David Chao, MD: Von Miller Injury Is Bad, But He Still Could Play This Season

Pro Bowl pass rusher Von Miller suffered what was described as a freak injury and top national reporters immediately chimed in pre-MRI with "fears of season-ending injury." Post MRI, those fears seem to be confirmed. 

Although there is no video, using insider knowledge from my time on NFL sidelines, I am optimistic that Miller can salvage part of his season. There is no public video of the injury but it seems to have happened on a pass rush, non-contact with only shells on. Miller "injured a tendon in his ankle on the last play of practice."

The immediate fear is Achilles tendon rupture but that does not seem to be the case. Fitting with the reports of no tendon tear at all and given his position and how it occurred, I believe Miller suffered a subluxation/dislocation injury to his peroneal tendons. This is much better news than if his Achilles were torn. There is precedent for same season return if this is the case. All of the reports indicate a tendon injury but no reference to a tear which supports my hypothesis.

The peroneal tendons wrap around the outside and back of the ankle as they insert onto the outside and bottom of the foot. It lifts and everts the foot to help elite pass rushers get around the edge. In this case, the injury to the sheath allows the peroneal tendon to jump out of the groove and flip around the distal fibula with a snapping sensation and immediate pain/weakness. He is headed to see a foot/ankle specialist and will likely need surgery. Because the repair is likely to the sheath and not the tendon itself, it bodes well for early recovery and a comeback later this season. Often with the procedure, a deeper groove is created to help keep the peroneal tendons in the track where it belongs.

I have direct experience with several early returns for NFL players in the same season. One case involved Chargers defensive end Luis Castillo (permission granted by player to publicly discuss his injury). In 2007, he dislocated his peroneal tendons in Week 9 vs the Vikings. I performed the surgery to relocate the tendons and repair the torn sheath to hold it behind the fibula where it belongs. Castillo was not placed on IR missing seven games before returning prior to the end of the regular season. He played in all three playoff games including the AFC Championship game and performed well enough to earn a 5-year $43.1 million extension that next offseason. I have been involved with other same-season returns at about 3 months (but as of this writing, had not been able to contact the players for permission to use their names).

I have not examined Miller and thus cannot directly compare his injury but one can see there is hope that his season is not done.

This is typically not an acclimation injury and i do not believe it can be blamed on the lack of an offseason program. Miller had a much-publicized case of COVID but there is no evidence that there is any relationship of the injury to the virus.

It is not unusual to have injuries happen on the last play of practice as in this case. How often does one hear about a friend getting injured skiing on the last run of the day? Muscles are tired, thus proprioception and protective reflexes are sometime slowed.

Miller's injury certainly is a big blow to the Broncos who might miss both of their star pass rushers. Bradley Chubb is coming off an ACL tear from Week 4 of 2019 and is still not 100% and might not even play in the opener.

With all this bad news, I strongly believe there is hope and precedent for a return in the latter half of this season for Miller. When he does, he may not be as effective flipping sides but depending on which ankle was injured, he should be quite effective rushing on the opposite side of his injury. Fingers crossed that the reports of season-ending are premature and all is not lost for Miller in this Broncos campaign.