Justin Smith injury: Long term health and the potentially controversial use of Toradol

USA TODAY Sports

We take a look at Justin Smith's triceps injury, and what could happen long term if he decides to play through the pain.

One of the biggest 49ers storylines heading into next week's divisional round matchup will be whether or not Justin Smith will be able to play. He has been out since the second half of the 49ers Week 15 win over the Patriots with a bone spur issue in his left triceps. Coach Harbaugh has indicated the injury will require surgery in the offseason, and according to his KNBR interview earlier this week, he is "hopeful" Smith will be able to play on Saturday.

If Smith is able to go, it is clear he will not be 100%. There are concerns about his ability to gain leverage on offensive linemen, and be his general awesome self. I think we could make some arguments that a 1 1/2 armed Smith is still better than a lot of defensive linemen, but it will still be a struggle for him.

There is another take on this that I had not thought about, but is an under-the-radar big deal. Former Pro Bowl fullback Lorenzo Neal appeared on 95.7 The Game on Tuesday (thanks to Grant Cohn for transcribing the interview), and he had some thoughts on Smith's availability for Saturday. Neal was asked if Smith would play, and whether he would be near 100%:

One, I know he can play. But the second question is the toughest. Guys are going to be hitting it, chopping it. He's going to be sore. And I know what he can do. They can put him on Toradol. They'll probably put him on a steroid package, a seven-day steroid package. I've done it many times, it tries to take the inflammation out of that area. They've probably got him on some Celebrex, some Biox. Got to be icing and stemming every day. Getting the inflammation out is imperative. You'll see him out there in a brace. And then what you do for the triceps, you've got to strengthen your shoulders, strengthen your biceps - do movements that aren't going to affect your triceps. The triceps is mostly when you extend. Justin likes to punch and lockout, so he's going to play and be limited. He'll have one arm to punch with, I think the other arm will be more to grab and wrap and tackle. He can still play, but it will be hard for him to punch and hit and read - he's one of the best defensive lineman at that.

The host asked if he thinks he'll be able to play, and Neal followed up with more on Toradol:

Yeah, because the day of the game, guys take a thing called Toradol. Toradol, they inject in your butt. It's a pain killer, it numbs the pain. You can play through it. Toradol, it's candy. It was tea for me. I was taking Toradol like I was drinking coffee. You're tight, you're sore, and it relieves the pain for those three hours. We'll see how Justin responds to it.

We all know pain killers are a part of the standard operating procedure of the NFL. While I don't know the extent of it, Neal's comment, combined with numerous other discussions of the topic show that it is a fairly common occurrence.

At the same time, Toradol brings a particular bit of controversy. While frequently used, players are now starting to become aware of some of the nasty side effects that can accompany its use. In 2011, several retired players led by Joe Horn filed suit against the NFL "accus[ing] the league and its teams of repeatedly administering the painkiller Toradol before and during games, worsening high-risk injuries like concussions."

Earlier this season, word came out that the NFL was trying to limit the use of Toradol to only "'acute, game-related injury where significant bleeding is not expected and where other oral medications are inadequate or not tolerated.'" It sounds like the NFL formed a task force of doctors to explore the side effects of Toradol, and they came back saying it should be primarily received orally. The players balked at this because they felt the injections were more effective in dealing with pre- and post-game pain.

Now, the NFL has been requiring players sign a waiver of liability for the use of Toradol shots. The drug can reportedly cause kidney, liver and other gastrointestinal issues in certain instances. The NFLPA has filed a grievance against the league for requiring this waiver, claiming it is a violation of the CBA.

The legal wrangling won't really affect Justin Smith as he decides what he wants to do a week from Saturday. I think he will try and play, but I don't know enough about the extent of his injury to know if it will keep him completely out of commission. I also don't know what long-term implications there are from completely tearing the triceps muscle at this point. He will need surgery in the offseason, no matter what, so I don't know if further aggravation of the injury would impact it. I recall that with Dez Bryant's finger, further injury could result in greater fractures, which could cause future crippling of the hand. I don't know if such an aggravation is possible with further tearing of the triceps muscle.

Whatever the case, Neal's comments provide a bit more of a look behind the curtain. These are things we know about, but to hear them in this kind of deal is always interesting, to say the least. We can't really judge without knowing the full details of the injury, and being in there with the doctors. So, we just wait and see what he decides and how it plays out.

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