Phenomenal, front page worthy post by Krauser here on Harvin and his medical history. Well done, sir! Ted

...5000 words on Percy Harvin's injuries...

I have a theory about Percy Harvin's injury history and his departure from the Vikings. My theory's based on a close reading of previously published information and my own professional experience (I'm a neurologist).

Obviously the medical information in this post is purely speculative and for recreational purposes only -- I've never met Mr Harvin and have no official medical opinion about his diagnoses or care. I'm not affiliated with the team or the NFL and otherwise have no direct or indirect contact with this situation.

I've added quite a few links throughout but not every fact here is sourced. Please let me know if you spot any errors and I'll update with corrections.

2009-10 (and before): migraines

The most important part of Harvin's medical history, as far as I'm concerned, is his long history of migraines. From all accounts, he had frequent and severe migraines from the age of 10 until the end of his 2nd season with the Vikings, when he was 22. Migraines were cited as the reason for Harvin missing 2 games in college and 3 games in 2009-10 (he missed the Bengals game at the end of the 2009 season and the Bills and Giants-in-Detroit games near the end of 2010). He also missed countless practices, including large chunks of time in training camp. In 2010, he disappeared from camp for a couple of weeks, apparently due to migraines. He'd originally been excused for his grandmother's funeral but did not reappear as expected and the team didn't know where he was. When he did resurface, it turned out he'd been having a flare up of his migraines.

Several points about this.

Migraines are a disorder of otherwise healthy people, men as well as women, and even severe and frequent migraines (chronic migraines) are not rare in the general population. It's not surprising for a healthy young man playing in the NFL to struggle with them. Harvin's not the first NFL player with migraines, you might recall that Terrell Davis won MVP in the Super Bowl after sitting out the 2nd quarter with migraine symptoms.

"Let down" headaches are a well-described phenomenon in some migraine sufferers, in which migraine symptoms appear on days of relative relaxation -- weekends for most people, but any day except game day for an NFL player -- so the seemingly convenient timing of Harvin's migraines could be a physiological phenomenon and not evidence of malingering to get out of practice while still playing on game days.

Migraines often include cognitive and emotional symptoms, but they are hardly ever incapacitating enough to prevent someone from sending an email or making a call in an emergency (or if they are, that degree of misery doesn't usually last for days upon days, or if it does, someone else should be there caring for the patient, in which case they would be able to relay a message). So the week or more during 2010 training camp when Harvin was off the radar was hard to explain purely from migraine symptoms.

2011 and since: no more migraines

Harvin's migraines resolved during the 2010-11 offseason. In an interview this spring he said: "I haven't had a migraine for two years". The improvement is usually credited to his being diagnosed and treated for sleep apnea.

Soon after returning to the 2010 training camp after missing 2 weeks for migraines, Harvin collapsed on the practice field and was taken to hospital. He had a migraine that day. From the description, it seems he had a syncopal or presyncopal episode. Eric Sugarman thought he might have been dehydrated or had a reaction (not an allergic reaction, just a side effect) to a medication he took to treat his migraine that day. In an interview with Tom Pelissero a few weeks later, Harvin disclosed that he'd been diagnosed with sleep apnea and that he was "feeling great" since starting treatment for it.

Weirdly to me, Harvin told Tom P in September 2010 that he was off his migraine meds. Even if sleep apnea was a major cause of his migraines (neurologists almost always think migraines have multiple overlapping causes, not a single cause that explains everything), one wouldn't expect the migraine-preventive medications to be discontinued o quickly. His neurological diagnosis was likely chronic migraine (given a long history of frequent and severe symptoms). Medications used to prevent migraines usually take weeks to months to have an effect, and are usually continued for months even after the headaches improve.

Sure enough, Harvin missed practices in September and October because of an "illness" -- officially, not migraines -- and then missed 2 late season games (after Childress was fired). By the end of 2010 (months after the sleep apnea diagnosis), he'd missed 36 full practices, parts of 13 other practices, 2 preseason games and 2 regular season games.

Harvin's migraines then apparently resolved right at the end of the 2010 season, since he told Tom P in June 2011 that he hadn't had a migraine for 5-6 months. At that time, he didn't credit the sleep apnea treatment for the improvement, but "a couple of things they found in my neck that I won't get into -- some things they found and fixed, along with diet and the rest of the things".

That doesn't sound very specific or amazingly helpful, but Harvin's migraines have apparently never returned.

Central sensitization: Migraine is a lifelong condition

Clinical and basic science research shows that people who are prone to frequent and severe migraines can develop "central sensitization", a state of neurological dysfunction in which sensory stimuli become heightened and unpleasant. This is seen most often during an acute migraine headache, in which sensitivity to light (photophobia) and noise (phonophobia) are common, and sensitivity to smells (osmophobia) and motion (motion sickness, dizziness/nausea) are also common. It's comparable to an amplifier for sensory inputs cranked up to maximum volume, so that even seemingly mild experiences become heightened, distorted and unpleasant.

There is evidence that many migraine sufferers retain at least a mild degree of sensory sensitivity at baseline, even between migraine headaches, so that they're always a little bothered by bright lights or scents, they get motion sick if they try to read in the backseat of a car, etc. This can extend to pain and symptoms elsewhere in the body: people with chronic migraines are quite likely to be diagnosed with painful or unpleasant symptoms in the rest of the body, including chronic pain disorders, chronic fatigue syndrome, irritable bowel syndrome, etc). While the origin of those syndromes is complex and not well understood, one element seems to be the sensitization of neurological structures (not just in the brain, including the spinal cord and peripheral nerves).

A person's tendency to have migraines persists even if their headaches get better. It's not a surprise if the headaches come back, even years later, and for no apparent reason. Central sensitization can also be a persisting problem, an lifelong tendency to various episodes of pain or unpleasant sensory symptoms.

What does that mean for Harvin'? He had severe and frequent migraines for years, that suddenly got better. His migraines may recur, sooner or later. And if he did develop central sensitization during his long years of migraines, he may have an ongoing tendency to developing other painful syndromes over the years.

Here's the point

For the rest of this essay, I'm going to speculate that Harvin does have central sensitization, and is prone to pain that is more severe and persistent than would be expected otherwise. I think his ankle injury last year and his hip problem this year are affected by migraine-related central sensitization. Understanding this tendency helps explain why the Vikings were willing to trade a 24 year old who was an MVP candidate last year.

To make that point, let's review Harvin's more recent injury history in detail.

2012: ankle sprain

This is the best timeline I've been able to put together for Harvin's ankle injury last year:

Nov 4: Harvin sprains his ankle playing Seattle. He'd been having a bad game, and the Vikings pass offense was terrible. Harvin fumbled deep in Vikings territory in the 1st quarter, the Seahawks recovered and scored right away. After a 2nd quarter red zone drive stalled when Ponder bounced a screen pass to him, Harvin followed Frazier along the sideline, shouting at him (video). He sprained his ankle in the 2nd half and had to be helped off the field. It looked bad at the time. He came back with the ankle taped but couldn't cut without the ankle giving out.

Nov 5: MRI confirms an ankle sprain. The severity of the injury isn't reported but Harvin says his ankle is injured "in 3 places" (meaning I guess the 3 ankle ligaments?). He talks bravely about playing the next week but its thought he won't return for a few weeks.

Harvin was listed as Out the next week against the Lions. The week after that is the bye. There was optimism that he could return for the following game.

He is listed as Doubtful for the Bears and Packers games that followed, but is downgraded to Out by game time. He doesn't travel to Green Bay. Kevin Seifert described him as "laboring to move faster than a walk" at a practice nearly 4 weeks after the injury.

Nov 21, before the Bears game: Harvin's last contact with reporters that season, says that he'd just gotten off crutches a few days ago and that there was only minor swelling.

"Weeks" after the injury, perhaps in late November, four NFL sources tell Tom Pelissero: "Harvin and Frazier had another heated exchange weeks later [from the Seattle game] in front of some players and staff, fuelling speculation about a deteriorating relationship that could spell the end of Harvin's four seasons in Minnesota... The incident was sufficiently impassioned some inside and outside the building believed that [the argument with Frazier], and not the ankle, was the driving force behind Harvin's trip to IR.

Dec 4, a month after the injury, 1500ESPN reports that Harvin's injury was a full ligament tear, a grade 3 sprain. Seems this diagnosis was made on the original MRI, a repeat scan or change in diagnosis isn't mentioned. As far as I can tell, the severity of the injury was not reported until December 4, a month after the game in Seattle. This is unusual: MRI reports on other notable NFL injuries have been publicized within a day or two (RG3, AP, Cutler).

Dec 5, midweek before the Bears game, Leslie Frazier's is vague about Harvin's injury at his press conference (video at 1:30): "Can't go into a whole lot of detail about his injury... he's done pretty much the things the trainers have asked him to do, but he won't be practicing today". A minute later Frazier gets asked "Are there any other issues with Percy beside the injury?" and deflects the question, doesn't say no. Someone asks if Harvin's season is over and Frazier says "it's hard to say".

A few hours later, Harvin is placed on IR. He does not seem to get a second medical opinion or a repeat MRI and surgery is not mentioned as an option.

He goes back to Florida to rehab his ankle, instead of staying to work with Eric Sugarman. Harvin's Twitter account reportedly never mentioned the Vikings late season run to the playoffs.

The Vikings beat the Packers on December 30 to make the playoffs, then lose the wildcard game on January 5, 9 weeks after Harvin sprained his ankle.

Post-season, he passes his exit physical. Again, no mention of a repeat MRI or further testing on his ankle. There is apparently no major concern about his ankle at the time of his trade to Seattle.

Unusual aspects of the ankle injury: analysis and speculation

The striking thing to me is that there were no reported attempts by the Vikings medical staff to reassess Harvin's ankle sprain even once it became obvious that he was not recovering as quickly as expected. Severe ankle sprains often take 4-6 weeks to recover, but the grade 3 severity of Harvin's injury was not publicized at the time the MRI was done, only after the decision must have been made to put him on IR. Initially, there was hope that he would be back on the field in 2 weeks, in time for crucial road games in Chicago and Green Bay (if the injury was known to be grade 3, why would he be expected back so soon?). Given that timetable, his recovery was behind schedule: he was very limited in his activity level (on crutches for 2 weeks, barely running at 4 weeks). Despite falling behind the expected recovery curve (under the supervision of a trainer known for producing faster recoveries than most), there was no mention of a repeat MRI to make sure the injury hadn't been aggravated, or an opinion from a surgeon, to make sure he was not at risk for permanent ankle damage. I suppose something like that could have happened behind the scenes, but you would think the story would have come out after he was traded.

The decision to put him on IR and let him go back to Florida was highly unusual. There were still 4 weeks left in the regular season. Even a severe ankle sprain should have mostly recovered in 6 weeks, soon enough that Harvin could have played in weeks 16 and 17. If the ankle had been reinjured in rehab, or was still so unstable that returning to playing would leave him at risk of permanent damage, you'd expect that to be reported. Instead, Frazier said:

"You realize for him, as well as for our team, this was the best thing to do, as opposed to try to make something happen that's not going to happen," Frazier said. "I think it helps all of us for him to concentrate on what he has to concentrate on from a physical standpoint, and knowing that he wasn't going to make the progress that was necessary for him to get back and play this season."



Frazier said surgery isn't yet being considered and said "got my fingers crossed that won't be the case." But, for the second straight day, the coach refused to get into much more of the specifics on the severity of the ankle injury. A Tuesday report on 1500ESPN.com said Harvin had suffered a Grade 3 sprain, which means the ligament was completely torn. Frazier said he hadn't been provided the Grade 3 term, but he admitted Harvin had suffered tearing and wouldn't go into any further detail.



"He made some progress at times, but it was incremental," Frazier said. "Just not the progress we needed to see along the way, so we've got to step back a little bit and try to do the things that are necessary for him and best for us and let him concentrate on getting well. He's such a valuable commodity. You don't want to do anything that's going to create some long-term ill effects."

I think Harvin's ankle injury wasn't really a grade 3 sprain, or else that would have been reported initially, and he wouldn't have been expected back so soon. I think it did heal as expected, in 2-4 weeks, and the Vikings medical staff had no concerns that the injury had recurred or progressed. They could have tested the stability of the ankle clinically and concluded that he was good to go. Despite that, Harvin remained very limited in his activity level, having trouble running and making cuts.

I think he had developed a pain disorder in his ankle that persisted even after the sprain had healed up to the point that is wouldn't have been expected to bother him too much, and it was that persisting pain and not any instability of the ankle which limited his ability to run and cut. Harvin's history of migraines may have left him vulnerable to sensitization of the pain structures in his ankle, which could have produced persisting pain and therefore difficulty with using the limb, even after the ligaments had healed sufficiently to be used normally. Pain can lead to bad mechanical habits in rehabilitation (from trying to minimize pain), and abnormal patterns of activity can potentiate and extend that pain, producing a vicious cycle.

If the Vikings training staff recognized that a pain disorder had developed, that diagnosis would have implied that he was not going to improve any time soon, as Frazier put it, "try to make something happen that's not going to happen". That's quite different than a persisting ankle injury, or one that was more severe than initially suspected, in which there'd be no reason to be so pessimistic that he would not recover with an extra few weeks of rehab.

It's hard for me to imagine a better explanation for the way the Vikings handled Harvin's injury in early December. It explains Frazier's vague answers and the seeming admission that Harvin hadn't fully done what the trainers were recommending (or maybe expecting?). It explains why there was no detailed medical information provided about the injury and why it wasn't healing (because it had healed, even though Harvin was still in pain and not running). It explains why the Vikings put Harvin on IR rather than keeping him week to week and hoping he'd come back for the last game or two of the season -- pain disorders have no expected timeline for recovery, so if they diagnosed Harvin with chronic pain in his ankle, IR would be an appropriate step. It explains why Harvin left Minnesota instead of working with Sugarman (who's good at making ankles stable, but not necessarily at making them hurt less), why surgery wasn't an option, and why there was no concern that he would pass a medical at the end of the year. I'm saying that he'd effectively passed a medical in early December, but still reported pain and was somehow unable to run and cut, and so the Vikings decided he wasn't going to get better and put him on IR.

Frazier seemingly tried to encourage him and challenge him to do more, having been given the good news from the training staff that Harvin's ankle was now stable enough for him to run on. Harvin, who may have still been experiencing pain as severe as the initial injury, would not have felt capable of using his ankle normally, even if it was stable from an outsider's point of view. If Frazier insisted he try, and Harvin ran at "50-60%" in the only practice he attended in the first week of December, one month after the injury, and Frazier challenged him to do more, that might explain this report:

According to four NFL sources, Harvin and Frazier had another heated exchange weeks later in front of some players and staff members, fueling speculation about a deteriorating relationship that could spell the end of Harvin's four seasons in Minnesota. Details of that altercation remain clouded, though it is believed to have begun in the training room at the Vikings' facility. There's no question Harvin was frustrated with the ankle not coming around. The incident was sufficiently impassioned some inside and outside the building believed that, and not the ankle, was the driving force behind Harvin's trip to IR.

You might think that Harvin is so tough on the field that no one would ever question his ability to fight through an injury. In fact, Harvin reportedly threw a weight a Brad Childress in November 2010 (after Moss left, before Childress got fired) when Childress accused him of dogging it on an ankle injury and kicked him out of practice. So there's a track record.

Note that my theory is not that Harvin is exaggerating his ankle pain or "dogging it" (refusing to try), but that he honestly experiences increased pain sensitivity. He is accurately reporting that his ankle still hurts too much to use normally, because that's how it actually feels to him, because of central sensitization. Unfortunately, from the outside, with only 'minor swelling" and a stable ankle as assessed by the training staff, it can look like he's not trying.

Frazier and the Vikings staff might have felt that they could not trust Harvin to do what was best for the team (the passing offense was brutal in the 2 games Harvin was expected back for and didn't play in, in Chicago and Green Bay, both losses), since he was taking himself out of the lineup despite being cleared by the trainers.

Harvin might have felt he couldn't trust the Vikings either. He left training camp in 2012 in protest of not being offered an extension on his rookie contract, and wanting a larger role in the offense than in 2011, when he didn't play on 3rd downs. It's reasonable to think that 2012 was Harvin's big chance to earn a huge contract, from the Vikings or elsewhere, and the ankle injury jeopardized that. If he'd gone back to playing at the end of the year at half speed, his stats would have been terrible, and he might have jeopardized his big contract. Harvin might have also been worried about a permanent ankle injury. If the Vikings hadn't traded him, he would have been playing 2013 on the last year of his rookie deal, and he would have had to protect his long term health to ensure a big payday.

A mutually satisfactory exit strategy was needed. Statements released to Tom Pelissero suggest that the decision to place Harvin on IR was made between the Vikings and his agent, Joel Segal. I would speculate further that the decision to trade Harvin was made before he was placed on IR, probably after his last attempt at practicing, in early December. The team needed to move on without waiting for Harvin to feel better (with no idea how long that would take), and Harvin needed to protect his long term interests and wait until he felt ready to return to the field. Recall Frazier's words at the time, "he's such a valuable commodity".

Harvin maintained total media silence from Nov 21 until the trade in March, commenting on the decision to go on IR only with a vague PR statement that does not give a specific reason for the decision, or its timing a month after the injury:

"It certainly is disappointing that I was not able to finish out this season with my teammates," Harvin said in a statement released by the team. "As a competitor, I definitely wanted to get back out on the field, but my injury has just not allowed me to progress to the point where I can help our team.



"I appreciate the efforts of our medical staff and the support of our fans in helping me through this process and look forward to coming back stronger and better than ever."

Harvin's media silence could have been a condition the Vikings placed on finding a trade for him, since that would give them a chance to maximize his market value. Both sides had an interest in seeing Seattle make a good enough offer that Spielman would be wiling to let Harvin go.

2013: Hip problem

I won't get too far into the weeds with this, the situation's still playing out.

Here's the timeline:

Harvin reported some hip pain during OTAs in June ("a sore hip flexor") and sat out one practice before returning. Despite that, when active, he "looked faster than anyone on the field". Pete Carroll described the injury as "minor".

As far as I can tell, nothing further was reported about his hip until training camp opened and he was placed on the PUP list. As recently as a week before camp, he was reportedly working out at "full speed".

An MRI was done on his hip on Thursday, the day players reported for camp, which reportedly showed a "slight tear" of the labrum of his sore hip.

Seahawks doctors did not recommend surgery for the problem, even after the MRI. Harvin requested a second opinion, and is scheduled to see an orthopedic specialist in NYC on Tuesday. It's speculated that surgery would cost him at least half the season, and he might be out for the year.

A slight tear of the acetabular labrum

An RN who works with trauma/orthopedic patients (and therefore probably knows more than I do as a non-ortho specialist MD about the subject) has posted an excellent primer about Harvin's injury on the Field Gulls site. If you're interested, it's worth reading the whole thing. The basic idea is that the labrum is a ring of cartilage around the hip socket that helps keep the ball of the head of the femur (thigh bone) in the socket of the pelvis. The labrum can be damaged by trauma, including sports, and also can degenerate with aging.

The Field Gulls post is excellent, but it's missing a crucial point of context. Labral tears are a common finding in asymptomatic people, even young people. A study of 45 asymptomatic volunteers (average age: 38, range 18-66) found 69% were found to have a labral tear on MRI of the hip, despite no current or prior history of injury, pain or surgery in that area. In other words, labral tears of the hip are a common incidental finding, the kind of thing that's common enough in normal people, where the body isn't quite perfect but it's still normal. Incidental findings are compatible with normal function, they shouldn't be blamed for symptoms.

This study suggests that the average NFL team who arranged an MRI of the hip for each one of its players checking into training camp (80+ on each roster), even though the majority of them don't have hip pain or other symptoms, would find 50+ players with at least a slight labral tear. The comparison is far from exact, because NFL players are younger and yet have a history of more traumatic exposure and activity with their joints, but the key point is: what's being reported as abnormal in Harvin's hip is statistically quite common, and is that sense normal, even if it isn't perfect.

Hip problem: Analysis and speculation

If Harvin's hip pain is happening despite no severe injury as its cause (try to find the point in that timeline when he got injured), a slight labral tear would be the kind of thing that might show up on his MRI anyway. It might have been there for years, not bothering him.

So why would his hip hurt and limit him in practice? Again, he's at risk for pain disorders that are not fully explained by injuries or other causes. He might have pulled a muscle, had a little pain that he was mostly able to work through initially, but then seen his pain increase ("the wind-up phenomenon") despite no further mechanical damage to the hip. Once he was off his practice regimen and favoring the hip, the pain and dysfunction could worsen further, as a vicious cycle.

That would explain why the Seahawks doctors recommended against surgery. You can be sure they would act quickly to intervene if they thought Harvin's hip was at risk for permanent damage. But if they see his pain as a separate issue from the labral tear, then operating to fix it would be risky and unnecessary.

Non-surgical management options for labral tears have been proposed. They consist of rest, physiotherapy and NSAIDs like ibuprofen or naproxen. So Harvin may have a clear medical diagnosis that implies that he needs to be careful not to overuse his hip, resting for most of training camp and limiting his time on the practice field, to make sure his pain doesn't worsen.

He would still be able to play in games, thankfully.

How worried are Harvin's VIkings teammates that he might have suffered a season ending injury? Not very:

#Vikings players here asking me/laughing about the Percy Harvin situation. They all think he plays in Week 1. — Tom Pelissero (@TomPelissero) July 29, 2013

So, my predictions:

Harvin won't need to have surgery on his hip this season, and not after the season either His hip problem will limit his participation in training camp, but he'll be ready to go for week 1. From time to time during the season, his hip pain will flare up and he'll miss practice, but usually not games There will be no visible effect on his speed or agility from it -- he'll continue to be very productive on the field

Conclusions

Migraines are a real neurological disorder. I don't think Harvin's faking or exaggerating his symptoms.

Harvin has had a number of poorly explained symptoms and difficulties which have limited his participation particularly in training camps and practices

Some of those episodes have led to conflict over his perceived effort level and commitment, not only with Childress but with Frazier, who's known to be a player's coach and a nice guy

Harvin's hip problem seems to be more similar to his migraines or his ankle (after it healed) than to any more serious or permanent injury. The Seahawks medical staff believe he will not need surgery, but the team is being supportive, putting Harvin on PUP and sending him to NYC for the second opinion today.

This may make it easier for Harvin to feel his symptoms are being taken seriously, and are not threatening to his situation (unlike before he signed his contract), which could make it easier for him to get better

I would expect him to play in week 1 and in most games this season. I think he'll be as dominant on the field as ever, even if the hip problem flares up from time to time.

As I said, I don't think Harvin is faking or exaggerating his symptoms, I think they're real to him. But at the same time, this ongoing pattern of hypersensitivity makes him "high maintenance" as far as a team is concerned, always at risk of a flare up of symptoms that will limit his participation in team activities.

Harvin is an amazing talent and a dynamic player, but as a Vikings fan, I'm glad they didn't give him a big contract and commit to building around him for the future.