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Wednesday, March 7, 2012
Manning's recovery still ongoing


Sometimes, even if a parting of the ways is anticipated, it is still difficult to process when it actually transpires. And so it is on this day as the Indianapolis Colts announce they will release Peyton Manning.

It is no secret that this cascade of events was triggered by questions about the veteran quarterback's health, specifically the health of his neck and its relationship to his throwing arm. The whispers of concern over Manning's health began last May, grew to rumblings in late summer and became overt points of discussion as the NFL season progressed. In medicine, the degree of success following a surgery, therapy or any other form of treatment is typically measured by return to prior level of function. In Manning's case, that would be defined as a return to play in the NFL.

So what everyone naturally wants to know is what degree of "success" will Manning achieve?

The problem facing all parties involved in this discussion -- the Indianapolis Colts, any NFL teams who might be interested in Manning, the medical personnel involved in Manning's care, Manning's representatives, even Manning himself -- is that the answer is not yet definitively known. Until Manning comes back to the football field and performs at a level comparable to where he left off -- or determines that he will not or cannot do so -- the return to prior level of function cannot be fully measured.

In the meantime everyone, including Manning, can only project what they think is reasonable to expect. Here is some of the material that factors into that analysis.

The chronology

This has been repeatedly documented in detail but the highlights surround Manning's surgery dates.

Peyton Manning
Peyton Manning was a spectator at team practices during the 2011 preseason.

On May 23, 2011, Manning underwent a procedure to address a bulging disc. He engaged in a rehab program away from the team facility. When training camp opened, Manning had not progressed to participating in team football activities.

In September, the Colts indicated Manning would miss the season opener and concern about his progress quickly elevated.

Hours later, the Colts announced that Manning had undergone a single-level anterior cervical discectomy and fusion (ACDF) with Dr. Robert Watkins in California. Manning subsequently returned to the Colts' facility to resume his rehabilitation. In December, Manning's fusion was declared stable and he was cleared to progress his activity. The takeaway at that point was simple: The fusion (the bony segment where the two vertebra are fused together with bone graft) had healed. Manning could gradually increase his activity without fear of damage to the area that was repaired. Theoretically, the remaining piece was regaining strength and conditioning of the muscles that support the area (neck, upper back) as well as arm strength, further cardiovascular conditioning and resumption of sport-specific activities.

Manning did not return to play during the regular season.

In December, SI.com reported that Manning had undergone an additional "procedure" on his neck. The term procedure is non-specific and does not reveal anything about what may or may not have taken place. Consequently, this information is hard to incorporate into any analysis of Manning's overall medical condition.

In January, reports surfaced of Manning increasingly working on throwing, suggesting he was making strength gains in his right arm. ESPN's Chris Mortensen reported that Manning was cleared by Watkins to resume play and that the Colts' neurosurgeon, Dr. Hank Feuer, told Manning it would be safe to return. Colts owner Jim Irsay responded by saying that Manning had not yet passed a team physical.

There have been no further formal medical updates from either the team nor any of Manning's medical providers.

The medical precedents

Cervical fusions are not altogether unusual. Significant improvement is reported for most patients with disc herniation but the majority of individuals who undergo the procedure are not trying to return to contact sports. But what if they are?

As it turns out, there are athletes who have successfully undergone an ACDF and returned to play in the NFL. Not only have they returned to football but one could argue that in most cases, they have returned to play in positions (such as defensive back or lineman) that are susceptible to far more routine repeated contact or collision than Manning's position of quarterback.

Dr. Joseph Maroon, professor of neurological surgery at the University of Pittsburgh Medical Center and team neurosurgeon for the Pittsburgh Steelers, has performed ACDFs on perhaps the largest collection of such elite athletes. In a paper to be presented this April at a conference in Pittsburgh, Maroon reports on a series of 13 athletes (eight NFL players and five professional wrestlers) who underwent an ACDF. Maroon notes that each of these athletes recovered to the point of being able to return to their sport. The recovery time frame ranged from as little as nine weeks to as much as 12 months. (Although all athletes were cleared to return to sport, two opted to retire.) Many of these athletes returned to play for multiple seasons; some are still active.

Like any surgical intervention, the ACDF doesn't come with a foolproof guarantee. "There is a 15 to 18 percent chance that an individual could develop a problem above or below the level of the fusion, but that is with or without football," Maroon says. "One athlete in this study did have that happen." Still, as Maroon points out, this procedure can extend the playing time for an athlete who might otherwise be forced out of his career because of injury.

Manning's specific rehab progress

This is the hardest element to assess from a distance. For a long time, we heard nothing. When Manning underwent his surgery in May, the NFL was in a lockout. According to the terms of the lockout, Manning, like all players, could not communicate directly with the organization. Additionally, his rehabilitation took place away from the Colts' facility and away from the rehab staff with whom he was accustomed to working throughout the season. (This is not intended to comment one way or the other on the quality of the care he received but rather as simple point of fact.) While we heard the occasional reference to Manning undergoing rehab and that he was making progress, there was little, if anything, specific.

Then the lockout ended. Training camps began. And suddenly it became obvious, simply by his absence from team workouts, his sequestration from the media even, that Manning was not far enough along in his recovery to participate in football activity. A month before the season was to begin, this was clearly a concern. This is when reports of lingering weakness in Manning's triceps began to surface and the words "nerve regeneration" came to light. Once the Colts announced that Manning was undergoing a subsequent surgery, a single level cervical fusion, it was clear that his progress had, at best, plateaued.

Peyton Manning
Manning has gradually been able to return to football activities.

Since that surgery, Manning's recovery has remained somewhat of a mystery. As his rehabilitation efforts continued away from the public eye, there could only be speculation, often fueled by comments from the various parties close to the situation, as to what Manning's real progress was. That is, until the video footage surfaced recently showing Manning, looking very much like a football player in helmet and pads, throwing a football very much like a quarterback needs to do. This is the first visual evidence of Manning being Manning-like and even this is merely a snapshot in time, many steps removed from returning to competitive play. But it signals progress.

As it stands now, Manning's evidence of progress in the video clip is the strongest affirmation yet that he has the potential to return to form. The window for him to make further physical or functional gains has not necessarily closed and no one can say with absolute certainty when that will happen. According to Maroon, within 12 to 18 months post-surgery an athlete has probably realized the maximum point of return. Even if Manning's May surgery is considered the starting point of the countdown clock, he is less than a year removed from that procedure. It's possible not only that Manning will continue to progress beyond the point where he is now, when teams will likely be wooing him, but that he could continue to improve even after returning to play. On the other hand, it's also possible that his body has achieved its full capacity for healing.

There is no way to definitively measure where Manning's maximum potential lies, no imaging test that will guarantee an outcome. Evaluating how completely Manning can and will recover is ultimately something that only happens in retrospect, with the assessment potentially ongoing for the duration of the next NFL season. That makes what the Colts are doing now and what any subsequent team who signs Manning later an exercise in uncertainty. There is a risk-reward element when it comes to medical conditions and athletes, which is nothing new. Free agents in all sports face these issues as prospective teams evaluate whether or not to sign them based, at least in part, on their medical history. Every year in the NFL draft these decisions are made as some teams pass on athletes whose medical concerns outweigh their perceived potential while other teams opt for the high upside and are willing to absorb the medical risk. The difference here is that this is not just any athlete; Manning is the face of a franchise, a projected Hall of Famer who is known equally for his work ethic and his contributions to the community as he is for his exceptional skills on the field, making the reward exceed the risk for many suitors.

Given the unknowns on the medical front, the only certainty at this point is that Manning and Andrew Luck, whom the Colts are expected to select with their No. 1 draft pick, will not be on the same sideline. The team that does succeed in securing Manning knows the potential for their investment; they just hope to also have a little luck on their side.