After Justin Fields sustained an aggressive hit to his right torso by Clemson senior linebacker James Skalski in the second quarter of the Sugar Bowl, his time down on the turf caused questions to swirl regarding the extent of his injury and its implications for Fields and the Buckeyes.
Viewers were quickly reassured by his swift return to play and subsequent dominant performance, but Fields remained in obvious discomfort throughout the remainder of the game.
There has been no official diagnosis made public regarding the specifics of his injury, and Fields himself said after the game that Ohio State “didn’t really give me a diagnosis," saying that in the medical tent he "took a shot or two and just ran back out there.” He was also reported to have not received X-Ray imaging at halftime.
These comments obviously led to a few questions and concerns regarding the injury evaluation process. When a forceful tackle like the one Fields endured leads to injury, there are several medical considerations. I will run through my typical thought process to hopefully shed light on what usually happens in similar scenarios.
If the athlete is clearly conscious, moving, and breathing after a tackle – as Fields was after the tackle on Saturday – the next thing to think about is anatomy. I consider all the important structures underneath the area that absorbed the contact. In Fields’ case, he took a blunt trauma via helmet (ruled as targeting) to the right torso. The structures in that area include the ribs, right kidney, liver, ilium bone (hip region), diaphragm, and the lung.
When I evaluate an athlete on the sideline or in the training room to determine the extent of the injury and next steps, I ask three questions:
- Are any of the injuries life-threatening or otherwise requiring immediate action?
- If not, can the athlete safely return to play with his injury? This takes into account the athlete’s ability to protect himself on the field and perform well enough to meet the demands of his sport and position.
- If the athlete is returning to play, is there anything I can safely do to make him more comfortable for now?
In the case of Fields’ injury, I would want to make sure there is no sign of a punctured or collapsed lung (e.g. Drew Brees’ injury this season). If he has no breathing distress, and his lungs sound normal with a stethoscope, I would move onto the liver and kidney.
After ruling everything else out, what’s left is the potential for a non-displaced rib fracture or a rib contusion (bruise). These two diagnoses are treated the same. Therefore, an X-Ray isn’t really necessary in the immediate game setting.– Dr. Aloia Earl
In a hospital setting, a CT scan or ultrasound could help to rule out organ injury. On the sideline in the medical tent, your hands are your absolute best tool. With a good physical exam, you can really localize the area(s) of most pain. Thankfully, the liver is very well protected by the ribs. A liver laceration typically causes pain in the abdomen and specific signs of guarding the right upper abdomen as it’s examined. A kidney injury causes pain with tapping a specific area of the low back/flank. I anticipate these areas were examined in Fields’ case and the most serious potential conditions were ruled out.
In regards to the diaphragm, that’s a big muscle. If it’s hit, it can spasm like any other muscle. This is the feeling of “getting the wind knocked out of you,” and it's uncertain whether Fields experienced this. Regardless, it resolves itself within a few seconds to minutes.
This leaves us with the bones. The ilium bone is very strong and sturdy, which might be the area Fields referred to when he said ”it’s pretty much my whole right torso that’s messed up and a little bit of my hip.” In many cases, a direct blow to this bone will cause more of a bone bruise than a fracture; this is termed a “hip pointer.” They are painful, but don’t compromise the structural integrity of the bone like a fracture would.
Now onto the ribs. It looks like Fields was hit along the bottom of his right ribs. The bottom two ribs (ribs 11 and 12) are called “floating ribs” because they don’t attach all the way around to the front. They are more flexible and less susceptible to fracture, though they can still possibly fracture with enough force.
Based on the hit he sustained, I would guess Fields’ 8-12th ribs took most of the force of his hit, with the 8-10th most likely to fracture. Again, he reportedly did not have an X-Ray during the game. In-game X-Ray is available at many Power 5 facilities, but it’s often difficult to diagnose rib fractures with an X-Ray alone due to the complexity with visualization around the lung markings. A CT scan, which is not available in the stadium, is a better, more detailed test for this.
The biggest risk with rib fractures is if the broken bone segment compromises any nearby structure (most commonly the lung), if the segment breaks through the skin (a compound fracture), or if several ribs in a row are all fractured (which can leave the underlying lung vulnerable). Back to using your hands as tools in the sideline medical tent, these more serious concerns can be ruled out without using an X-Ray, in most cases.
Fields is fortunate to have access to some of the top medical care in the country to help mitigate the sequelae of his injury and keep him in the best possible shape to compete for the National Championship. Based on the available information, I do not anticipate his on-field performance will be affected in any way next Monday.– Dr. Aloiya Earl
After ruling everything else out, what’s left is the potential for a non-displaced rib fracture or a rib contusion (bruise). These two diagnoses are treated the same. Therefore, an X-Ray isn’t really necessary in the immediate game setting.
The cornerstone of treatment for both issues is pain-control while the body heals itself. There is no cast for a rib fracture, like there would be for a wrist, for example. Rib fractures and bone bruises heal on their own with time, typically in about 4-6 weeks. In a contact sport athlete, in addition to pain control, the area should be protected. This can be done with rib guards within shirts, extra rib padding, and/or flak jackets, and it seemed Fields did have extra padding in the area after the half.
The goal of pain control for rib injuries in the context of sports medicine is twofold: first, to allow the athlete to be able to take full deep breaths and second, to allow the athlete to perform with normal mechanics.
The pain of a rib bruise or fracture often causes patients to take shallow breaths to avoid irritating the area, which over time can lead to lung issues including partial collapse because the lung isn’t expanding like normal. With pain under control, full breaths are easier.
In regards to Fields’ mechanics, he’s a right-handed quarterback. Any time he throws, he is stretching and activating the muscles which connect his right ribs to each other (intercostal muscles) which is going to aggravate pain related to a potential rib fracture or bruise. By controlling his pain to a tolerable level, he may still feel the discomfort but not enough to interfere with his passing mechanics or accuracy.
Back to the 3 questions, specific to my interpretation of Fields’ possible injury:
- I anticipate any serious injury requiring immediate attention was ruled out in the tent.
- I suspect he had pain and injury over his right ribs and possibly iliac crest. In this case, with serious risks ruled out, there’s a conversation between the athlete and the medical staff to determine if the athlete feels comfortable returning to play. Fields felt he could go, and he did.
- 3.There are several options for pain control. One option is a lidocaine injection to numb the nerve that sends pain signals from a rib injury (intercostal nerve block). There is a level of risk assumed with this, as with any medical procedure, but there are safe techniques to minimize the risk. The most important consideration is avoiding puncturing the underlying lung (ex- Tyrod Taylor’s case). Another option is an injection of anti-inflammatory medication into a large muscle (usually the gluteus muscle) to provide faster symptom relief than what could be provided by an oral medication. There might have also been extra rib padding added for Fields in the second half.
Based on his performance in the remainder of the Sugar Bowl, Justin Fields seems to have had the best possible outcome from his medical evaluation and intervention. The art of sports medicine lies in the aforementioned triage process, with the goal of allowing athletes to return to play with certain injuries in elite-level, high-stakes games like the College Football Playoffs, as long as it can be done safely with the athlete’s best short-term and long-term health in mind. In the words of Ryan Day to ESPN at halftime, "He’s a really tough kid. He's got the heart of a lion. He's got to play for 30 more minutes."
After the game, there may have been a more detailed evaluation with a CT scan or other tests for Fields, depending on the progression of his symptoms. Often the few days after a direct trauma like that are the most painful, due to the swelling that settles in the affected area.
Fields is fortunate to have access to some of the top medical care in the country to help mitigate the sequelae of his injury and keep him in the best possible shape to compete for the National Championship. Based on the available information, I do not anticipate his on-field performance will be affected in any way next Monday.