David Chao, MD: Alex Smith is Back, But With Major Limitations

The fact that Alex Smith is back onto the football practice field on an active roster means he should be given the “Comeback Player of the Year” award based on that alone.  

The gruesome injury (not for the squeamish) that could still cost Smith his career, nearly ended with an amputation to save his life. So while I join in the parade of congratulators I also brought the rain clouds with me.

The unfortunate reality is that there is no way Smith can be even close to the same Alex Smith that he established himself as over the course of his 13-year career. Expectations that he is going to carry this momentum back to being that player is simply not possible. He – and we – will have to learn what the new version of Alex Smith will be, due to the limitations with his leg.

Although I don't know him personally, I root for the fellow San Diegan. I remember watching him and Reggie Bush in the same backfield while both played at the local Helix High. In some ways I feel like Ebenezer Scrooge delivering this report, but I feel compelled to give a dose of reality while we celebrate.

This video from his wife clearly shows the residual effects of the injury, infection and 17 surgeries.

As he comes down his front steps he favors his right leg and limps. His next 6-7 steps clearly show the hiking gait and foot drop as he needs to lift his knee higher to clear the droop of his foot - since there is no real ankle control to lift it. One can see the foot "flop" but also note there are steps where the foot dorsiflexes (goes up) indicating calf weakness as well. The black "sock" is a typical compression sleeve but also likely worn to hid the inevitable ugly multiple scars.

The fracture wasn't the issue, as the break was not dissimilar to that of Joe Theismann in 1985 who didn't have the same complications. The fact that there was a puncture thru the skin that introduced a piece of sock and other bacteria into Smith's body, combined with the early attempt for fracture fixation allowed the infection to spread. Images from the ESPN production (Project 11, and it is excellent) documented the details for the world to see. It clearly shows that Smith with exposed bone across almost the entire length of his tibia with extensive muscle loss.

He will return to play with an ankle foot orthosis (AFO) and this will affect his mobility. Others have done it before. Dan Marino tore his Achilles in 1993 and suffered complications. Upon return he needed to play in an AFO to support his push off and altered the way he lined up with an exaggerated asymmetric stance to help him get out from under center more quickly. The Hall of Fame QB did play and have success for six more seasons.

Even with the AFO, Smith will have mobility, just less than before as evidenced from the video below. In fact, I would still pick the Washington quarterback over my friend (and patient) Philip Rivers in any foot race, agility drill or in escaping defenders. Indeed Smith is shown in practice today using the AFO and thus much more mobile than his wife's post from his home driveway without it.

This is the best story to come out of the Washington football club in years.

As much as I say Smith will not be the same, I do believe he will make the 53-man roster. His attitude, knowledge and veteran guile will allow him to be a contributor even if it is just as a positive veteran presence. He reportedly has guaranteed $17 million salary if he makes the squad or not so it makes sense to have him. 

To be clear, it is safe for Smith to play with a brace. The fracture is healed. The leg is what it is.

Furthermore, Washington will not be endangering Smith for public relations sake.

Does Smith risk injury by being less elusive? Possibly. However, that is the same for any QB across the league and I assume he will adapt to his limitations and be able to protect himself.

Smith is said to get starter reps and will battle for the No. 1 job. If that happens -- and I doubt that it does -- it would mean a complete reset for Washington moving on from last year's first round draft pick, Dwayne Haskins. New head coach Ron Rivera and offensive coordinator Scott Turner are familiar with newly acquired signal caller, Kyle Allen, who knows the offensive system and that may be the real challenger to start.

For Smith to even be at this point is not only a literal medical marvel it is also a testament to who he is as a man. This is the Comeback Player of the Year, and perhaps the feel good story we can finally celebrate from a dismal 2020.