from a level surface.

An example of a BAPS board in use for physical therapy.

After a month from the surgery date, a stationary-bike program is incorporated to both increase ROM, increased resistive strengthening, and also endurance. Walking programs are also performed to retrain the ankle to ambulate with a heel-toe gait pattern and to avoid future problems with compensation movements that could hinder recovery or performance. At around 8-10 weeks with clearance from the MD, running may begin as long as the patient is walking normally and there is little to no pain with the activity. As one would expect, paced walking progressing to jogging to running will take several weeks as tolerance is built up. Noted in the tweet by Jon Scott, he was observed running in mid-March. While there isn’t video available to identify the quality of his running, knowing he was cleared back in February, by now I would expect he can run for a pretty fair duration of time and without bracing.

Despite progressing to running, healing is still occurring in the bone and surrounding tissues. Keeping this in mind, it is not expected that his rehab or any rehab for that matter always follows a linear path or is exact based on time frames. As a result, players may be ahead or behind the rehab but as long as they are moving in a positive direction, the time frames can be altered to ensure the ability to return to 100%.

At 2 months out, entire lower extremity strengthening is incorporated such as squats, lunges, dead lift, clean and jerk, etc to help assist regaining the strength lost in the legs while recovering from surgery. Sport-specific agility drills such as karaoke (grapevine) drills, back pedaling, sidestepping, run & pivot are started to begin to progress towards football activities. At this point, there are no real limitations other than if there is pain present to reduce loads on the surgical area. This is where a physical therapist can get creative with exercises and find new ways to challenge the player and ensure that they can handle the activities required for NFL football.

At this time, a PT may also consider assessing for outcome measures. These are standardized questionnaires or physical tests that a PT would perform with the patient to assess to see where they are in their recovery either from a subjective, objective, or physical standpoint. The patient does have short- and long-term goals throughout rehab but these are more measurements of ROM, strength, pain, etc. The standardized testing is more absolute with regards to whether someone is cleared to move into the next stage in rehab or if they need to continue in the current stage. These can be done at evaluation and then through the rehab process as necessary. Assessments such as the LEFS, FAOS, and Kaikkonen can all provide some information regarding how a patient is performing and provide checkpoints in time to either track progress or whether there is a change in status. Tests such as the Star Excursion Balance Test and vertical jump test can provide a more direct physical component for mobility. While these may be used with Milano, these alone aren’t dictating his progress and may possibly not even be used as these athletes are being tracked much closer by both the rehab and ortho staff than a traditional patient.

Overall, Milano is about 14 weeks out from surgery, which is three-plus months; normal recovery time can be six months. Back in December when he suffered this injury, I had stated six to nine months, taking the low end of that time frame. In normal populations, people may be cleared to getting back to regular activities and regain some sort of normalcy in their lives after three to six months. However, Matt Milano is not normal; he is an elite-level athlete and requires further training to ensure he gets back to his prior level. While I am not the treating therapist, my goals short-term would be to make sure that the ankle returns to normal function in both ROM, strength, and avoiding pain/swelling after activity. My assumption is that he is not quite there yet and simply requires more time. Long-term, he needs to return to football-specific activities and ensure that he can go 100% without compensations or complications.

We saw this happen with Trent Murphy last year coming off an ACL tear; he was focused on his rehab and getting back on the field, but we saw that he was not 100% football-ready. As a result, we saw him deal with a lot of difficulties with muscle strains early on, indicating his body was not ready for football. The fear with Milano is that he has a history of hamstring strains. While hamstring strains are not career-threatening, having Milano suffer one early in OTAs, training camp, or early regular-season games will only hinder his football progression. Looking long-term, Milano should be able to participate with everything during OTAs and may only be limited if he experiences pain/soreness. There is a concern that he may have issues related to hardware in the joint regarding irritation, but they only remove these materials in the event that it is safe and warranted. Surgeons don’t like to remove hardware unless there is an absolute need.

Come training camp, Milano should be pretty much back to normal; outside of the hamstring issues mentioned above, I have no other concerns. While protocols do assist with guidance in rehab, each person progresses through recovery individually. As a result, some people are fast and others slow. Milano has demonstrated that the time and money invested into him already aren’t wasted by poor or ineffective rehab. From the initial injury until now, everything appears to be normal and this ankle injury should be an afterthought once real games start.