SANTA CLARA, Calif. — Kyle Shanahan on Wednesday verified that there’s been a remarkable reversal in the prognosis for quarterback Jimmy Garoppolo, who fractured his left foot in the 49ers’ win over Miami. But he also attempted to temper Tuesday’s report from ESPN’s Adam Schefter, which suggested Garoppolo could return in seven to eight weeks — during a potential 49ers playoff run.
“It’s not a Lisfranc (injury),” Shanahan said. “They don’t have to do surgery on it. So it’ll be a big recovery, but much less than what we anticipated. Which is awesome news for him in the offseason. He’ll be good to go right away, so it won’t be like last year.
“There’s that way outside chance, late in the playoffs, something like that, but it’s just an outside chance. We’re not really real optimistic about that, but they didn’t rule it out.”
In the immediate aftermath of Garoppolo’s injury Sunday, Shanahan had said Garoppolo “broke a few things in there” and would need surgery. Shanahan had reportedly been told by 49ers head athletic trainer Dustin Little that Garoppolo would be out for six months.
That was because the 49ers thought Garoppolo had suffered a type of Lisfranc (or mid-foot) injury that carries a severely elongated recovery timeline. The outlook has changed drastically since then — Shanahan even said he believed the QB might have broken only one bone Wednesday — but it’s obviously still hard to gauge the potential dynamics of a Garoppolo return this season.
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What’s the most likely recovery timeline for Garoppolo, based on the information available? Can the 49ers do anything to speed the process up? Since the time frame of Schefter’s report coincides directly with the playoffs — the divisional round and conference title are seven and eight weeks away — every subtlety is of the essence.
In an attempt to answer some lingering questions and better illustrate the dynamics behind the changing diagnoses for Garoppolo over the past several days, The Athletic spoke with Dr. Eric Giza over the phone Tuesday.
Giza is the chief of the UC Davis Orthopedic Surgery department’s foot and ankle service. He’s worked and done research with Dr. Robert Anderson, one of the most renowned foot and ankle specialists for professional athletes in the United States. Giza provided knowledge that’s helped put Shanahan’s points regarding Garoppolo’s foot in better context.
Why did the 49ers initially believe Garoppolo suffered a Lisfranc injury?
Based on the location of Garoppolo’s fracture in initial X-ray imaging, the 49ers thought Garoppolo had suffered that dreaded type of Lisfranc injury — a tear of a specific mid-foot ligament that essentially binds the foot together.
“In what’s known as the classic Lisfranc injury in sports, if you tear that ligament, the bones in the middle of the foot can spring apart,” Giza said.
Since this classic Lisfranc injury can have such a devastating impact on the structure of the entire foot, it usually requires no weight bearing for six weeks to go along with the insertion of plates, screws or a more advanced device. All that repair work creates the six-month return timeline the 49ers initially believed was ahead of Garoppolo.
But in the absence of bone displacement, such a severe Lisfranc injury must be verified by examination of the key ligament in question — and that must be done by an MRI. Garoppolo escaped the worst-case Lisfranc scenario once a further battery of tests — presumably including an MRI and CT scan, Giza said — was conducted.
Shanahan verified Wednesday that the ligaments in Garoppolo’s foot escaped fully healthy, which is operative in the good news of his diagnosis.
“No ligament damage,” Shanahan said emphatically. “That’s a good thing.”
So what exactly is Garoppolo’s injury?
Shanahan did not provide specifics about which bone or bones Garoppolo fractured Wednesday.
Here’s how Shanahan answered a follow-up question that attempted to clarify whether Garoppolo broke one or multiple bones (since his postgame comments Sunday seemed to indicate the latter): “I believe just one, but I don’t dive into it as hard as you guys ask me. I know it’s a serious injury that’s most likely going to keep him out for the year and I know it’s really good news that there was no ligament damage or anything, so he’ll be fine once the broken foot heals.”
The foot is a complex structure containing 26 bones.
“If the concern was Lisfranc, he probably has a fracture somewhere in the second or third metatarsal,” Giza said, referring to the two longer bones on the inside of the foot that are connected to the second and third toes (counting from the inside and the first, “big” toe). Here’s a diagram.
The Lisfranc joint and tendon of importance are right above those metatarsals, in the middle of the foot. So based on the information available, that’s where Garoppolo’s fracture or fractures likely are.
Is there fluidity in Shanahan’s return-to-play timeline for Garoppolo?
The fact Garoppolo does not need surgery is key here. Multiple medical experts said that should give Garoppolo at least a chance to return on the timeline of a garden-variety fracture.
“The bone goes through its natural healing process,” Giza said. “Usually, it takes bones six weeks to heal if it’s a break.”
If it is only one bone, there is no ligament damage (ruled out a LisFranc), and they have elected to not surgically treat the broken bone (indicating it is likely stable / not too far out of place), then ~ 6 weeks seems reasonable for a bone to heal.
— Dr. Nirav Pandya, M.D. (@DrNiravPandya) December 7, 2022
Why the longer seven- to eight-week prognosis for Garoppolo in Schefter’s report, then?
“Best-case scenario,” Shanahan said. “Not to play football in seven to eight weeks, but to heal. … They just say how long it takes to heal, and it usually takes a little bit more (to be ready to play) after that.”
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Might Shanahan be erring on the side of caution with that timetable? Giza confirmed that the average time it takes for a fracture to heal in a 31-year-old without any outside enhancement is six weeks.
It’s also worth noting that professional athletes typically have advanced bone-healing resources at their disposal.
“There are things like electromagnetic bone stimulators and pulsed ultrasound (technology) that stimulates bone growth,” Giza said, listing some potential treatments for Garoppolo. “They’re probably going to have him in an AlterG — an antigravity training treadmill — and in the pool where you can be almost no body weight. Stuff you do for pros that keeps them in shape and engaged. That’s why, potentially, he can come back sooner.”
There are also bone-building medications like Forteo, which professional athletes have reportedly used to speed up recoveries from fractures in the past.
“Your bones are constantly remodeling themselves,” Giza said. “A demo crew and a builder is always at work. So when you have a fracture, first the demo guy has got to come in and clear out all the blood and the other pieces and then the bone-building cells go to work. And that drug is used to stimulate the bone-building cells.”
Shanahan, when asked, indicated that some of the aforementioned bone-regenerative treatment might be used in Garoppolo’s case.
“They do a lot of that stuff,” Shanahan said. “I’m not familiar with any of it. But he’ll do whatever helps.”
For the time being, the 49ers will entrust their offense to rookie quarterback Brock Purdy and wait to see how Garoppolo’s healing process unfolds. One step at a time. That’s the only workable approach to a situation that’s already taken some sharp twists in just a few days.
“More so than anything, I’m happy for Jim,” 49ers linebacker Fred Warner said in the locker room Wednesday. “That’s a huge difference in terms of recovery time and rehab for him. My little brother, he went through a Lisfranc and it took him a long time to recover from, so the fact that (Garoppolo) doesn’t have to go through that is big time for him.
“I’m more so concerned about him than anything. There’s no rush for him. I’m happy for him and if he comes back, he comes back.”
(Top photo: Ezra Shaw / Getty Images)