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Sunday, June 7, 2009
Nelson's injury allows for early return

By Stephania Bell
ESPN.com

Jameer Nelson
Jameer Nelson returned to action from a torn labrum several weeks faster than expected.

Just four months after undergoing shoulder surgery, Orlando Magic point guard Jameer Nelson has already answered the question of whether he could play and whether he would play in the NBA Finals.

As the Magic face off against the Los Angeles Lakers, however, one question remains the same: What exactly is a realistic expectation for Nelson at this point?

The answer is complicated and requires a look back at just what has happened for Nelson and his team in the past few months.

Nelson was essentially considered done for the season in February when he underwent surgery to repair a torn labrum in his right shoulder. After all, who knew then that the Magic would be in the Finals? And even if that was taken into account at the time, most athletes in a contact sport (and yes, if you've been watching the playoffs, there should be no doubt that basketball is a contact sport), require about six months to return to competitive play after a surgery like Nelson's.

So why is Nelson able to play after four months if the timetable to return is generally closer to six? There are two things that are taken into consideration when establishing time guidelines for an athlete's return to play following injury.

The first has to do with the time it takes the injured tissue to heal. Biologically, different tissue types require varying amounts of healing time, generally related to blood supply to the area. Better blood supply equals more nutrition, which in turn means faster healing.

As it turns out, the labrum, which is a ring of fibrocartilage in the shoulder joint, has a poor blood supply and therefore requires several months to heal. (Incidentally, a torn labrum will not repair itself. During surgery, the labrum is stitched together, and then anchored to bone. Tissue healing takes place at the site of the bone-labrum interface.) After four months, some healing is expected to have occurred, but the labrum remains supported by the sutures. In other words, between the sutures and the early healing, the repair itself should be in decent shape in Nelson's case.

The second factor involved in return to play is far more variable and harder to quantify. It has to do with all of the other elements required for an athlete to be "game ready." Those include the obvious things like full range of motion and strength of the muscles around the shoulder.

It also includes more complex variables like physical conditioning (endurance), agility and sport-specific skills like shooting, passing and ballhandling. Ultimately the goal is to get a player back to his style of play at a pace that allows him to blend with the team. In Nelson's case, that style is one of physical play and a willingness to endure contact. It is in this latter realm where the challenge of returning Nelson to a playoff status lies.

Clearly, Nelson met all of his rehab targets (perhaps even exceeded them) in order to be in the position for eligibility now, but it is evident, to some degree, in his play thus far that he has had such a limited window of time to get his feel for the game back and to re-establish complete confidence in his shoulder.

In Game 1, we witnessed some errant passes in Nelson's game. His jump shot also appeared to be off the mark -- that is, when he was willing to take it. Most notably perhaps, we saw Nelson as less of a force inside. The biggest risk for labral injury in basketball is contact at the top of a shot. When a player's shooting arm is overhead, encountering hard contact with a defender's arm is where separation of the labrum tends to occur.

It is fair to say there is some risk of reinjury, but the risk is not necessarily much higher than that of any non-injured player. Nonetheless, when a player is returning from injury, until his confidence is fully restored, he tends to be a bit more hesitant when it comes to those situations, even if it is subconsciously. This is not to say that his contributions may not be valuable, and it is a well-known rehab philosophy that returning to competition, in some measure, is the final stage of rehab. In other words, these more complex variables should improve as Nelson continues to play.

With each shot, each pass, each drive to the hoop, as his body gets the feel for the game back and his shoulder passes each test, he regains timing, skill and most importantly, confidence that he can, in fact, perform at a competitive level.

Whether this is ideal for the team overall, that is a decision that ultimately rests with the coach and team management. The Magic have already indicated that they plan to continue to utilize him, and they expect his play to improve throughout the series. The concern is whether they can afford the luxury of allowing him to progress in his rehab if they end up falling further behind in the series.

Stephania Bell is a physical therapist who is a board-certified orthopedic clinical specialist and a certified strength and conditioning specialist.