Gronkowski no sure thing for Week 1

Updated: May 29, 2013, 9:43 PM ET
By Stephania Bell | ESPN.com

Patriots tight end Rob Gronkowski has now undergone four surgeries on his left forearm; this much we know for sure. All the chatter since his most recent procedure indicates optimism on the part of the Patriots with regard to Gronkowski's progress. But what are we to expect realistically heading into the 2013 season?

At this point, the questions far outnumber the definitive answers when it comes to Gronkowski's health. It only makes sense to recap the series of events that have comprised the Gronkowski forearm saga to differentiate what is known from what is not known at this point. Then, perhaps, we can try to gauge what to expect when the Patriots open their season this September.

Known

Nov. 18, 2012: Gronkowski breaks one of two bones in his left forearm, the ulna, while blocking on an extra-point attempt. The ulna runs from the elbow to the pinkie finger. Of the two forearm bones, it is the one more vulnerable to injury during blocking plays in football. The fracture requires surgical stabilization, which is performed by team orthopedist Dr. Thomas Gill. The surgery is deemed successful and Gronkowski embarks on a program to maintain physical conditioning, gradually transitioning to rehab as the forearm permits. Expected downtime is somewhere in the neighborhood of four to six weeks, depending on how the bone healing progresses.

Dec. 30, 2012: Gronkowski returns to action in the Patriots' regular-season finale against the Miami Dolphins, exactly six weeks post-injury. He has two catches for 42 yards and a touchdown.

[+] EnlargeRob Gronkowski
Jim Davis/The Boston Globe/Getty ImagesRob Gronkowski lasted only seven plays before reinjuring his forearm in January.

Jan. 13, 2013: During a divisional playoff game against the Houston Texans, Gronkowski takes a fall and lands on his left forearm (which is sporting a protective shell wrapped in padding). The fall is not unusual and is not out of the realm of normal for Gronkowski. It is obvious, though, when he gets up from the ground that he is not comfortable and he is removed from the game. It is later reported that Gronkowski has re-fractured his forearm (exactly eight weeks after the original injury) and will require a second surgery to insert new hardware and stabilize the ulna. His season is over.

Jan. 14, 2013: Gronkowski undergoes surgery to repair the second fracture in his forearm, which involves replacing the original hardware. The break is in a slightly different location on the ulna than the original fracture, just above the location of the original plate, a phenomenon that is not uncommon. (Panthers wide receiver Steve Smith also suffered two consecutive forearm fractures in 2009-10. Although his injuries were to the other forearm bone, the radius, he also required two surgeries with hardware but was then able to return to competition.)

February 2013: Gronkowski is diagnosed with an infection in his forearm. He undergoes an open procedure to wash out the forearm in an effort to clear the infection and is subsequently placed on a course of antibiotics.

May 20, 2013: Gronkowski undergoes procedure No. 4, surgery to remove the hardware implanted in the second procedure and replace it with fresh hardware. The surgery is performed by Dr. Jesse Jupiter. Tissue biopsies are performed, but it is reported by ESPN's Adam Schefter that doctors are encouraged the infection has finally been resolved.

Unknown

The original cause of the infection is not known, nor does it necessarily matter. Any time an invasive procedure takes place, there is a risk of infection; ultimately the most important thing is complete eradication of the infection in order to avoid more serious health complications and to achieve full bone healing. During the interval between the cleanout procedure and this surgery, there was a window (after Gronkowski had completed a post-surgical course of antibiotics) where the infection could have cropped up again. Lab tests and observation would have been ongoing during that window and Gronkowski's timetable leading up to the fourth procedure suggests there was no measurable evidence of infection recurrence. The next step was to test the tissue directly intra-operatively, hence the biopsies.

Early reports following Gronkowski's fourth procedure suggest the infection appears to have cleared. While those reports are encouraging, it is too soon to be 100 percent sure that it is gone. Should the infection persist, alternative measures would need to be taken, which could threaten Gronkowski's status for the season. The hope, clearly, is that the infection will not be an issue going forward, but that remains, as of this writing, an unknown.

[+] EnlargeRob Gronkowski
AP Photo/Damian StrohmeyerRob Gronkowski has 38 touchdowns in 43 career games, but has had difficulty returning from his forearm injury.

If the infection is indeed a thing of the past, the assumption is that Gronkowski's forearm bone will now be able to heal completely, but that also remains uncertain. Given the setbacks in the healing process thus far, it can be expected to be a slower progression than after the initial break. If all goes well from this point forward, the anticipated timetable for the bone to repair itself to the degree necessary to absorb contact in football would likely be on the order of three to four months. Although the ulna is not typically thought of as a weight-bearing bone, it becomes one for a football player who must be able to make contact in the form of blocking or fall with full body weight onto the forearm. Given that Gronkowski initially broke his forearm on a blocking play and subsequently re-fractured it on a fall, along with the delayed healing of the bone thus far and the need for him to repeatedly perform those same injury-provoking activities upon return to play, the medical staff will undoubtedly want convincing evidence of bone healing before allowing him to engage in contact. Training camp begins in a little more than two months. It is hard to imagine him being cleared for full activity by then. Assuming the healing progresses well, there are no motion restrictions and he regains full strength in the forearm, there will be a gradual reintroduction of load-bearing or contact activities. The question then becomes whether there is enough time on the calendar clock to meet the start of the 2013 season.

It would not come as a huge surprise if Gronkowski were to start the season on the physically unable to perform (PUP) list. He would then be forced to miss at least the first six games, but could extend his absence if needed. As ESPN's NFC West blogger Mike Sando notes, this year's revision of the rules governing return to practice after being placed on the PUP list allows players until after their team's 11th game to be activated. They then have up to three additional weeks to return to game action.

But that's not all.

The Back

It is now being reported by Schefter that Gronkowski will be undergoing spinal surgery with Dr. Robert Watkins in mid-to-late June. Spine problems are nothing new for Gronkowski, who underwent surgery to address a disk problem -- performed by Watkins -- while in college at Arizona. There was much discussion about Gronkowski's long-term back health during the 2010 NFL draft, since he had missed the entire previous college season as a result of the ailment. The Patriots opted to take a chance on that back health, however, and it seemed to pay off. In fact, Gronkowski did not miss any time during his rookie year and injured himself (high-ankle sprain) only late in the playoffs of the 2011 season.

But in the past year there were signs that it was again becoming a problem. Gronkowski appeared on the injury report for multiple weeks beginning in late September with a "hip" problem (hip problems are often linked to low back problems and, in fact, there were rumblings at the time that his back was at least a part of the issue). Despite Gronkowski playing through the ailment, he did not always appear to move well and even appeared to be struggling at times before injuring his forearm in late November.

It is not surprising, then, that as he has ramped up his training following the forearm procedures, the back is making itself heard again. After all, back problems are rarely a single-episode occurrence. It is also common after undergoing surgery at one spinal level to have subsequent issues at another level of the spine. It is also common to have more than one level be affected at any given phase; it may just have been a matter of time before this current area of Gronkowski's back began to bark. According to ESPN Boston, this is not the same issue which plagued him at Arizona. This merely suggests it is not the same spinal level which is giving him trouble. The spine is an integrated unit and compromised health at one spinal motion segment (two vertebrae and the disk in between) will affect the others around it. It may take time to manifest itself and one can often function well for an extended period of time, just as Gronkowski has, without incident. But sooner or later, there can be associated problems.

The back issue doesn't necessarily threaten Gronkowski's career; it just becomes something else that needs to be addressed. Conservative measures such as rehabilitation are typically the first treatment of choice and it would seem that has been the road map so far for Gronkowski. If the symptoms persist, then other more aggressive measures, such as surgery, are considered. Since Gronkowski will already be forced to take it slow to allow his forearm to heal, the thought could be that he can now rehab both post-surgical areas simultaneously. Still, the acknowledgment that his back is giving him this type of trouble makes his overall health status heading into the 2013 season that much less certain.

This is still very much an evolving situation for the young star tight end, and there will be much more to watch for as the summer progresses. The optimal scenario would have Gronkowski fully healed and ready to start the 2013 season on time, but he is already expected to miss the start of training camp in late July. While not impossible for him to make a Week 1 appearance, it appears unlikely.

Everything would have to happen perfectly from here forward, and the road has been anything but perfect thus far. A more likely scenario would have Gronkowski joining the team at some point after the season has begun, but it is too soon to say just when that might be.

In the end, the most critical overall outcome is one where Gronkowski is infection-free with full healing of his forearm and resolution of his current back problem. Only then can football even begin to be a consideration.