Smith to rest hurt shoulder, but surgery a possibility

San Francisco 49ers starting quarterback Alex Smith, who has struggled with shoulder and forearm problems since suffering a Grade III separation of his right shoulder on Sept. 30, will likely need at least two more weeks of rest and rehabilitation, and even then might still require surgery to repair the damage.

The first overall choice in the 2005 draft, Smith was examined on Tuesday by noted orthopedic surgeon Dr. James Andrews in Birmingham, Ala. Sources close to Smith said Andrews apprised the third-year veteran that the shoulder separation was not significantly improved and might actually be worse in some ways than when he initially viewed the original MRI of the injury three weeks ago.

"It's a third-degree separation, which is what our doctors diagnosed originally," 49ers spokesman Aaron Salkin told ESPN.com's Chris Mortensen. "He needs a couple of more weeks of rehab, then we'll see where he's at."

Smith will return to the Bay Area and undergo more rehabilitation. Smith's agent, Tom Condon, told Mortensen that Andrews believes "surgery may be necessary" if the shoulder does not stabilize after two weeks of therapy.

Given the results of Andrews' examination, there apparently is some possibility now that Smith will not play again in 2007.

Until Tuesday, Smith had not visited with Andrews in person since the injuries. Andrews had, however, studied the MRI results and other tests conducted in San Francisco and had essentially served as a consultant to the 49ers' medical staff.

Smith, 23, complained last week that his throwing arm was "killing" him, and revealed that, in addition to the shoulder separation, he had developed tendinitis in his forearm. He had a cortisone injection for his forearm soreness at mid-week but that did not markedly improve the condition.

Condon suggested that the tendinitis, which kept Smith from being able to grip the ball properly and almost certainly contributed to his recent inaccuracy, may have resulted from an overly aggressive rehabilitation regimen on the part of the 49ers.

There was definitely some tension last week between Smith and head coach Mike Nolan. The quarterback broadly hinted that Nolan was perhaps not as supportive of him as he could have been. Nolan indicated that he may not have understood the seriousness of the injury and said that Smith wanted to play.

Both sides eventually agreed that, at the least, there was a lack of communication. Condon agreed that nobody had the correct information.

"The original MRI didn't show its severity but Dr. Andrews said that's because Alex was laying down when he had the MRI," he said. "Whenever Alex sat up during the exam Tuesday, his clavicle moved way up. That's not normal. It affects him most severely when his arm comes through on his throwing motion."

Nolan criticized Condon on
Monday for airing his opinions.

"I don't respect the source," Nolan said. "It would be like
me trying to pretend to be a doctor."

In his seven starts this season, Smith has completed 94 of 193 passes for 914 yards, with only two touchdown passes and four interceptions, for a passer rating of 57.2. Perhaps in part because of the shoulder and forearm injuries, the former Utah star has appeared to regress in some areas over his performance of a year ago.

Smith started the first four games of the season before sustaining the shoulder separation, then missed two games before returning to the lineup for three contests. With his arm clearly aching -- some opponents and teammates said Smith grimaced nearly every time he threw the ball -- he sat out last Sunday's game and veteran Trent Dilfer started.

Dilfer will remain the starter for Sunday's upcoming game at Arizona, and likely for the foreseeable future.

Senior writer Len Pasquarelli covers the NFL for ESPN.com. Chris Mortensen covers the NFL for ESPN Insider. Information from The Associated Press was used in this report.