But on Feb. 11, 2019, Smith set out to achieve even more.
Along with his wife, Elizabeth, and physician Robin West, Smith traveled to San Antonio that day to visit the Center for the Intrepid, a rehabilitation facility for wounded combat veterans. West, who is also the team physician for the Washington Football Team, knew at some point during Smith’s recovery that the medical guidance of the military would be needed for an injury that was more akin to a blast wound than anything normally suffered on a football field. So she contacted a friend who worked at the center, and after he received clearance from the Office of the Secretary of Defense, the quarterback was suddenly surrounded by strangers who understood him better than anyone else could at the time.
“When we first walked in, it was so interesting seeing these warriors who had the same kind of injury and they’re fighting. Either they’ve had an amputation or they’ve had a limb-salvage like Alex, and they’re all determined,” West said in an interview with The Washington Post on Sunday. “Their number one goal was to get back to combat. That’s what they do. These are Army Rangers, very elite military, young guys in their 20s, and a couple of them were getting released to go back to being Army Rangers, and they had horrible injuries.
“And all of a sudden it was like a fire was lit. We spent the day there, and as we were walking out [Alex] grabbed me and said, ‘Hey, Dr. West, when are you going to clear me to play football?’ And that was the first time he had ever talked about it.”
Smith resolved that day to return to his sport, a feat many believed was impossible given the extent of his injury. West had seen numerous injuries of the sort, especially in her training as an orthopedic and sports medicine surgeon.
“We just don’t see guys come back from them,” she said. “And especially at the elite level, this is not the kind of injury we see.”
Yet Sunday, Smith cleared a hurdle that few — including, perhaps, his own coaches — anticipated as recently as two months ago. The 36-year-old was activated from the team’s physically unable to perform list for training camp, and for the first time since his injury in November 2018, he strapped on a practice jersey and a burgundy-and-gold helmet and took the field again.
“A lot of people may not have even survived the injury, but he never accepts no for an answer,” West said. “He’s had so many setbacks. The ESPN documentary [“Project 11,” which premiered in May], it shows such a small part of what we all went through, especially him. There were so many setbacks along the whole course. But at every setback, he said: ‘Okay, what’s the next step? Where am I going next?’ That’s the kind of person he is, and I think that’s what made it possible. He got dragged down and never said, ‘Oh, I’m not going to do it.’ It was always like: ‘Okay, that didn’t work this time. What’s going to work next time?’ ”
‘Let’s give it everything we’ve got’
Smith’s arduous recovery has so far spanned 638 days and included 17 surgeries, first to repair his fractured tibia and fibula, then to fight off a bacterial infection that nearly took his life.
“He wanted to go home that night [he developed the infection], actually,” West said. “It was Tuesday night, and I was leaving Wednesday because we were going to play Dallas [on Thursday] and I had been operating all day. I went to say bye to him after surgery, and he didn’t look great to me, but he didn’t have any fevers or anything. He wanted to go home, and I said: ‘Alex, just stay one more night for me. Just one more night.’ ”
With the help of Smith’s wife, West convinced him to stay a little longer. That night, his fever spiked and he became septic.
“Had he been at home, what would’ve happened? Because he may not have known,” West said. “We’re monitoring everything with the nurses, so you get the call in the middle of the night.”
In the days that followed, Smith’s surgeons operated on him daily to try to clean out the bacteria and control his infection. By the weekend, he had to decide whether he wanted them to continue to try to save his leg, which had been ravaged by the infection, or to amputate.
Only one person, among his family and surgical team, was truly in favor of limb-salvage when considering the risks: Smith.
“Yeah, pretty much,” West said. “They were all supportive of him. When he’s so sick, you’re just like, ‘Whatever you can do to save him.’ [The infection] was creeping up his leg, and every time we went back to the operating room you’re taking more and more muscle, and more and more bone. What’s he going to be left with? And then at that point you have to cover it, so you have to take muscle from the other leg and you have to take muscle from his back, potentially, and then that’s when everyone’s like, ‘Well, is it worth it?’ ”
And even then, after the muscle transfers and the skin grafts, there was still a possibility that amputation might be required anyway because of a slow-growing infection. But once Smith’s fever was under control and the surgeons had to start covering the leg that was gutted of soft tissue, the call was made.
“He was adamant about it,” West said. “ ‘Let’s give it everything we got.’ ”
Smith left the hospital in December 2018 to begin a difficult recovery. After nearly two months* in a wheelchair with a long external fixator that ran from his foot to his thigh, Smith transitioned to a shorter fixator that wrapped around his lower leg. Eight months on that and walking around with the aid of crutches eventually gave way to walking again, running again, working out again and throwing again.
His first throw took place at the Center for the Intrepid, while kneeling and talking to veterans who suffered similar injuries and had the same resolve to get back to their former lives.
Smith’s most recent throws came Sunday at the Washington Football Team’s indoor facility in Ashburn.
‘He’s definitely unique’
Just before the start of camp, Smith, whose $16 million salary for 2020 has already been fully guaranteed, received medical clearance from West and the rest of the surgical team following a series of X-rays and scans.
Smith wears a sleeve and a brace on his lower right leg because he doesn’t have full strength in his leg after the debridements. Muscle from his left leg was transferred to fill the front part of his right leg, but not to create movement. Rather, the tissue and accompanying artery were added to provide coverage and a blood supply to help the bones heal.
Smith still has his right calf muscle, which allows him to plant his back foot and run. But to help him with dorsiflexion, or the ability to lift up his foot, he uses a customized SpryStep brace. Smith knew Denver Nuggets forward Michael Porter Jr. was using a brace to successfully treat his drop foot, and Dallas Cowboys linebacker Jaylon Smith used a similar one a few years ago for the same purpose.
“I reached out to [the Nuggets] because all the braces were too big for Alex," West said. "As a quarterback, he needs foot agility. ... So we got him this brace, and it’s working great for him.”
West said she has no concerns about his leg and its durability, or about whether it can withstand the force of 300-plus-pound linemen falling on top of it. The titanium rod in his tibia can more than withstand such collisions, she said. Any trepidation is from the potential of a compensation injury.
“We always said that once that bone is healed enough and we think that you’re not at risk to do anything, then we can clear you,” West explained. “His ask to us was: ‘Hey, can I ski? Can I run? Can I go try and play?’ And we said: ‘You can go play. You can do whatever you want. Now, are you at higher risk for something else for your knee or your ankle? Potentially. You’re playing a contact sport where it’s a very, very high-risk sport.’ I mean, how many times does a guy sprain his ankle and then he tears his ACL the next week? We see that a lot.”
But after receiving the green light from his doctors, Smith still had to get Coach Ron Rivera’s approval and pass his team physical. He had to show he could make the necessary football movements and that he could protect himself when facing the pass rush.
After Smith took significant strides last week in his recovery while staying within the PUP parameters, Rivera and the team’s medical staff signed off on his return. He still has plenty to prove, though, as the team wraps up its second phase of camp and begins practicing in pads this week.
Smith will be eased back into full practice and will start with mostly individual drills while being monitored closely. That means any notion of a true competition between him and second-year quarterback Dwayne Haskins will come down the road, if it happens at all.
For now, Haskins is the presumed starter. And for now, Smith is getting the chance he had hoped for while serving as a mentor to Haskins on the field.
But if West has learned anything over the past 21 months, it’s that “for now” means little when it comes to Smith. He has no limits.
“I’ve been in the NFL for 18 years, so I’ve worked with a lot of athletes. He’s definitely unique,” West said. “They all physically are special, and many of them mentally. But the combination together — he’s certainly a little different than many.”
*Correction: An earlier version of this story incorrectly reported that Smith was in a wheelchair with a long external fixator for about three months.
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