Road to recovery

Peyton Manning's appearance in the Denver Broncos' first exhibition game Thursday night was more than just a preseason dustoff. It was more than a series of passes and handoffs and a drive that ultimately ended with an interception in the red zone. It was one more item for Manning to cross off the list of experiences to demonstrate to himself and to anyone watching that he is on the road to recovery. It represented one more step in Manning's long march back from the longest hiatus of his NFL career.

The statistics were not overwhelming. Manning was 4-of-7 for 44 yards. Perhaps his most signature Manning-esque play was a 19-yard throw over the middle to receiver Eric Decker, who figures to be a regular target this year. The drive was capped by an interception in the red zone on a pass slightly behind intended receiver Brandon Stokley. No doubt Manning would have preferred to end his night differently but, after all, isn't that what the preseason is all about? A time to work out the kinks, to test a new offense and, in his particular case, to record his progress toward a return to full play in the NFL.

In the time since Manning's surgery to fuse the sixth and seventh vertebrae of his cervical spine (neck), the question has shifted from "Can he ever come back to play in the NFL?" to "How will he perform when he returns?" (With everyone naturally wondering, "What happens the first time he gets hit?") The first question has been answered. When the Broncos signed Manning, it proved there was a team confident enough in his ability to return to the NFL that they were willing to expend some capital. Manning taking the field Thursday night proved he was physically able to return. Forget the fact that it was only one series in a preseason game, there were real NFL teammates lined up beside him and real NFL opponents coming at him. There is no longer any doubt that Manning will indeed line up under center for the Broncos this season. Cross that item off the list.

The issue of getting hit is not as much a medical concern as it is a case of fans needing reassurance that Manning will, indeed, get back up after that first big blow. It's worth noting that Manning's surgeon cleared him to return to football late last fall. Dr. Robert Watkins performed Manning's fusion surgery on Sept. 8. On Dec. 1 after a post-operative re-evaluation, Watkins stated the fusion had achieved "firm fixation." In other words, the two vertebrae that were fused together with the aid of a bone graft showed evidence of healing. At that time, Manning was cleared to begin throwing and to increase the vigor of his rehabilitation. In February, Manning was again evaluated and, according to an ESPN report, was given the green light to return. A statement from Watkins read, "As a result of this examination, Manning is medically cleared to play professional football." Clearance for Manning's return was supported by Colts' neurosurgeon, Hank Feuer, who added, "If you were my own son, I'd tell [you] to go play."

Other players have returned following similar surgeries to play in the NFL. In fact, they have arguably returned to positions much more susceptible to high velocity impact or repetitive impact than that of a quarterback. Dr. Joe Maroon, team neurosurgeon for the Pittsburgh Steelers, has performed similar operations on multiple professional football players and professional wrestlers, all of whom were cleared to return to their sports. Maroon notes the procedure can extend the playing time for an athlete who otherwise might be forced to retire because of injury.

While the medical professionals involved in Manning's care would not return him to play if they lacked confidence in his ability to withstand the contact associated with the game, no one is denying there are risks inherent in football. The argument could be made, however, that Manning is no more at risk from a substantial injury as a result of a direct hit than any other NFL quarterback who steps onto the field. There has not yet been an incidence of a player post-cervical fusion suffering a severe spinal injury after returning to competition. Still, it is ultimately a turning point in the recovery process when a player absorbs that first big in-game blow after returning from major injury -- whether it be neck, shoulder or knee -- and bounces back up realizing everything is still intact. Manning will be no different, and a collective exhale among Manning's teammates, fans and likely even Manning himself will follow. It will be one more item to cross off the list.

Given the evidence that his fusion was solid, the limiting factor to Manning's return last year was his arm strength, or lack thereof, as the nerve healing unsurprisingly lagged behind that of the bone. Injury to the nerve between the sixth and seventh cervical vertebrae affected the triceps strength in Manning's throwing arm. Restoring stability to the neck via the fusion removed the source of irritation to the nerve, but lingering effects from the injury would take more time to resolve. And, as is always the case with nerve tissue, the degree to which it would recover was unpredictable. The only means of assessing progress was measuring the return of function in Manning's arm. Gradually, the signs of improvement began to show.

When video of Manning throwing a football surfaced last winter, it was the first glimpse anyone on the outside had of him performing the skill most integral to his position. It may not have been definitive proof that he could return to NFL competition, but it was the most encouraging sign to that point that it was possible. As Manning progressed from throwing in a video to throwing to his new Broncos teammates in offseason workouts, their comments hinted at his return to "normal." Decker summed it up by saying, "I'm not his doctor but … catching balls from him, it looks like there's nothing wrong to me."

The start of training camp with practices open to the public afforded everyone an opportunity to witness Manning in action. The up-tempo pace and ongoing communication with his receivers were a classic Manning sight, as was his resolve to spread the ball around. Passes were not falling short of their intended mark, they were not wobbly, shaky or slowly delivered, and Manning looked by all accounts, Manning-like. Practice in pads only increased everyone's intensity. While the medical staff kept a watchful eye on Manning's activity, there were no obvious limitations in his routine, no forced rest periods due to setbacks. Participation in training camp and a successful return to daily practice? Check another item off the list.

Now that Manning has gone from hopeful for return to a virtual certainty for return, what's left? It will require a full season for Manning to completely check off most of the items remaining on the list. There will be various conditions under which he will perform (the altered grip of a wet football, the increased demands of throwing into driving wind), and there will be the necessary reactions at game speed (evading a defender and throwing on the run, making a cross-body throw while off balance or out of position), all of which will tax his throwing arm in different ways. Manning will need to perform for four quarters, not four completions. His endurance not only for an entire game but also for a 16-game regular season will be tested. All of this would be challenge enough for any 36-year-old quarterback away from the game for the better part of two years. Mix in a few surgeries and the associated recovery process and the task becomes bigger. Even Manning doesn't know what his maximum return will be. As he told Sports Illustrated's Peter King, "Where I'll be, percentage-wise, I don't know." He added, "I don't know if I'll feel the way I've always felt again."

It will be only in retrospect once the season is complete that Manning will have proven whether he could, in fact, endure another season in the NFL and his performance will indicate whether or not he was able to live up to expectations. In the meantime, the assessment of those who knew him pre-injury and are still playing with him is perhaps the best measure of just how far along he has come. After Thursday's game, Stokley, who played with Manning in Indianapolis, had this to say to reporters. "To me, there was no difference. He still throws the ball great. … I think we are just going to try to build on this and get better every week."

And every week that Manning plays, with every challenge he faces across the course of an NFL season, the quarterback -- who has already defied some skeptics' belief he would never set foot on the playing field again -- can cross another item off the list.