The shoulder injury that has sidelined Ravens linebacker Ray Lewis is as individual as it is commonplace.
That's why no one knows for sure whether he'll need season-ending surgery and the months of rehabilitation such an operation would bring - a possibility coach Brian Billick acknowledged this week.
"You just don't know. Each case is different," said Dr. Edward McFarland, director of the division of sports medicine and shoulder injury at Johns Hopkins Hospital. "The critical things are really how many things are torn up. The other critical factor is he's in a very high-demand sport that puts a lot of stress on your shoulder."
Many athletes can heal on their own within weeks and return to play once they have full - and pain-free - range of motion. So far, Lewis has neither.
"They're going to wait to see if first he can overcome the pain of that injury, which is pretty severe," said Dr. Anand Murthi, an orthopedic surgeon and assistant professor at the University of Maryland School of Medicine.
"Slowly, they'll want him to get his motion back. That'll be the tough part," he said. "If he can't move his shoulder into certain positions where he doesn't feel unstable, then they would probably push toward having it surgically repaired."
Only Lewis and his doctors know exactly how much damage he did to his left shoulder when his arm jammed into the ground during a game Oct. 6 in Cleveland. But orthopedic surgeons and sports medicine experts described yesterday the type of injury Lewis may have suffered and what an operation - and rehabilitation - might entail.
The shoulder is the junction of three bones: the upper arm bone, or humerus; the collarbone, or clavicle; and the shoulder blade, or scapula. Normally, the head, or ball, of the upper arm bone fits into the cuplike part, or socket, of the scapula. A shoulder becomes dislocated when the ball comes out of the socket.
Ravens officials have said Lewis suffered a partial dislocation, or subluxation, in which there is still some contact between the ball and socket.
Some injured football players can return without an operation - wearing a harness or brace, which helps keep the shoulder from being knocked out of place again, McFarland said. Peter Boulware, a Ravens linebacker who dislocated his shoulder, used a harness during the 1999 season.
"Linebackers tend to have more trouble with injuries of the shoulder because they have to use their arm in so many different positions," McFarland said.
Referring to whether Lewis will need surgery, he said: "It's a very difficult decision to make in his case because of the demands of his position. He plays with reckless abandon."
Continuing to play with the injury might make him a less aggressive and able player, the surgeon suggested.
"He's such a great athlete he might be able to play with one arm, but not many people at that level can participate unless they're 100 percent," he said.
Ravens trainer Bill Tessendorf has said that about 80 percent of players who suffer a first dislocation of the shoulder can recover fully in three weeks, but that some players - including Lewis - require longer.
A magnetic resonance imaging of the All-Pro linebacker's shoulder this week showed that the swelling had gone down, but he has had continued pain, in part because of a piece of bone that flaked off the shoulder socket.
Tessendorf declined to comment yesterday on Lewis' injury and how his recovery is proceeding.
Another possible problem with Lewis' injury, UM's Murthi suggested, is that it may have caused a Bankart lesion - a tear in the soft tissue that, along with the ligaments, holds the shoulder joint together. That tissue, known as the labrum, acts sort of like the bumper on a car. If it is torn, the shoulder may slip out of place.
In either a full or partial dislocation, ligaments, too, can be torn enough to leave the shoulder unstable and prone to reinjury.
Operations to repair such damage are common - and, in most cases, successful. Surgeons essentially take the soft tissue and sew it back to the socket, then tighten up the torn ligaments, which tend to stretch out as the body tries to heal them naturally.
The surgery can be done with an open incision, which would be about 5 centimeters long, or arthroscopically, which is less invasive. Doctors would be more likely to use the open incision approach on a professional athlete.
Murthi said the operation takes a couple of hours and can be performed with either a regional anesthetic, in which the arm would be numb and the patient would remain awake, or under general anesthesia. It has a success rate of over 90 percent.
John C. Mahoney, director of outpatient physical therapy and sports rehabilitation at Kernan Hospital, said different athletes respond differently to the same injury in terms of everything from pain to healing time.
"It's hard to determine exactly how far [Lewis' shoulder] came out and how much soft tissue damage he did and how that soft tissue is going to respond" to the damage, he said.
Rehabilitation can be a long, slow and sometimes frustrating process.
An athlete should have no active muscular contraction for about four to six weeks after surgery, Mahoney said. Once the soft tissue has healed, the player can start moving his shoulder gently, practicing various ranges of motion. The next phase of recovery is the strengthening of the shoulder muscles. Athletes should not return to contact sports for anywhere from four to nine months.
It could be at least another three or four weeks before Lewis and the Ravens decide whether he needs surgery or can play again this season without it.
"If he's in excruciating pain, it's not worth taking any type of risk putting him back in there," Mahoney said.