This spring, Anthony Spencer spent about six weeks lingering on the free-agent market before finally signing a team-friendly one-year contract to return to the Dallas Cowboys, which—considering that Spencer made the Pro Bowl with 11 sacks and 95 tackles in 2012—came as a surprise to many.
But those familiar with what Spencer is attempting to overcome medically weren't likely as shocked that the 30-year-old received little respect as a free agent.
"Once you start damaging the articular cartilage, there’s nothing else for you to do," said Will Carroll, Bleacher Report's lead sports medicine writer, of the microfracture procedure Spencer underwent on his balky left knee eight months ago. "This is pure Hail Mary."
"It’s a desperation move," added Carroll, "and we’re seeing it less and less because the success rate isn’t great."
See, about a year ago, not long after Spencer signed a one-year franchise tender worth $10.6 million, he developed a bone bruise in that knee, leading to a scope in late July. The scope didn't solve the problem, and so on Oct. 1, after he'd been placed on injured reserve, the pass-rushing stud was anesthetized on an operating table so that a surgeon could drill multiple holes into the bone in his knee.
To describe the procedure, Carroll used the word "destruction."
“It’s brutal surgery," he told me this week. "You’re punching in and creating these big holes in the surface of the knee. When you see the surgery done, you’re just like, ‘Wow.’”
The idea is that the stem cells and blood from the marrow will come through those holes to become fibrocartilage, which cushions exposed bone. The problem is that fibrocartilage isn't real cartilage.
“It’s basically a big scab," said Carroll, "and that scab becomes the cushion and friction that the knee is missing.”
The real stuff, though, is irreplaceable.
"The surgeon’s trying to create a layer of cartilage to give [the patient] some layer of shock-absorbing properties in that area," said Dr. David Geier, an orthopedic surgeon and sports medicine specialist based in Charleston, South Carolina. "The problem is that’s not typically as good as the normal cartilage you have, and it tends to break down over time. We just don’t have an easy or reliable way to make cartilage new again."
That's why so many professional athletes have trouble fully regaining their mojo after undergoing the procedure, which was pioneered a quarter-century ago by Dr. Richard Steadman.
A study conducted in 2009 by surgeons at Drexel University found that one in five NBA players who underwent microfracture never played again.
Now, considering that the study had a sample size of just 24 to work with, as well as the fact that it's logically difficult for non-starters to find work at a pro level coming off such a major injury, that conclusion should probably be taken with a grain of salt. But the study also found that performance typically dipped—often significantly—for those who did come back.
To rate before and after performance, researchers compared minutes per game and player efficiency ratings -- a combined measure of per-game scoring, rebounds, steals and other statistics. The average player efficiency rating fell from 15.5 pre-injury to 12 in the first season played after surgery. Time played per game fell by about 5 minutes.
Two years after surgery, 17 players were still active. Their performance lagged significantly behind a control group of similar players who were never injured. But they showed a trend toward improving performance and game times.
"This may indicate that athletes who are able to mount a sustained comeback, greater than two years after surgery, will return to near their pre-injury levels of playing time and performance," study authors Douglas Cerynik and colleagues concluded.
Spencer can't afford to wait two years, nor can the Cowboys.
A study of 25 NFL microfracture patients conducted by Steadman and some cohorts in 2003 concluded that "the treatment does not limit careers but in fact prolongs them." But merely returning isn't necessarily tough. Getting back to where you once were (double-digit sack zone) is a different quest.
According to a summary from the Davidson University biology department, that study also found that "many of the patients did not produce optimal results until their second postoperative season." So a prolonged career is one thing, but can Spencer regain everything he lost?
Let's look at some NFL precedents:
|Patient (age)||Before surgery||After surgery|
|R. Bush (24)||27 starts in 3 decent seasons||51 starts in 4 seasons, still active|
|M. Colston (28)||Consistent 1000-yard WR||Consistent 1000-yard WR|
|J. Beason (27)||3-time Pro Bowler||Great comeback 2013 season|
|T. Thomas (27)||Reliable starter||Probably more of a backup|
|G. Cherilus (27)||Reliable starter||Reliable starter|
|D. Sharper (35)||Pro Bowler||Started just one more game|
|W. Jones (34)||Pro Bowler||Never played again|
|K. Phillips (23)||Flourishing youngster||Played well for 2 years, fizzled|
|S. Smith (25)||Pro Bowler||3 starts the rest of his career|
|F. Robbins (32)||All-Pro||3 more decent seasons|
|C. Canty (30)||Solid starter||Slight decline, still reliable|
|K. Winslow (24)||Breakout third season||5 solid years, immediate Pro Bowl|
|C. Pitts (30)||No missed starts in 7 years||7 starts in 2 years, disappeared|
|R. Geathers (26)||23 sacks in 5 seasons||10 sacks in 4 seasons|
|T. Brown (31)||16.5 sacks in 4 seasons||Never played again|
|S. Davis (30)||3-time Pro Bowler||Performance dropped, but was old|
|T.Davis (30)||3-time All-Pro||Never played again, but was old|
|J. Newberry (30)||2-time Pro Bowler||Faded with 17 starters in 2 years|
|M. Lepsis (33)||Reliable starter||Played only 1 more season|
CBS/NFL.com/NBA.com/Rotoworld/ESPN/Pro Football Talk
The sports medicine experts Bleacher Report spoke to for this article kept reminding us that every case is different, and nobody could speak specifically to Spencer's situation. All we can do is go on what we have, and we know that age, size and playing style don't help his chances of getting back to form.
He's 30 now, and there's no disputing the fact that the younger you are, the easier it is to heal. Plus, we're talking about a 262-pound gentleman, and the knee is a load-bearing joint.
"If you compare a 265-pound linebacker to a 155-pound tennis player, the tennis player may well have an easier recovery," said Dr. Steven Singleton, who has inherited many of the now-retired Steadman's patients at The Steadman Clinic in Vail, Colorado.
"He’s a big dude," added Carroll, "and with every single step he’s putting weight on an area that’s already significantly damaged. How long is that microfracture going to last? We don’t know."
Singleton also noted that the explosiveness Spencer requires as an edge-rusher could put him at a disadvantage compared to players at positions that merely require them to move their knee straight forward or laterally (an offensive lineman, for example).
It's harder to twist, cut and explode out of a three-point stance while avoiding putting extra pressure on the glorified scab doctors have created in place of what used to be cartilage. Spencer needs to be able to do all or most of those things, which doesn't bode well.
"If he can’t explode out of a stance and if he can’t resist being pushed back, which is going to put even more pressure on his knees," said Carroll, "he’s worthless."
That would stink for the Cowboys, who have deemed Spencer to be worth $3.5 million. They know, of course, that re-signing him was a complete gamble, and considering their salary cap quagmire and their lack of depth and talent up front on defense, it's easy to understand why they'd be willing to roll the dice at what remains a reasonable price for a former Pro Bowler.
When this whole microfracture development occurred back in October, Spencer's agent, Jordan Woy, tweeted that doctors expected Spencer to be 100 percent by January or February. But he was actually still on crutches when the new year arrived, according to the Associated Press (per The Washington Post).
Now word has emerged from the horse's mouth (via ESPN.com's Calvin Watkins) that Spencer could start the 2014 season on the physically unable to perform (PUP) list.
That's not encouraging.
“This injury [is] really uncommon, you rarely see guys coming back from it,” Spencer said, according to Watkins. “So, I’m really not looking at any type of timetable. I’m just on my body schedule; where my body is, that’s where I am.”
The strange thing about Steadman's procedure is that despite sounding and looking horrific, it's considered in the medical community to be both brilliant and efficient. Put simply, if the goal is to give a pedestrian the ability to walk and run again without pain, it works.
But pro athletes need to be able to do a hell of a lot more than that, and there are many factors outside of the microfracture surgery itself that play a role in ruining careers that experts could argue were destined to be ruined regardless.
Singleton notes that when a player's career fizzles out post-microfracture surgery, it could have as much to do with the circumstances that led to him having to undergo said surgery in the first place. Usually, it's a last resort as a result of decades’ worth of damage done.
That applies to this case, since Spencer had already hurt his knee and was rehabbing.
"Before the surgery, the athlete may already be developing muscle atrophy or stiffness in the joint that could lead to scarring or scar tissue," said Singleton, "and that can compound the issue. Because if in addition to this cartilage injury there is some muscle atrophy or inflammation in the joint, it makes it that much tougher."
Still, new avenues are being explored. Stem cell, platelet-rich plasma and joint fluid injections have become alternative options, as well as forms of treatment that could complement microfracture surgery. In fact, Singleton says following up microfracture with a series of stem cell treatment injections could be beneficial.
And more could be on the horizon.
"We’re looking at a couple different ways to try to augment or make that fibrocartilage even more like normal cartilage that somebody was born with," said Singleton. "Because we have yet to really recreate—with any kind of surgical cartilage restoration technique—cartilage that is as good as what we were born with. So that’s something that we’re really working on."
That doesn't do Spencer much good now.
New York Yankees pitcher CC Sabathia received a stem cell shot last week in order to treat the damaged cartilage in his right knee, but that was one step short of going under the knife (or in this case, the ice pick). Spencer's knee has already been perforated, but he could decide to tack on stem cell treatment as a final resort.
“I've gotten to where I am by listening to my body and rehabbing and doing things at the pace of my body,” Spencer said, via AP. “That’s one of the biggest things with this surgery I’ve read is just being patient. I’m just not pushing it anywhere past that.”
The good news is that after nearly 20 weeks on crutches, four MRIs and early-rehab days in which he spent 15 or 16 hours lying in bed, Spencer's knee is currently stable. And the fact that there was only about a three-month gap separating the initial trauma from the microfracture procedure could work in his favor.
In that 2010 analysis of Greg Oden's predicament at The Oregonian, Dr. Kai Mithoefer, Director of Sports Medicine at Harvard Medical School's Harvard Vanguard Medical Associates, told Rojas-Burke that the time between cartilage injury and microfracture surgery is a legitimate factor in relation to success rates.
A very important factor for return to sport is also how long the athlete had the cartilage injury before microfracture surgery was done. We have shown that if the time to surgery is shorter this significantly increases the ability to return to competitive high-impact sport. Failure to treat cartilage defects can result in larger defects and joint degeneration that again creates a less favorable healing environment.
"The concern when you’ve got an area of cartilage damage," Geier told us, "is that it eventually spreads, it progresses, and you develop more and more degenerative changes throughout the knee."
That could be one reason Spencer remains cautiously optimistic, as does his boss.
"There have been players who have come back from an injury like Spence’s," said Cowboys head coach Jason Garrett, per Watkins. "And when you have Spence’s character, his makeup, the kind of person he is, you certainly want to give him every chance."
But what choice do they or any of us have right now? Again, this is Spencer's Hail Mary. He was desperate, and so were the Cowboys. It's apparent from the information we've accumulated here that Spencer should be capable of making a proper recovery, but merely regaining everyday-Joe strength in that knee might not be good enough for a man required to outrun and outwrestle 300-pound offensive tackles for a living.
In order to save the Cowboys in the post-DeMarcus Ware and post-Jason Hatcher era, Spencer has to be superhuman. The odds don't favor that happening, but it wouldn't require a miracle either.