RGIII saga spotlights risk of NFL's injury dance

• Team, player took chance with injured knee that he previously hurt in 2009
• NFL players say the pressure to perform is high, as is fear of losing job if they don't play
• While some say NFL should hire independent doctors, others defend system, say injuries inevitable

Injuries always will be an occupational hazard in the NFL: Brains slosh around in the skull, bones fracture and ligaments tear, often after high-impact collisions but sometimes — as in the case of Robert Griffin III — because of sheer misfortune.

When it comes to brain trauma, the league has tightened medical procedures regarding concussions and cracked down on illegal helmet-to-helmet hits. Players, often reticent about such matters, are encouraged to be more open about symptoms.

But what about potentially debilitating musculoskeletal injuries that might carry risky or career-threatening implications?

In the painful case of Griffin, the Washington Redskins' rookie dual-threat quarterback, the questions are many.

Should Griffin, who underwent knee surgery Wednesday in Pensacola, Fla., have played last weekend on an already-destabilized joint? Was Redskins coach Mike Shanahan to blame for not pulling his quarterback during the playoff game? Did the Redskins' medical staff fail to adequately protect the player?

Those concerns prompt another question: Should the NFL employ independent physicians to remove potential conflict-of-interest concerns regarding medical assessments?

"Everyone knew the issues,'' Tony Yates, president of the NFL Physicians Society, told USA TODAY Sports on Wednesday. "They went into it with eyes open. This was a very special game for (Griffin), so the risk-reward ratio was changed. Everyone was willing to take the calculated risk, if you will.

"Sometimes it works. Sometimes it doesn't.''

This time, it did not.

James R. Andrews surgically repaired Griffin's torn right lateral collateral ligament Wednesday, along with what the renowned doctor called a "re-do'' of the quarterback's 2009 anterior cruciate ligament reconstruction. "We expect a full recovery and it is everybody's hope and belief'' that Griffin will be ready to play in 2013, Andrews said in a statement.

It is unclear whether the 22-year-old quarterback will be ready for training camp in August. Recovery could take as long as nine to 14 months, James Gladstone, co-chief of sports medicine at Mount Sinai School of Medicine told USA TODAY Sports.

"In experienced hands, even in a worst-case scenario with both ligaments torn, the young man has the potential of returning to his full level,'' says Leon Popovitz, a New York-based orthopedic surgeon.

The NFLPS provides medical and rehabilitative care for players, and supports the certified trainers of all 32 teams. When players are injured, they are routinely examined by trainers, who can consult with sideline team physicians to make reasonable and expeditious decisions.

The structure of the relationship between the team physician and the team is determined by ownership, the NFLPS says. The league requires a minimum of two physicians per team on the sideline for every game. However, many teams supply two orthopedic surgeons, two internal medical specialists and perhaps even a neurosurgeon.

Entering the divisional round of playoffs this weekend, coaches such as San Francisco's Jim Harbaugh understand that the medical staff has the final say on player availability. Justin Smith, a 49ers defensive end, has been practicing with a brace on his left arm to protect a partially torn triceps muscle. No decision has been made regarding his availability for Saturday's game against the Green Bay Packers.

"It's not something where we, as coaches, pretend to be in somebody else's body or that we have our medical degree,'' Harbaugh said.

Coaches have noticed the league's more cautious approach.

"I'm making way better decisions than I used to,'' Seahawks coach Pete Carroll said. "I've been made more aware. I was always just, 'Tough it out.' I can totally feel the shift'' in heightened awareness.

League increases 'surveillance'

Injuries are a hot topic every week in the NFL, and for good reason. Records, legacy and pride are at stake — along with hundreds of millions of dollars, including money wagered via legal and illegal gambling.

The commissioner's office gives "significant scrutiny regarding how injuries are handled, much more than you ever would believe,'' Jim Bradley, the Pittsburgh Steelers' team physician, told USA TODAY Sports.

Part of what the NFL medical staffs call "injury surveillance'' includes the relatively new "eye in the sky'' — a certified trainer in the press box to look for anything medically suspicious that might have gone undetected.

Griffin, a team captain, started last weekend's playoff game against the Seattle Seahawks wearing a brace on his right knee for a third game to protect a sprained lateral collateral ligament.

"Players play with strained ligaments all the time,'' Bradley says. "If you took out every player who tweaked his knee, you wouldn't have a lot of (front-line players) in the game. You would be playing people (fans) don't want to see.''

The head coach's job "is not to tell the player when he's going in or out — that is for the medical staff,'' Bradley said. "The coach's job is to determine if the player can perform at the required level,'' which is a judgment call.

In Griffin's case, self-imposed competitive pressures appeared to rule the day. After the game, he said, "I'm the best option for this team.''

Seahawks fullback Michael Robinson says, the young signal-caller did what he was trained to do.

"I think the message when we're young is (that) you were considered a punk if you had a little injury and you couldn't play,'' he told USA TODAY Sports. "You're bred to play through stuff.''

As ESPN analyst Tom Jackson, who played middle linebacker for 14 seasons in the NFL, told USA TODAY Sports: "The player mentality always will be problematic. At times, they need to be protected from themselves.''

Griffin threw two touchdown passes in the first quarter in the loss to the Seahawks before he aggravated his knee injury. The Redskins' medical staff followed protocol in allowing him to stay in the game, the league said. NFLPA medical adviser Thom Mayer will review records from the Redskins to be sure the requirements were followed, the union told USA TODAY Sports.

Shanahan says he approached the quarterback during the game and said, "You OK?'' He says Griffin responded, "I'm fine.''

But Griffin's knee buckled in the fourth quarter as he attempted to scoop up a bad snap.

Shanahan later was roasted by arm-chair quarterbacks for leaving Griffin in the game. Art Briles, who coached Griffin in college, says he understands why Griffin kept playing: "It's like (former Texas Longhorns coach) Darrell Royal said: 'You are going to dance with the one who brung you,' '' the Baylor coach told USA TODAY Sports.

NFL culture a factor

Griffin, by his own volition, tempted the football gods.

"The DNA of a competitive athlete is to never back down,'' Robert Huizenga, a former NFL team physician, told USA TODAY Sports. "The adrenaline in a game of that magnitude is so high that even if you had common sense, it leaves you very quickly.''

That attitude is no surprise to Hall of Fame running back Curtis Martin. The former New England Patriot and New York Jet understands the decision Griffin confronted last weekend.

"Unless my bone was sticking out of my leg, then everyone knew my mentality — I was going to play,'' said Martin, forced out of pro football in 2007 with a degenerative bone condition of his right knee after producing the league's fourth-highest career rushing total (14,101 yards) in 11 seasons.

"(Former coach Bill) Parcells told me, 'It's always good not to come out of the huddle because you never know who's going in the huddle''' (to replace you), Martin told USA TODAY Sports. "So, I never wanted to come out of the huddle ... But it is difficult to manage (possibly) damaging yourself long term and playing for the moment.''

Added Martin: "If it's anyone's fault as far as decisions like that, it's the player's fault. Many of us conceal our injuries or downplay how bad they are just so we can be out on the field.''

Remember what happened to Jay Cutler two years ago?

With a wobbly left knee, the Chicago Bears pulled Cutler early in the second half of the 2011 NFC Championship Game, which the Bears ultimately lost. Unknown at the time was that Cutler suffered a painful sprained medial collateral ligament.

Cutler's toughness was questioned immediately. He was skewered by current and former players, including Hall of Famer Deion Sanders who tweeted: "Im telling u in the playoffs u must drag me off the field. All the medicine in pro lockerrooms this dude comes out! I apologize bear fans! . . .''

Said Denver Broncos safety Mike Adams said, "Look at Cutler's situation. He was hurt, he didn't play and he caught a lot of flak for it. Now, (Griffin) is hurt and they are saying, 'Oh, you shouldn't have played him.' You can't win in this business.''

In Griffin's case, his right knee already had quite a medical history.

At Baylor, the quarterback tore the anterior cruciate ligament in the knee in 2009. After he sprained his LCL in the same knee last month, Griffin missed only one start.

During the Seahawks' game, Griffin looked so wobbly that, "if this had been a fight, the (ring) doctor would have thrown in the white towel,'' Huizenga said.

"There have been star players who, at the first twinge of a hamstring (pull), take themselves out. And, boy, do the coaches and owners hate their guts,'' Huizenga said.

Huizenga believes that the league should hire independent doctors to evaluate injured players instead of teams choosing their physicians.

"I've always said that we need an impartial observer — someone without a financial incentive in the game and not a golf partner of the owner,'' said Huizenga, who wrote the book, "You're OK, It's Just a Bruise,'' after nearly a decade as team doctor for the Oakland Raiders.

Not everyone agrees, including Dr. Neal ElAttrache. A former orthopedist for the Los Angeles Rams who performed the reconstruction of Tom Brady's left knee in 2008, ElAttrache says times have changed.

"We're at a point now where the incentives are so well-aligned between the player, the medical staff, the ownership and the coaching staff to do what is right by the player,'' he told USA TODAY Sports.

The NFLPS's Yates called Huizenga's idea "ludicrous.''

"A doctor is still a doctor; he has a genuine interest in the player,'' he said. "The player is not paying the doctor because it's not the structure of the business.''

Joe Perlman, a Houston-based physician who spoke before an NFL medical committee in 2011, says the current system is a good one. "Now, are you occasionally going to get guys like Robert Griffin getting re-injured? Yeah, it's football — it's not synchronized swimming.''

Contributing: Jarrett Bell, Jim Corbett, Lindsay Jones, Gary Mihoces, David Leon Moore