Can Andrew Luck Return to Form in 2018?

A detailed look at why Luck's recovery hasn't progressed as quickly as hoped and how concerned you should be about a return in 2018

The Ongoing Saga of Andrew Luck

Until June, Andrew Luck wasn't much of a story. There may have been a raised eyebrow about Luck's limited practice participation over the past two seasons and a little nervousness over January's surgery, but it seemed likely we'd see Luck back on the field leading the Colts in Week 1.

The first hints of trouble came during June minicamp when Luck seemed defensive with reporters about his recovery. The news around Luck would progressively become more and more alarming. Now, after multiple specialist opinions, the Colts moved their franchise quarterback to injured reserve and prompted still more questions about Luck's future

The questions are complicated.

Why hasn't Luck recovered as quickly as hoped?

Will additional rehabilitation have a good chance at success?

Does Luck need another surgery?

And the most important question:

Is Luck fighting to save his career?

These are complicated questions. And there are no simple answers.

As I often have when discussing Luck, I'll be relying heavily on conversations I've had with Dr. Jeff Budoff, a noted upper extremity specialist who contributes to RotoViz.

What We Know

  • Luck likely suffered a subluxation (i.e. partial dislocation) of his throwing shoulder in September of 2015.
  • Luck was frequently limited in practice and continued to play through pain through the 2015 and 2016 seasons.
  • Luck elected to have surgery to repair labral damage in January 2017.
  • Luck has been unable to complete the throwing phase of his rehabilitation.
  • Luck had multiple steroid injections and changed his rehab personnel and protocols at least once in the past two months.
  • The Colts now concede Luck has no chance to return in 2017, eleven months after his surgery.

Recent Reports Add Clarity

Ian Rapoport and Chris Mortensen were finally able to squeeze meaningful detail from their sources and shared their findings on Sunday morning. Per Rapoport, Luck sought at least four additional opinions. The consensus was that Luck quit throwing for 2-3 months and focus again on rehabilitation. Rapoport further noted that none of the specialists felt surgery should be an imminent consideration. 

Particularly pertinent are the following passages from Rapoport's feature (bolded passages are mine):

The belief is that additional issues arose in Luck's shoulder, which are byproducts of playing through the torn posterior labrum for two years. That, not the labrum, has led to the setbacks. ...

Luck does have several problems inside his shoulder in other parts beyond what was repaired -- most of which came from his mechanics changing due to compensating for the injury. Doctors have tried to figure out if the soreness is from his original issue (they don't think so) or new issues.

The shoulder doesn't look bad when examined. But there are little ailments that haven't been resolved. Over the last four weeks, Luck has spent weekdays in Birmingham, Alabama, working with Kevin Wilk, one of the nation's most respected physical therapists. And it has not gotten better. He'd rehab, then get sore, then shut it down. Every time he got close, he'd get sore. ...

Yet, when camp loomed near, the main factor holding Luck back drew into focus: the other injuries around the posterior labrum tear. The fraying caused other parts of the shoulder to overcompensate.

His timeline got pushed back when the season started, and they believed he'd possibly return by Week 6. But Luck never quite got over the hump. He'd constantly ask those he worked with why his shoulder felt this way, why his shoulder felt that way. The cerebral quarterback always wanted to know and understand every step along the way, never quite sure why his shoulder felt so sore.

Though Rapoport's story suggests Luck's current plan is to rehab without throwing for 2-3 months, Mortensen tweeted Luck will be re-evaluated by his surgical team in December.

What Could Be Wrong With Luck's Shoulder

Budoff, who has extensive experience with labral repair and revision surgeries, has been kind enough to discuss the common difficulties facing those who have had a surgery similar to Luck. Recognizing the limitations of speculation based on media reports, there are multiple possible complications to consider.

**Shoulder capsule too tight after his labral repair

Fixing the type of labral injury Luck sustained is a technically challenging procedure. Scarring -- which is a necessary and expected part of the healing process -- sometimes leads to shoulder stiffness which then must be stretched out during rehabilitation. The resulting limitation in range of motion can cause soreness during rehab. This is one reason a successful surgery could still result in a longer rehab than expected.

**Residual shoulder instability after his labral repair

It's possible Luck's shoulder was loose and unstable in more than one direction. A repair of the posterior labrum could be successful but cause previously subtle instability elsewhere in the shoulder to cause pain, particularly at the end of a quarterback's throwing motion. This is another reason a successful surgery may still result in a longer rehab than expected.

**Cartilage damage

Damage to the labrum can be associated with damage to the cartilage overlying the bony socket of the shoulder joint. In short, that would mean Luck has pre-arthritic changes in his joint that cannot be predictably addressed surgically. Cartilage lesions have never been reported in Luck and are probably the least likely concern on this list.

November 12 Update: It's now been reported Luck traveled to Europe for treatment. Players do this to receive stem cell injections which are not approved in the United States. These injections may have an anti-inflammatory effect but their primary purpose is to -- hopefully -- regenerate tissue. And that almost always means a cartilage concern. Peyton Manning sought out these treatments to assist with nerve regeneration but this isn't a concern with Luck.

**Rotator cuff tendinopathy

Luck continued to play and throw for nearly two seasons with an unstable shoulder joint. The rotator cuff functions as the backup stabilizing structure of the shoulder and had to compensate and work extra hard to maintain stability in the shoulder. Overuse causes damage to the tendinous insertions of the rotator cuff muscles, a condition called tendinopathy. This is the most likely cause of Luck's soreness after he began stressing his shoulder by throwing.

Rapoport's story notes "changing mechanics" and "overcompensation" and injuries felt to be a "byproduct" of continuing to play through the original injury. That's highly suggestive of a rotator cuff injury. One might also read hints of residual instability in Rapoport's story but those are much less clear.

What Luck Now Faces

The story from Rapoport includes more specific notes than any we've seen to date. And it suggests there's a strong consensus against surgery. But Luck has been adjusting his rehab protocols since the end of June and is no closer to returning.

The clock is already ticking on 2018. If Luck is dealing with rotator cuff issues, addressing them now is important. If Luck needs further stabilization of his shoulder or release of excessive scar tissue, it would clearly be better to have that handled sooner than later.

Despite the specific notes from Sunday, something doesn't add up. An additional 2-3 months of rehab could put Luck into February before a change in course is planned. Mortensen notes the next re-evaluation is coming next month. That seems more plausible. But it also -- unfortunately -- seems unlikely Luck will have made progress by then.

Budoff feels it could be time to examine Luck's shoulder under anesthesia to determine whether he has any subtle instability and/or tightness. Any findings would be followed by arthroscopic surgery to confirm the diagnosis and address these concerns. Former NFL team orthopedic surgeon, Dr. David Chao, also believes an early surgical approach is warranted

Rapoport's article also noted the possibility of surgery in the future. No player wants to have surgery, but it seems odd to wait and continue to hope for a different rehab outcome.

Chance of Returning to Pre-Injury Form

There are still too many unknowns to predict whether Luck will make a full recovery. Despite having access to the very best surgeons and rehab specialists, Luck's struggles to date highlight the difficulty in returning an overhead throwing athlete to form after major shoulder surgery.

But it's too soon to say Luck has a career-ending injury. 

If Luck's failure to progress through the final throwing phase of rehab is due to rotator cuff tendinopathy and he chooses a surgical approach, he will likely undergo a very similar procedure and rehab protocol to what Cam Newton went through last year. While the two scenarios cannot be directly compared -- Newton wasn't coming off a complicated labral repair or known to have shoulder instability -- Newton was cleared to throw within four months of his March 2017 surgery. It's possible Luck could make a similar recovery. Other surgical interventions could have comparable rehab timelines.

November 12 Update: If Luck is seeking out stem cell injections, it's a very concerning development. There were no earlier reports of a cartilage lesion -- and still aren't. But there is no reliable or predictable regeneration of cartilage with stem cell treatments. Hopefully, this is a last-ditch effort to relieve inflammation before surgical intervention. Cartilage damage isn't something predictably addressed by surgery. If it's a cartilage condition keeping Luck from throwing pain-free, there's a much smaller chance of him returning to pre-injury form than if he's dealing with rotator cuff or stability issues.

What to Watch For As Luck Recovers

If Luck chooses a surgical approach in the coming weeks, we'll be dependent on media and team reports to provide clarity on his expected recovery. Regardless of whether Luck chooses surgery or not, the end game remains clear. In order for Luck to return to play, he'll have to complete the throwing program that's already stymied him multiple times. And once he's cleared that hurdle, he'll have to prove he has enough arm strength and stamina to play the quarterback position effectively.

Andrew Luck's 2017 may have ended. The long road to 2018 has now begun.

Check back for more injury analysis throughout training camp and follow on Twitter @JeneBramel for breaking injury news, commentary, and analysis of injury news around the NFL.