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Wednesday, July 29, 2009
NFC West injury analysis with Stephania Bell


Posted by ESPN.com's Mike Sando

NFL training camps bring hope and anxiety as teams worry about injuries altering the trajectories of their seasons.

If Seahawks quarterback Matt Hasselbeck aggravates the disc problem in his back, then what? Even rival teams' fans acknowledged Hasselbeck's health as a key variable in the division when I asked which NFC injuries scared them the most.

"Hasselbeck and the overall health of Seattle's o-line have to be No. 1," DWRinAZ wrote.

49ers fan redng0ld singled out San Francisco right tackle Marvel Smith's back situation as pivotal in the division. "If he stays healthy," redng0ld wrote, "we got ourselves a Pro Bowl-caliber RT. If not, we got Adam Snyder, who is not much more than a versatile backup."

"Has to be Steven Jackson," Rams fan Casey Schneider wrote. "'Spags' [Rams head coach Steve Spagnuolo] is committed to the run and we don't have a lot of depth behind Jackson."

"Why is Kurt Warner not being mentioned here?" joe_cool585 asked.

He's on the list, Joe.

As promised, ESPN injury expert Stephania Bell has delivered. We spent more than an hour on the phone Tuesday analyzing key injury situations in the division. Her experience as a physical therapist, board-certified orthopedic clinical specialist and certified strength and conditioning coach helped establish more clearly defined expectations.

And now, on to the injury analysis, grouped by team:

Matt Hasselbeck, QB, Seahawks

Injured body part: disc trouble in his back

Surgery type: none

Stephania Bell: Any time you have a disc problem, you are always at risk for re-injury. The disc is never the same after a significant injury. It is damaged tissue. Once the inflammation subsides, you may not have symptoms and it can form some scar and heal to a degree, but ultimately, it is weaker. The good news is, the best measures for preventing recurrence are getting as strong as you can and being in the best shape possible. Hasselbeck has certainly done the right things. His core is stronger and he has dropped weight. It's not something like a ligament, though, where once it's been reconstructed you can say, 'OK it's fixed.'

Disc problems are by nature recurrent. The first flare-up last year was when they flew to Minnesota on a long flight. [Former coach Mike] Holmgren dismissed it as an old back problem, nothing new. There you go. It was an old injury. They are lucky in that he was able to avoid surgery. I would put that in the plus column for him. The fact that it was not the first episode and it was so severe, those were the strikes against him.

He got hit a lot last year and certainly minimizing that could only help. But many times it's things like a plane flight that can flare it up. Unfortunately, there's no true way to predict the likelihood of recurrence. He could go years and be fine or he could have another episode this season. All you can do as an athlete is put yourself in the best physical condition possible as a measure of protection.


Walter Jones, LT, Seahawks

Injured body part: knee

Surgery type: microfracture

Stephania Bell: Microfracture surgery is a procedure designed to fill in where there is a hole, a defect, in the cartilage. When you get bone-on-bone contact as a result of cartilage breakdown, it's incredibly painful. Microfracture surgery provides the protective covering of cartilage (not quite identical to the original, but functional) so they don't have pain.

With Walter Jones, it depends on where the defect was. The Seahawks said the surgery was to a non-weightbearing part of the knee. If weightbearing, it's subject to a lot more stress. Microfracture on non-weightbearing parts tend to do better. When they say non-weightbearing, it usually refers to when you're walking. A consideration especially with linemen, however, is it can be a part of the knee that is not weight bearing when you are walking or running, but when they get into a squat, it can be in a position where there is a lot of contact pressure. At some point during the squat, for example, there is a lot of pressure where the kneecap contacts the thigh bone [femur]. Usually, in a squat and coming out of it, they will hit that contact point somewhere. There are also increased points of contact between the thigh bone [femur] and the leg bone [tibia] when the knee goes through a full arc of motion [as in a squat] compared to the points that contact during regular walking.

Overall, if Jones' injury was in a location where there is minimal weightbearing, it bodes better for him in the long term.


Patrick Kerney, DE, Seahawks

Injured body part: left shoulder

Surgery type: arthroscopic

Stephania Bell: A lot of these guys who are linemen get shoulder instability issues -- as a result of their repeated blocking and tackling -- that can be very difficult to definitively diagnose. They can get a labral tear. They often feel like their shoulder is slipping. Once they get it repaired, the shoulder feels a lot tighter and the instability discomfort is resolved. It shouldn't be a big deal. Kerney also underwent surgery to remove bone chips from an elbow. In terms of recovery, that one is not a big deal. If he were a thrower, then you would be more concerned.


Nate Burleson, WR, Seahawks

Injured body part: knee

Surgery type: ACL reconstruction

Stephania Bell: Remember the situation with Deion Branch last season. For receivers and running backs following this injury, they will be doing everything and feel that they are ready to come back, but no matter how much they train and run and practice, until they are in a game situation where they don't know where someone is going to hit them or come at them, it changes how they play. You often don't see them playing like themselves until their second season. If Burleson is ready to go full bore and doing everything full speed, I would expect him to be picking it up [in terms of confidence in the knee and appearing effortless in route running and playmaking] by the midpoint of the season.

The first few games back are t
ruly the final stages of rehab following ACL reconstruction. Look during camp for any hesitation, little comments that he makes as to whether it was pretty good or he feels a little slow. Watch all the things where he is off-balance where he has to dodge something, go up in the air and land on it. It's a subtlety, but it's a big difference between being back 85 percent and 100 percent. With T.J. Houshmandzadeh there, I think it's going to be interesting because that is going to open it up more and that could help a guy like Burleson.


Kurt Warner, QB, Cardinals

Injured body part: hip

Surgery type: repair torn labrum

Stephania Bell: He should be fine. With him at minicamps and doing 7-on-7s and moving around, I don't think this will present a big issue for him. Given his age, it's not a big surprise he had this surgery. If anything, this probably makes him feel a little more flexible. Sometimes they feel a pinching or tightness when they have these labral tears in their hips. I don't think this is a significant thing for him.

My bigger concern with Kurt Warner is his potential for more of the hand and the elbow injuries he has had in the past. Finger fractures, thumb, elbow sprains. Those injuries are more of a concern for him at his position.


Gabe Watson, NT, Cardinals

Injured body part: kneecap

Surgery type: follow-up

Stephania Bell: It sounds like they removed some of the pins they put in after he fractured his kneecap before last season. This is an area where it can get very tight and stiff because the large quad muscle runs over it. He is a big guy, so he is going to generate a ton of compression on his quad, which in turn compresses the kneecap when it contracts. It could have been terribly irritating with those pins. When they went back in, they reportedly removed some of the pins. The pins are there to help the bones come together. Once the bone has healed, if the hardware causes discomfort, it is best to have it removed. Just by removing the hardware, sometimes that takes care of the pain. He may also have had some scar tissue as well that they addressed.


Lyle Sendlein, C, Cardinals

Injured body part: shoulder

Surgery type: repaired labrum, supraspinatus muscle

Stephania Bell: The supraspinatus muscle is one of your rotator-cuff muscles. It depends where it is torn. It can tear away where it attaches and if he were a thrower, he couldn't get his arm over his head. As a center, he could probably be functional playing through that injury, but it's painful. It was probably very uncomfortable and affected his arm strength. Once repaired, as a center, he should be OK. It's a nasty injury, but not as complicated as it would be for a quarterback or pitcher. It's a significant rehab, but a lot less lengthy than if he were an overhead athlete.


Tye Hill, CB, Rams

Injured body part: knee

Surgery type: repair cartilage damage

Stephania Bell: The fact that he had this surgery after Week 4 and then missed the rest of the season suggests this was a more significant meniscus tear. You hear about this a lot, where a guy has a meniscus injury, they do a scope and he comes back fairly quickly.

There are two menisci in your knee. They help cushion the knee joint. It's not necessarily just, clip it out, no big deal. If you have to take out a big chunk, you have the potential to develop arthritic-type problems a lot faster. Factors such as the size of the tear, the location and the overall condition of the athlete's knee help determine the course of action. Reportedly Hill also had persistent swelling and a bone bruise associated with this injury, so the healing was delayed. The hope then is that he'll be in good shape now heading into the season.


Justin King, CB, Rams

Injured body part: left big toe

Surgery type: repair torn ligament

Stephania Bell: It's a variant of turf toe. You have ligaments underneath where the big toe attaches to the ball of your foot. If you have a minor stretching or tearing of the ligament [a sprain], that can be turf toe. If you jam your toe, that can also be turf toe. If you completely tear the ligament on the undersurface or pull away some of that plantar plate, then you have gross instability of the toe and it needs to be repaired.

The problem is, you need so much motion in your toe. It has to extend somewhere between 70 and 90 degrees for you to be able to push off and run. It has to be strong enough to support that. But after you have surgery, the first thing you do is immobilize it, which is necessary to allow the tissue to heal. The hardest thing after an injury like that then becomes, can they then get the motion back and get the agility back to be able to push off and plant and cut and pivot? As a defensive back, obviously that is huge.

You've seen a couple guys with these toe injuries. LaDainian Tomlinson struggled last year after a toe injury. Antonio Gates had a surgically repaired toe injury and he also struggled a good part of the year.

King is young and if he had a clean ligament rupture without a lot of bone damage and arthritic changes in the toe, then his chances of coming back to his prior form are much better. I would really be watching him in training camp and these preseason games to see how he looks. The last element to come back is the agility, pivoting and twisting freely on the toe.


Steven Jackson, RB, Rams

Injured body part: thigh

Surgery type: none

Stephania Bell: Steven Jackson is an amazing physical specimen, but he has a history of missing games. It's these lingering muscle strains. Sometimes these athletes who are highly trained, like high-performance machines, are fairly disabled after a significant muscle strain. When they get a muscle injury, there can be a lot of bleeding. He had groin and hamstring injuries in 2007, and last year it was the quad. He is big and physical and will take a lot of contact and he uses his legs so much to drive.

It's dangerous to talk about predictions, but when you look at the trend, the pattern is that he hasn't been able to make it through a season without injury. It sounds like the Rams improved their offensive line. Tha
t can only help. The better the holes are opened up for him and the less contact he has to take, the less resistance he has to overcome while running, can only help.


Alex Smith, QB, 49ers

Injured body part: shoulder

Surgery type: bone chip removal

Stephania Bell: Just based on what he has been doing so far in minicamps, the 49ers should be encouraged. It was an unfortunate series of events. He had a Grade 3 AC sprain, which is a very significant injury. If you have a less severe sprain like a Grade 1 or a Grade 2, it's pretty standard, usually no surgery. When you have a Grade 3, the ligaments anchoring the collarbone to the tip of the shoulder are completely torn and it often looks like the collarbone is going to pop through the skin.

If he was a lineman, they might say, 'Even if it doesn't look pretty, you can play just fine with that.' If you are a thrower, your mechanics are going to be affected. He tried, but he really couldn't perform with that separation, so they went in to fix it. They reconstruct the joint but it's not an easy rehab. It's hard to get your mechanics back. Then he had another setback where a piece of bone broke that required yet another surgery.

It's not a case of Alex Smith being a wimp. He had a really tough injury. Then this freak thing happened on top of it. It sounds like from the way he has been throwing the ball in the spring that he is well past it. People need to remember that for the better part of three years, he hasn't had a normal shoulder. I think he really has a chance to look a lot different than what we have seen in the last few years. I think he could be a bit of a surprise for people this year.


Marvel Smith, RT, 49ers

Injured body part: back

Surgery type: none on back since 2007

Stephania Bell: The Steelers let him go. The Niners knew what they were getting and as we discussed with Hasselbeck, these disc problems do not necessarily go away. When you are talking about a guy who is 6-5 and 300-plus pounds, that compounds the issue. I would not be surprised if it is an up-and-down thing from week to week.

He is not going to magically turn around and recover. But it's not to say some of those problems won't go into hibernation for a while. These guys are forced into hyperextension frequently. Many times they are pivoting off one side when they are blocking. These things are stressful to the spine. It's amazing you don't see more problems.

Usually, the structure that is the weakest in the spine is the disc. A number of these linemen have disc problems. On top of the demands of their position, they perform heavy weight training, which can pose some risk, especially if they lose their form. When I see a guy with the injury pattern and the history he has had, and then he's had previous surgery, I suspect that the tissue is not fully healthy. It's not a great outlook.


Michael Crabtree, WR, 49ers

Injured body part: foot

Surgery type: 'Jones' surgery

Stephania Bell: His injury should be a non-factor assuming he has done everything he was supposed to. Last I heard, he was working out with the staff and he was running. I'm very interested in seeing if it is behind him. This is not the kind of thing you think about getting re-injured. The best thing he did was have the surgery when he did and not delay it.

The fifth metatarsal is the long bone on the outside of the foot. The injury, until fully healed, affects speed and cutting simply because of the body part involved. The key is really, bone injuries are typically very straightforward as injuries go. When you have a fracture, once that fracture heals, it typically becomes a non-issue. Once the bone has healed, an athlete should be at no increased risk for re-injuring the area.