NFL draft medical evaluations are critical

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DETROIT LIONS GENERAL manager Brad Holmes sat alone in his home office on a Sunday night in early April 2022, rewinding the tape, fast-forwarding, freezing the frame and trying to sort out the conflicting thoughts running through his head. The player on Holmes' screen was Jameson Williams, the mega-talented All-American wide receiver from Alabama. Holmes was entranced.

"There are certain guys you watch where you get a reaction and you throw the remote down or something like that," Holmes said. "I'm watching him and dropping the remote."

It was where the tape finished that Holmes' appreciation gave way to doubts. Williams' brilliant season ended abruptly at the 12:28 mark of the second quarter of the national championship game against Georgia on Jan. 11, 2022, when he tore his left ACL at the end of a 40-yard reception. Doctors who treated Williams, listed as ESPN's No. 6 overall prospect at the time of his injury, said they expected him to regain his 4.3 speed. But Holmes had been down this road before with a star player.

While with the St. Louis Rams in 2010, Holmes was part of the front office that drafted former Heisman Trophy winner Sam Bradford No. 1 overall, handing the Oklahoma quarterback an $86 million contract that included a then-record $50 million in guarantees before he had played an NFL snap. Bradford had thrown 88 touchdown passes to 16 interceptions as a Sooner, but his final collegiate season was ended after three games by an injury to his throwing shoulder that required surgery.

While pre-draft medical evaluations of Bradford suggested the shoulder was healed, it would be hard for Holmes or anyone who watched the quarterback in the NFL to argue Bradford was ever the same player he'd been at Oklahoma. Bradford went 18-30-1 and without a playoff appearance in four seasons with the Rams. His career was further derailed by two serious knee injuries, and he retired in 2018 at age 30.

Holmes considered all of this as he agonized over Williams, whom the GM believed was "clear and away" the best receiver in the 2022 draft. He triple-checked the medical information with his staff.

Unseen to the public, pre-draft medicals are a critical component of the draft process and an annual subject of internal debate for the GMs, scouts, coaches and team owners who must decide which players are worthy of millions of dollars in new rookie contracts. No team wants to be the one to pay too high a premium for an injury-weakened player. No team wants to be the one that overreacted to an injury to a player who became a star and select someone else. And, perhaps most critically, no team wants to be accused of overlooking an injury or preexisting condition that compromised a player's physical well-being. Holmes and the Lions found themselves in this type of quandary over Williams.

Detroit's analytics department ran studies on wide receivers coming off ACL injuries with encouraging results. The Lions felt good about his knee holding up and figured with his speed he was so fast that even at 90% "he'll [still] be one of the fastest guys in the NFL," per Holmes. A deep dive into his character revealed Williams' love for football.

Holmes held his own deep-seated cautiousness about pre-draft injuries up to the light.

"I was like, 'Can I have this approach all the time throughout my entire career? And is it a lazy way of thinking?'" Holmes said. "Medical advancements [when Bradford was picked were] different than they are now. So, I'm trying to be open-minded. I had to remove [Williams] from that box and look at myself in the mirror."

The Lions ultimately made a 20-spot jump to select Williams with the No. 12 overall pick, and gave up a significant amount to do it. With a late start to 2022 as he continued his injury recovery, Williams was limited to six games and one catch (a 41-yard touchdown against the Vikings) as a rookie. In a sense, Holmes, head coach Dan Campbell and the Lions are still holding their breath over the pragmatism of the pick. And so is the group that handed Holmes that much-scrutinized pre-draft medical evaluation.

"Dan and I felt we were in a position to acquire a player like this and don't need him for Day 1," Holmes said. "It's a long-term thing. We didn't need to rush him back."

IN THE HOURS and days after Buffalo Bills safety Damar Hamlin suffered cardiac arrest following a tackle against the Cincinnati Bengals on Jan. 2, medical opinions were sought from all corners of the NFL-viewing public. While the specific cause of the Hamlin cardiac event was finally revealed on Tuesday to be an unpredictable case of commotio cordis, a question was raised in the immediate aftermath of the injury that was central to the conjecture: Were Hamlin, the Bills or the wider NFL community aware of any preexisting condition? The question spoke to the vital nature of pre-draft medicals.

"The purpose is to find out what we need to help the player with," Eric Sugarman, former vice president of sports medicine with the Minnesota Vikings, said in general terms about the process. "It's critical we handle it. These are people before they are athletes."

In 25 years with the Vikings, Sugarman saw firsthand the expansive process teams go through to feel confident about drafting a talented prospect. The pre-draft medical process begins well before the NFL combine, which started in 1982 largely as a way to centralize medical testing for players. In the present era, scouts are on the ground at colleges, fact-finding on a player's health during the season. They will do the same at the Senior Bowl in late January/early February, where players receive a routine physical upon arrival in Mobile, Alabama, overseen by the game's medical director, former NFL athletic trainer Dean Kleinschmidt, to ensure they can participate in practices and the game. Teams are permitted to ask players about their injuries during in-person interviews that week.

And in late February, part of the combine scene in downtown Indianapolis will include 300-plus players bouncing from room to room at Methodist Hospital, undergoing a thorough physical or MRIs and X-rays in front of a panel of doctors and team athletic trainers.

An NFL team physician, selected informally based on availability, will oversee each player's physical. Other team medical representatives are then split into five or six rooms, and the physician will usher the player into each room to explain his injury history. COVID-19 prompted the league to streamline the process -- instead of 10 representatives per team, there might be as few as two now, such as a team doctor and head athletic trainer. That makes for "less of a tug-and-pull" experience for the player, Sugarman said. But doctors still work to find consensus, which results in multiple evaluations in a highly scrutinized, all-day event that some liken to a cattle call.

Sugarman estimates roughly one-third of the players are relatively healthy, but nearly everyone has something -- from minor ailments to major knee injuries to even heart abnormalities or, in a couple of extreme cases, leukemia.

"It can be a positive [to be flagged]," said Dr. David Chao, former San Diego Chargers team physician who now runs Sports Injury Central. "Every so often you find a guy with, let's say, a heart issue, and you may end up saving his life."

Or a player can get a head start on addressing an injury. At the 2009 combine, doctors identified a stress fracture in top pick Michael Crabtree's foot. Crabtree underwent surgery and was ready for camp. The injury didn't affect his stock much, as he went No. 10 overall and played 11 years in the league.

After the combine, teams get to work on monitoring progress, poring over scenarios, and those flagged return to Indy in mid-April for a recheck. A selection of good players in every class are sent back to Indy if flagged. Just last week, Syracuse running back Sean Tucker, considered a mid-round prospect who was not cleared to participate in the combine because of an undisclosed medical issue, received clearance during his recheck in Indy and will host scouts at an April 24 pro day on Syracuse's campus.

In complex cases, teams might compare notes on a player's condition up until draft day. Team trainers and doctors are responsible for "accurate and consistent" evaluations, both for the player and owners spending millions on prospects, Sugarman said. But opinions among medical personnel can differ -- as can the manner with which they apply those opinions.

"There are 32 ways teams do business," Sugarman said. "Teams have a different risk scale. Some are willing to take the medical risk, some aren't."

The case of Kwity Paye is but one example illuminating differing interpretations of pre-draft medicals. The star Michigan pass-rusher and first-round prospect was preparing for the 2021 draft when a pre-draft physical detected "high levels of troponin in my bloodstream," Paye said. Troponin is a protein found in the muscles of the heart, and too much of it is a link to increased risk of heart attack.

Some teams researching Paye's condition requested additional testing, including the New York Giants, whom Paye believes were the original team to flag him. (The Giants declined comment on Paye's contention.)

"It was B.S., bro," Paye said. "I've never had a heart condition in my life. It was frustrating."

Paye's agents worked overtime for separate medical opinions that would help clear up the issue. Paye would eventually be picked in the first round by the Indianapolis Colts, though his draft position at No. 21 was slightly lower than the consensus prediction, and Paye was not the first defensive lineman off the board as ESPN's Todd McShay and others had previously predicted.

Colts general manager Chris Ballard said he isn't afraid to remove a player from his board because of medical concerns as he trusts his doctors. In the case of Paye, Ballard got a thumbs up.

"At the end of the day we ask [the team doctors] a million questions, and when they give us an answer, we go with it," Ballard said. Paye has had two productive seasons in Indianapolis but will always wonder whether his draft stock slipped because of the flag.

"The Colts had no issue with it," Paye said. "They saw how I played, they saw how I worked and what kind of man I was. At first, they didn't think I would fall to them."

Paye wasn't the only high-profile player from the 2021 draft dealing with such an issue. Browns linebacker Jeremiah Owusu-Koramoah said he believed he had a chance to go in the first round in 2021, but a pre-draft physical revealed what the former Notre Dame star called "a little jump" in the heart rate.

Owusu-Koramoah says doctors who noted the spike did not relay to him that the issue was anything to worry about. But some teams had concerns, and wanted more assurances.

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Owusu-Koramoah says he declined at least one request from a team to retest closer to the draft.

"I'm not going to do something when I told you there's nothing wrong," the player said.

Owusu-Koramoah was picked near the end of the second round, No. 52 overall, and he said he believes the issue of the pre-draft medical was a factor in his slide.

"I literally got that, in messages from GMs, 'Hey, we would take him in the first round, but it's a big chance with first-round picks with heart problems,'" Owusu-Koramoah said. "I got about six of those."

Player frustration with the process is natural, but their perspective is unique -- in their early 20s, feeling indestructible on the field, with livelihoods and draft positions on the line. Team doctors don't have that problem.

"They don't care about the external chatter over where a player should be, or has the potential to be, drafted," said Stephania Bell, ESPN senior writer and injury analyst. "They will present the information back to the organization, which can then make the decision."

TEN WEEKS AFTER he suffered a torn left ACL in a loss to South Carolina, Tennessee quarterback Hendon Hooker was at the Senior Bowl in Mobile, Alabama. Hooker was there not to compete against the assembled all-stars but rather against himself, sitting in his hotel room with a portable STIM machine that was assisting in his rehab.

Hooker vowed to project confidence in interviews with NFL teams, one of which will likely select the 25-year-old quarterback in either the first or second round of the draft. He knew teams would also want to examine his knee.

"I don't think they would expect my leg to be as strong as it is now, 100% weight bearing by week six, doing lunges and squats," said Hooker from the Senior Bowl practice field in early February.

Teams that interviewed Hooker wanted status updates and injury history. Hooker gave assurances this was his first major injury and said he plans to compete for a starting job during training camp, looking "better than ever."

"I'm well beyond where I'm projected to be," Hooker said of his recovery.

While Hooker's optimism is commendable, it will be up to teams to determine whether his injury represents a long-term risk.

Hooker is one of several players managing injuries during the pre-draft process, including USC offensive lineman Andrew Vorhees (tore his right ACL at the combine) and Boise State safety JL Skinner (torn pectoral muscle sustained while training in February).

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Teams typically follow a basic checklist to assess injury risk. Cincinnati Bengals director of player personnel Duke Tobin considers longevity or degenerative concerns, potential for production drop, recovery length, whether the player will "lose" explosion for good or heal "as a whole."

"They've been playing football for all their life, so they all have stuff. Will the stuff threaten his ability to be effective or not?" Tobin said. "We might take a guy [the doctors] are less sure about sometimes, but we don't shy from the info. We don't lobby opinions. We don't lobby scouts to grade him higher or lower, and we don't lobby doctors to change their opinion."

Team opinions on a player's injury can vary wildly. Just take Kansas City Chiefs guard Trey Smith, who slipped to the sixth round of the 2021 draft amid concerns over a blood clot condition in his lungs, a known condition that Smith had addressed and played through while in college at Tennessee.

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After the Chiefs selected Smith No. 226 overall -- at least 125 slots lower than some projections -- assistant general manager Mike Borgonzi told reporters, "we feel completely comfortable where he's at medically to play for us."

Two years later, Smith has started 33 games, won a Super Bowl and become one of the promising young guards in football.

For teams, the decision to select injured players takes conviction that will be tested at various stages of the draft process. The players, meanwhile, will begin draft day with an extra layer of uncertainty. Next week, players including Hooker can do little more than wait to see whether their draft stock was impacted by a medical review. They can also try to remain positive.

"My doctor ... has done a great job communicating how my recovery should be and how I should take care of myself," Hooker said. "I'll be good to go by camp time, ready to compete, be better than ever."

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