Tua Tagovailoa’s Return From Injury for Alabama-L.S.U. Comes With Risk

TUSCALOOSA, Ala. — Three weeks ago, the star Alabama quarterback Tua Tagovailoa hobbled off the field late in the first half against Tennessee. He ducked into an injury tent along the sideline, then emerged and walked with a slight limp up a tunnel to the locker room. The next day, the school announced that he’d had surgery on his right ankle.

Tagovailoa, who returned to practice 10 days later, is expected to start on Saturday against L.S.U., a game that gives the winner an inside track to the College Football Playoff. His final status will not be determined until just before kickoff.

His anticipated return might be considered miraculous in some quarters. But it is seen as routine here, where a cutting-edge surgical technique, hyperaggressive treatment and a competitiveness have in recent years allowed Alabama players to return much earlier than expected from an often debilitating football injury: the high ankle sprain.

And for Tagovailoa, it really has become routine. He had the same surgery, rehab and quick return last December from an injury to his other ankle, the left one.

Tagovailoa has been kept from speaking with news reporters since he was injured, so it is hard to say why he chose to take this path — and whether being the potential No. 1 pick in the N.F.L. draft next April, which could bring a signing bonus worth about $25 million, was a consideration.

In recent years, top pro prospects have increasingly skipped bowl games that did not factor in the national championship to guard against injuries that could affect their draft position. And last year, Nick Bosa, a former Ohio State defensive end, had abdominal surgery in September and chose to prepare for the draft rather than return to the Buckeyes, which irked some of the team’s fans. (He was drafted second over all by San Francisco and given a $22.4 million signing bonus.)

Alabama Coach Nick Saban has praised Tagovailoa’s parents for their old-school values and Tua for his diligence in rehab, but he said he would not allow a player to return from an injury unless he could perform at a high level, whether he had no N.F.L. future or a bright one. However, he also spoke of “the warrior mentality” that N.F.L. teams want to see.

“So, I’m not saying every player is capable of that, and I’m not saying every player is like that,” said Saban, who spent eight seasons as an N.F.L. head coach and assistant. “But the question is what really creates value for you?”

He added: “Now I don’t really try to promote that with the players, but I’m just saying there’s another side to all of this that if you’re capable of playing and you choose not to play, is that a good thing or a bad thing?”

Tagovailoa’s progress over the last three weeks has been tracked diligently by the local news media. When practice was opened briefly to reporters on Oct. 30, a day Tagovailoa worked out with the team, the only Tagovailoa among six quarterbacks doing drills was Tua’s younger brother, Taulia. There have been updates on the injured Tagovailoa running on an anti-gravity treadmill, his round-the-clock treatments and how there was less swelling after this surgery than following his procedure last year.

Alabama’s rabid fans — and Tagovailoa’s teammates — are not the only ones invested in his return.

Saban, who ultimately decides whether Tagovailoa will play, can earn as much as $800,000 in incentives if Alabama wins the national championship. There is additional prestige — and business — at stake for the Andrews Sports Medicine clinic in Birmingham, which employs Norman Waldrop, the Alabama team doctor who performed the surgery. The same goes for Jeff Allen, the head athletic trainer, who treated Tagovailoa last December during a trip to New York for the Heisman Trophy ceremony.

There is no indication that Saban (or anyone else) will pressure Tagovailoa to play, but it happens frequently. A recent National Athletic Trainers Association survey of nearly 1,800 college athletic trainers found that nearly one in five trainers reported a coach playing an athlete who had been deemed medically unfit, and more than one-third said a coach had influenced a hiring or firing on the sports medicine staff.

“There’s an inherent conflict of interest,” said Kain Colter, the former Northwestern quarterback who in 2014 led an unsuccessful effort to unionize his team. One of the reasons he wanted to unionize was for access to better health care, including second opinions.

“There’s a culture of playing through pain, playing through injuries — the injury rate is going to be 100 percent if you’re on the field all the time,” Colter added. “You’d hope you’d have independent medical advice.”

That is uncommon for college players, who are prohibited from hiring agents who can solicit opinions from doctors who have no financial agreements with teams. Kelechi Osemele, an offensive lineman for the Jets, had shoulder surgery last month after eschewing the team’s advice to take painkillers so he could continue to play. He filed a union grievance over lost wages after his surgeon found more extensive damage than was initially believed.

Thus far, it seems, Alabama players have leaned heavily on the advice of Waldrop, who has performed the so-called “tightrope” surgery on close to a dozen Alabama football players, beginning in 2014 with Cam Robinson, an offensive tackle who now plays for the Jacksonville Jaguars. (Robinson declined an interview request.)

In the arthroscopic procedure, holes are drilled just above the ankle in the fibula and tibia — the two lower leg bones — and a high-strength suture (the so-called tightrope) is run through them and fastened. If any of the three ligaments that run through the area is torn, it can also be repaired during surgery.

The procedure allows for greater stability during rehab, which can be more aggressive, cutting in half what can be an eight to 12 week recovery.

The technique was published in 2004 by Brian Thorne, a Scottish orthopedic surgeon who sought an alternative to using a screw to stabilize the bones; sometimes screws would break and another surgery would be required to remove them.

One of the procedure’s earliest acolytes was Thomas Clanton, a former team doctor for the Houston Texans and Houston Rockets, under whom Waldrop served a one-year residence. Clanton has performed the surgery on close to a dozen Alabama football players.

Clanton, who operates out of the Steadman Clinic in Vail, Colo., said wealthy programs like Alabama have comparable data to that of N.F.L. teams, who can use players’ pre-injury strength and agility levels as a baseline to measure against during rehab.

“It’s a way of determining performance characteristics: looking at their seven-step drop, seeing how they move down the line on an option, how quickly they can turn,” Clanton said. “It’s a whole new world out there.”

Despite the success of the surgery, Clanton said there are still skeptics. He said he examined a college basketball player recently who had torn ligaments in his ankle. The player’s father was adamantly against surgery, so the player was treated with a cast. Clanton said there are also some in the medical community who question how quickly players are sent back on the field.

“You’d hate for something bad to happen to a player who has the prospects Tua has for a professional career,” Clanton said. “Knowing Norm, I know he had the conversations about the risk and benefits. As a physician, your goal is to get the patient well and get the patient back to whatever they want to do.”

In the end, Clanton said, Waldrop can offer his assessment of how the surgery has gone and Allen can offer his assessment of how the rehabilitation has gone, but Saban has to decide whether Tagovailoa plays.

Saban said he will first ask the player not whether he wants to play — because they all do — but what he can do.

And then?

“He’s always made great choices and decisions,” Saban said of Tagovailoa. “He’s smart, he’s bright and I don’t think he would put himself in a position, nor would we want him to put himself in a position where what he does moving forward would have any effect on his future.”

That is a lot to ask of a 21-year-old — maybe even more than asking him to try beating L.S.U.