SANTA CLARA, California -- In what has become an early spring tradition for the San Francisco 49ers' top decision makers, chief executive officer Jed York, general manager John Lynch and coach Kyle Shanahan and their families took off to Cabo San Lucas, Mexico, in March.
The trip is designed to be a final respite before the new league year begins. This year, there was one dark cloud looming over sunny Cabo -- quarterback Brock Purdy's pending elbow surgery.
After taking over as starter in December, Purdy led the 49ers to a 7-1 record before tearing the ulnar collateral ligament (UCL) in his right elbow in the first quarter of the NFC Championship Game loss to the Philadelphia Eagles. By the time the Niners' braintrust landed in Mexico, Purdy's surgery -- and ascent to the starting role on a more permanent basis -- had been delayed 40 days as he waited for the swelling to go down.
But York, Lynch and Shanahan weren't holding their breath over the timing of the surgery. Their concerns centered on which of two possible elbow surgeries Purdy was going to have.
The hope, based on multiple rounds of medical tests and opinions, was Purdy would have what is known as a UCL repair with InternalBrace augmentation. The repair requires no tendon graft to completely reconstruct the ligament -- making it less complex than the traditional UCL reconstruction, commonly known as Tommy John surgery. The typical five to seven month recovery would open the door for Purdy to return late in the summer, thus allowing the Niners to sign Pro Bowl defensive tackle Javon Hargrave to a four-year, $84 million contract and bring in Sam Darnold as a low-cost veteran quarterback option.
The fear was that once Purdy's ligament was exposed in the operating room, the visible damage would exceed the strict requirements for a repair and he would need Tommy John surgery, which comes with a lengthier recovery time. The extended return to play window would have jeopardized Purdy's 2023 season and forced the Niners to look at costlier quarterback alternatives at the expense of other roster upgrades.
The answer wouldn't become clear until Dr. Keith Meister opened up Purdy's right elbow.
"I just stayed positive and lived in hope because it would've been not so good if we had to go the other direction," Shanahan said. "There always was a chance of Tommy John."
A little more than a decade ago, the UCL repair option didn't exist; all athletes with UCL injuries severe enough to prevent them from being able to throw, regardless of the tissue quality of the damaged ligament, had to go with what had become the gold standard: Tommy John surgery.
But March 10, the Niners got the call from Meister, offering the Niners optimism that their presumptive starter could be back for the beginning of the 2023 season and, at minimum, guarantee his return early in the campaign. Purdy was able to go the InternalBrace route. That's no small thing for a team with a loaded roster that has been to three of the past four NFC championship games and is seeking its sixth Lombardi Trophy.
Purdy became the third professional quarterback to have the UCL repair with InternalBrace, joining ex-49er Nick Mullens, now with the Vikings, and Clayton Thorson, a fifth-round pick of the Eagles in 2019.
"That was really good news," Lynch said. "[That] was the one we were hoping for."
ON JAN. 29, Thorson was watching the NFC Championship Game at his suburban Chicago home when, with 7:03 left in the first quarter, Purdy took a big hit from Eagles pass-rusher Haason Reddick as he was about to throw.
After the play, cameras cut to Purdy on the sideline shaking his right arm. As Fox broadcasters speculated about the injury, Thorson found himself talking to the television
Based on the hit and Purdy's reaction, Thorson immediately knew what was wrong. Purdy had torn his UCL. Thorson had suffered the same injury fewer than eight months earlier.
"I'm watching him on the sideline hold his fingers and trying to grip the ball and I was like, 'Oh no,'" Thorson said. "I was just watching it and I was sick to my stomach for him."
While Thorson knew what the injury meant for Purdy, he also knew Purdy could be back sooner than expected. Thorson had undergone the InternalBrace repair surgery June 7, 2022, and returned to football 209 days later.
Thorson was the starting quarterback for the USFL's Houston Gamblers when he took a hit to the elbow as he prepared to throw a deep post route. In the moments after the hit, Thorson felt pain in the elbow, but when his team quickly got the ball, he went back in.
As Thorson tried to lead a scoring drive right before halftime, he again dropped back to throw with a wideout coming open 20 to 25 yards downfield. Thorson cut it loose but the ball never turned over. It sailed on him with little spin and though his receiver caught it, Thorson knew something was wrong with his elbow.
At halftime, as Thorson tried to move the elbow from side to side and rotate it, the pain increased. Finally, a team doctor delivered the initial diagnosis.
"He was like, 'Have you heard of Tommy John?'" Thorson said.
TOMMY JOHN PITCHED for seven Major League Baseball teams over a 26-year career that included 288 wins and four All-Star appearances. Despite that lengthy run, John is known as much for the surgery that bears his name as his baseball accomplishments.
John tore his UCL in 1974 while pitching for the Los Angeles Dodgers. After unsuccessfully waiting and hoping rest might suffice, Dr. Frank Jobe, the Dodgers' team physician, suggested a surgical solution that had previously been limited to wrists and hands. The idea was to replace the ligament in John's left elbow with a tendon graft from his right forearm.
The surgery was a success. After a lengthy recovery, John -- whose career would have otherwise ended -- returned in 1976, winning 164 games and retiring in 1989. Tommy John surgery became the standard procedure for throwing athletes with torn UCLs. The injury and subsequent surgery were increasingly common in pitchers, but other athletes -- javelin throwers, softball players and an occasional quarterback -- also got the procedure.
Craig Erickson, who played for five NFL teams from 1991 to 1998, is believed to be the first NFL quarterback to have had Tommy John surgery.
Like Thorson, Jake Delhomme was watching when Purdy's elbow injury happened. Delhomme, who led the Carolina Panthers to five playoff victories from 2003 to 2009 and an appearance in Super Bowl XXXVII, tore his UCL in 2007.
Delhomme had been managing elbow pain for nearly two years when, in a Week 3 win against the Atlanta Falcons, he threw a simple checkdown and felt the ligament tear. At the time, the only choice was Tommy John.
Two weeks after the UCL gave out, Dr. Pat Connor, the Panthers' team physician, performed the surgery, using a graft from Delhomme's left hamstring and cleaning up other issues like bone spurs in the elbow.
Delhomme took on a six-plus month recovery and returned, saying his arm felt better than ever. It was a relatively short recovery from the surgery, but Delhomme's injury wasn't the result of a traumatic hit. He started 27 games for the Panthers over the ensuing two seasons and Carolina went 12-4 in 2008, his first season after surgery. His production dropped, but Delhomme says that was because of wear and tear on his body and not arm issues.
"Tommy John was kind of foreign to football to be really honest, because it was mostly baseball players that did it," Delhomme said. "It wasn't many football players ... We attacked it head on. It had to be fixed. There was just no other way around it."
At least not then.
THORSON WAS IN Birmingham, Alabama -- the home base for all USFL games -- when he suffered his elbow injury. Birmingham is also the home of perhaps the most famous sports surgeon in the country, Dr. James Andrews, and the Andrews Sports Medicine & Orthopaedic Center.
In 2011, Andrews and Dr. Jeff Dugas pondered Tommy John surgery for another patient when Andrews looked at Dugas and made a suggestion.
"He just said, 'Hey man, we've got to come up with a better option,'" Dugas said. "It was like we had just one hammer for every nail ... 'How could we make this better?'"
Tommy John was the procedure used to repair UCL injuries for nearly four decades and Andrews believed it was time to find an alternative that could reduce recovery time.
In 2006 and 2008, Dr. Felix Savoie had published a pair of papers about the potential for using anchors, a screw mechanism made of metal or biodegradable materials which can dissolve in the body over time, which could be inserted into the bone and held in place by a suture attaching to the ligament, to repair the UCL.
Around the time Dugas and Andrews started seeking options other than Tommy John, Gordon Mackay, a Scottish foot and ankle surgeon, had begun using "InternalBrace" -- what Dugas calls "a construct" that includes anchors and a collagen tape so strong he likens it to Kevlar -- for ankle ligament reconstructions.
Dugas reached out to Savoie and Mackay. He came away from those conversations believing he could make it work in an elbow. The concept involved repairing the damaged ligament (instead of replacing it with a graft) and reinforcing the repair with the InternalBrace which would serve as a "check-rein" to protect the ligament during healing.
Over the next two-plus years, Dugas and his staff tested the construct on cadaver elbows to gauge how it would hold up to the stress and tension placed across the joint during throwing.
By early summer 2013, Dugas was confident in the surgery. He just needed the right candidate. That July, Mark Johnson, a 17-year-old left-handed pitcher from nearby Carroll High in Ozark, Alabama, came to Dugas with persistent elbow pain.
Instead of defaulting to Tommy John, Dugas presented the InternalBrace option, prefacing by telling Johnson he wouldn't know if the surgery would work until after it began.
Johnson checked the necessary boxes -- high grade partial or complete tears of the ligament away from the bone, good tissue quality and not worn tissue that had turned into "gelatinous gray stuff that used to be the ligament" and no ruptures in the middle of the ligament -- and became the first to get the InternalBrace repair on his elbow.
Stephania Bell demonstrates how the ulnar collateral ligament InternalBrace system works.
Five months and three days later, he was cleared to return to baseball. Less than seven years later, the repair made its way to the NFL.
Late in a loss to the Dallas Cowboys on Dec. 20, 2020, Mullens, then starting for the 49ers, had suffered a big hit from Cowboys defensive end DeMarcus Lawrence. Mullens tore the UCL in his right elbow. The InternalBrace option had begun to emerge and Mullens became the first professional quarterback to have the surgery in January 2021. He was back in time for training camp with the Eagles and has since signed multiple free agent contracts with the Minnesota Vikings.
"The first place my mind goes when I think back on this is that just 10 years ago the procedure was not even a thing," Mullens said. "I'm grateful that it's an option now. [If I had Tommy John surgery] I would have had a full year off. For Brock, he wouldn't even have been in consideration to start the season."
IN THE WEEKS after Purdy suffered his injury, he did an extensive fact-finding mission. He sought first, second and third opinions, hoping to find the best long-term solution for his elbow.
Because the UCL repair with InternalBrace has been in use for a decade, there isn't long-term data. Early returns have been positive, according to Dugas, who along with his colleagues, have performed the procedure on two professionals, 10 to 15 college and high school quarterbacks and roughly 600 athletes from other sports. Return to play (RTP) at a previous or higher level of performance, considered the gold standard measure of success in the sports medicine, is 93% following the procedure; the high bar of RTP following Tommy John surgery is 86-88%.
"To find a way to have surgery, get the ligament healed up but also cut down the recovery time, I think is huge," Purdy said.
Purdy hoped to have the procedure done by Meister in February but Purdy's elbow had too much swelling.
"You want to get surgery as fast as possible," Purdy said. "You want to get rehab rolling. So, when it kept getting delayed, I was like, 'OK, I'm trusting in Dr. Meister and what I'm told from our doctors and everything because they know what's best.' ... I think we all looked at it from every different angle and I thought that's what the best plan was."
As Dugas points out, setting a definitive timeline after surgery isn't a one-size-fits-all proposition. It takes five to seven months for most patients to come back from the surgery.
It varies depending on the severity of the injury and much depends on how things look after the first eight weeks. According to Dugas, that time includes no throwing or stresses of any kind, just healing.
During the immediate post-surgery period, the rehab includes range of motion and plyometrics to maintain joint mobility and to provide controlled, gradual stresses to the healing ligament. Basic plyometrics start with two-handed throwing of light medicine balls, followed by a progression of one-handed movements like bouncing a lighter ball off the wall and throwing weighted balls against trampolines.
If everything progresses as expected, the throwing progression starts 10 to 12 weeks into recovery. It begins with throwing a half-weighted football and builds to throwing a prescribed number of balls at fixed effort and distance. The final portion of the rehab is mimicking a game week by throwing roughly the same number of passes an NFL quarterback would during the regular season.
And, as Mullens points out, regaining confidence takes some time.
"Obviously you focus on the elbow and your physical recovery but it's equally important to focus on the mental recovery, too," Mullens said. "I don't know if mentally I was as confident as I could have been. I would tell myself, 'Dude, work on your mind. Have trust and faith that things are going to work out.'"
All of which makes establishing a date for Purdy's return guesswork, though the Niners and Purdy believe they'll have a much better idea when he hits the 12-week mark in early June and can begin a throwing program. In the meantime, the 49ers will split first-team reps between Trey Lance and Darnold in a competition for the starting job until Purdy can return without restriction.
The early returns on Purdy's recovery have been good -- he set social media abuzz by using his right arm to high-five fans at a San Francisco Giants baseball game. The 49ers will not rush Purdy back, but there's growing optimism he could return during training camp.
Brock Purdy is in the building tonight 👀 pic.twitter.com/HExBKQguuo— SF Giants on NBCS (@NBCSGiants) April 22, 2023
"What's more encouraging is what I'm hearing every day from our people, from Brock," Lynch said. "He's making great progress ... As I understand it, he's definitely on schedule hitting all the checkpoints and we're very encouraged by his rehab."
Which means when Lynch and Shanahan depart for their respective summer getaways, be it to Cabo or elsewhere, they'll do it with a little more peace of mind.