July 5, 2010

Under The Knife

Reactivation

by Will Carroll

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¡Hola, amigos! Acabo de regresar de una semana en Mexico - una semana de playa hermosa, la cerveza, y el beisbol no. (Mi espanol mejoro un poco tambien.) Oh, wait... English now. A week away provides a perspective, the same way that a fortieth birthday does. Being away, especially during a week where player after important player seemed to go down, reminded me why I do this every day. I see baseball through the lens of health and while sometimes, it would be a bit more accurate to wait or do something like write once a week or so, the story is lost. A player is injured-how bad is it? What is the medical staff doing? How are the players reacting? Is there a roster move? Is the team capable of filling in for the lost player? So much more happens than just the injury. Some of you missed having UTK here every day, some of you didn't, and the vast majority didn't notice, reading the rest of the content here. That's okay with me. I'm telling stories that involve injuries, not writing about injuries. It took me years to realize that and a beach. No matter ... a las lesions!

Chase Utley (sprained thumb, ERD 9/1)
Let's get this clear right now: a sprain is a tear. A sprain can be mild, with minimum tearing. It can be severe, up to a complete rupture of the ligament. I won't fault most for mixing up "sprain" and "strain," because that happens and it's a mistake at worst, a typo at best, but not being able to understand that a sprain or strain is a tear? That one I'm going to call people on, and you should too. With Utley as with several others around baseball, they've all done pretty much the same thing in varying degrees, but it's the mechanism and function that is the big question here. Thumb ligaments tend to be strong in relation to the fine muscles and small bones of the hand, which can often mean that a sprain also involves a tearing away of the bone (an avulsion, or avulsion fracture). Utley injured his thumb when it was pulled back (away from the hand), overtaxing the ligament meant to support the thumb. After a few consultations, Utley decided to have the surgery, which puts him out five weeks and likely a bit longer. Utley's grip is going to be affected, so bat control and to some level power will be affected even after his return. Since this is likely going to run into late August, Utley may have limited opportunities for rehab assignments. It all adds up to a very tough way to come back. The record of the Phillies at that point could affect things as well. I can't imagine them running away with it or falling so far behind that they can give Utley extra time. Utley's likely going to beat my ERD by a week, maybe two, but don't get the idea that it's going to be Utley at 100 percent that's back at that point.

Shin-Soo Choo (sprained thumb, ERD 9/1)
Pretty much everything said about Utley above, holds true for Choo. Choo injured his thumb diving for a ball, having his thumb pulled back by the turf. While Choo hasn't yet had surgery, it remains an option. Where things differ is with the Indians' situation. Last year, the team was willing to shut Grady Sizemore down early, and while miracles happen, it doesn't look like this team is going to make a big run. If Choo could come back around September 1, is there any reason for him to do so? Choo is a bit more reliant on bat control than Utley, so this could affect him slightly more, though I think the differences in their skill sets will make this look very even and very similar as they return. Choo continues to be held back by injuries from being a real star, but at 27, it seems like he's headed down a J.D. Drew path. Look at Drew's career numbers before you think that's an insult.

Aramis Ramirez (bruised thumb, ERD TBD)
Ramirez is having more trouble with his thumb. After a DL stint and time to adjust to a new grip, Ramirez looked like he was putting things together. He had a little hit streak going and the power seemed to be on the upswing despite a lack of homers. Now he's reinjured it during a swing, meaning that the grip wasn't the full answer, that it wasn't fully healed, or that he's doing something that's over-stressing the area-perhaps all of the above. Bruises are like that, and can recur swiftly. While the Cubs haven't given much indication of the severity, Ramirez was out on Sunday and there's no clear timeline for his return. Obviously, more adjustments will need to be made. The real worry here is that there's no way to adjust while keeping Ramirez healthy, which would force him back to the DL. Ramirez showed he could hit, but risked a recurrence. How the Cubs handle this is going to be very key-they have the pressure of trying to catch up in their division coloring this. It looks as if they're going to try to get him back this week, then buy him rest over the next few weeks to continue treatment.

Victor Martinez (fractured thumb, ERD 7/15)
Jason Varitek (fractured foot, ERD 8/15)
Dustin Pedroia (fractured foot, ERD 8/1)
Clay Buchholz (strained hamstring, ERD 7/20)
Josh Beckett (strained back, ERD 7/20)
I thought things looked rough for the Red Sox before I left for Mexico, but it didn't get better. The biggest issue is at catcher, where back-to-back (or rather hand to foot) injuries to Martinez and Varitek forced a trade to fill the position. Martinez's thumb injury is not like those of Utley, Choo, and Ramirez-it's a simple traumatic fracture on his glove hand that is painful enough to keep him from catching. Sources say that hitting is also a problem, but not as much, since the fracture is on the shaft of the bone and can be easily splinted. Martinez should have no real issues with the healing, so coming off the DL and getting back behind the plate shouldn't take much more than the minimum, plus a bit of an assist from the All-Star break. It's a bit of pain tolerance, a bit of common sense, and a bit of how, if at all, it affects his grip.

It's much more of a problem for Varitek. Like Pedroia, the broken foot will keep him out around six weeks, although in his case it's a different bone (the second metatarsal). The difference is the demands on those bones. While Pedroia is asked to move laterally more and puts a lot of pressure on the foot during his swing, Varitek has to squat and has the danger of foul balls and home-plate collisions. There's some chance this could take slightly less than six weeks. As I said with Pedroia, the advances in the care and healing of broken bones is making its way into sports medicine. The idea that Pedroia could be out on the field just days after a fracture is a bit ridiculous, however. Pete Abraham made a great point in his Boston Globe column that if Alex Rodriguez had tried something similar, the press would have crucified him. Pedroia took a stupid risk with no discernible gain. His foot, however, is healing more rapidly than would normally be expected. I say "normally" in the context of "a couple years ago", not that he's making some miraculous recovery. It's that these advances are forcing us to re-set the rehab expectations for certain injuries. The ERD is a little bit shorter for Pedroia, no pun intended.

The story on Buchholz has gone back and forth a bit. Strained hamstring or hyperextended knee? Dessert topping or floor wax? The answer: Both. Buchholz hyperextended his knee initially, a mechanism of injury that causes structural issues inside the knee much more often than it creates muscular problems. There were reports both ways because the actual injury was a strain to one of the tendons of the hamstring at the bottom of the muscle, where it attaches near the knee. This is similar to, but not as serious as, what Jose Reyes dealt with last season. The Sox finally pushed Buchholz to the DL over the weekend. The tendon strain shouldn't be a long-term problem. The Sox are conservative with pitchers, plus this allows them to control Buchholz's innings a bit. He should be back shortly after the All-Star break. In the meantime, the news continues to be good with Josh Beckett: he's been able to recover on normal rest between simulated games and will next throw in Ft. Myers. He'll need to build back up some stamina. Previous higher pitch counts were discounted a bit, since the team knows that "pen pitches" and "game pitches" don't cause the same stress. At most, he'll have two rehab starts and should be back just after the All-Star break.

Jorge Posada (sprained finger, ERD 7/7)
Like Victor Martinez, Posada injured his glove hand. Posada has a sprained left ring finger, caused by a simple "pull back" as the ball hit the top of his glove and more or less yanked. Martinez' thumb fractured under a similar stress, and Posada's connective tissue took the worst of his. The simple answer would be to split it or even just tape a couple of fingers together, but that's tough to make work with a catcher's glove. How the finger reacts to catching and gripping is going to determine the course of this injury. Catchers hate missing time with what's perceived to be a minor injury, but the Yankees have options here, both behind the plate and at DH. That allows them the luxury of giving Posada some rest, letting the finger heal up. I don't think he'll miss much more than a couple of days, but be sure you see some evidence that his grip isn't an issue before you put him back in your lineup. We can only hope Joe Girardi is doing the same.

Joe Mauer (hip/back issues)
If Twins fans have some Maalox handy, now would be the time. Rumors have been out for about a month that Mauer has been dealing with some sort of hip injury, though there have never been any specifics or people credible enough to put much out there. Now the rumblings are getting a bit louder, and it's tough because if someone says "hip," could that mean a recurrence of Mauer's lower back (SI joint) issue from last year, which can often cause pain to radiate down to the leg, butt, and hip area? It could, but there's enough info now that I don't think this is the case. Mauer continues to deal with his back problem, but that's different than this "specific hip issue." There's not enough to say what it is, but eliminating things is a step. Mauer appears to be "Chippering" his way into the lineup, something that's worried me for a while given his insistence on catching. I've often advocated that Mauer shift, at least partially, out from behind the plate. Even if he insists he's a full-time catcher, the Twins have about 180 million reasons that they shouldn't listen to that argument. This hip thing is worrying and is leading to some speculation that he could be headed for some sort of acetabular labrum surgery. There's no evidence for that; I just can't imagine the Twins would put him at that kind of risk, allowing him to play through it, though "can't do further damage" is often carte blanche for a team. That does tell us that Mauer's likely headed for some sort of off-season procedure, which could affect his fantasy values for 2011.

Manny Ramirez (strained hamstring, ERD 7/20)
For once, things are pretty straightforward with Manny. A strained hamstring has pushed him to the DL and he should be back at or near the minimum, with no long-term concerns. The only really interesting thing here is that the Dodgers delayed, even doing an MRI before pushing Manny to the list. Does that indicate that they weren't sure of the severity or that they were worried that it was something more than "just" a strained hamstring? I'm not sure, and because I missed some time, I'm not sure I can figure it out. The LA Times reported that Don Mattingly was talking about Ramirez's timing returning, so it's quite possible that the team was trying to figure out how to keep Ramirez from losing that while still protecting the hamstring. With the All-Star break in there, Ramirez could miss a minimum of games while on the DL, but don't be surprised if this one drags out a bit. There's more here, and I'm still catching up.

Carlos Beltran (arthritic knee, ERD 7/15)
Weather has held Beltran back a bit. The Mets had hoped to have him going on back-to-back days in the outfield by now, but rain and wet conditions have prevented that. On the other hand, sources have said that Beltran's ability to do that isn't clear, had the weather cooperated. Those back-to-back games will now come sometime this week, perhaps Monday and Tuesday. How he plays in the game is nice, but it's his body's response after the game that has been the toughest to gauge. There's some swelling, but the medical staff has been able to control it, allowing him to get back out there without more significant damage or a rolling degradation. One note that's come up is that if there's much more of an issue and microfracture returns to the picture, the Mets will need to make that decision quickly due to the six- to nine-month minimum recovery period. We'll have a lot more information on Beltran by this time next week and by the time the Mets get back on the field after the All-Star break, Beltran is likely to be out there with them.

Edwin Jackson
Jackson was handled in an interesting fashion following his no-hitter. First, the D'backs gave him a couple of extra days off, essentially having him skip a start and start on his throw day. That's good management, not only buying him some extra rest, but keeping him on rhythm. (Note that some pitchers like Phil Hughes and Mike Leake have been skipped to protect their arms, but that their rhythm appeared off in the next start. You can call it "rust" if you like.) Secondly, they were willing to take him out pretty quickly. It didn't hurt that he wasn't effective and struggled through five innings. I actually think Kirk Gibson could have pulled him earlier, but he was in one of his first games as manager. It's hard to ask him to make that tough a call at that point. Jackson's management over the next few starts is key, but the D'backs are at least off to a good start with this.

  Yovani Gallardo (strained oblique, ERD 8/10)
The only thing Gallardo can't do is stay healthy, it seems. His latest injury is an oblique strain, a problem that will cost him a month. The Brewers want-need-to have him out there, but they also have seen the season slip further and further away. That's mostly been a function of the pitching (or lack thereof.) With Gallardo out until August, we have to wonder if this will affect the Brewers trade plans. Gallardo shouldn't have much issue with this once the strain heals. He's had a lot of injuries in his short career, but none of them seem related. His knee problems were traumatic and he returned very quickly. This is just "one of those things," and at 24, it could prevent Gallardo from overtaxing his talented young arm. In the long run, this injury could be a good thing for Gallardo and the Brewers. Right now though, it's a real problem. Doug Davis' return will help, but it's not going to help them win games. I've advocated against trading Prince Fielder, but if that's what it takes to get a couple pitchers to lock down the third and fourth slots, I'm seeing the benefits now.

Jose Reyes (strained oblique, ERD 7/20)
I don't get Jerry Manuel at all. After Reyes strained his oblique, Manuel started saying that he wanted to keep Reyes around to play defense and pinch-run. The problem there is that both activities can tax the strained oblique and cause a setback. It's too bad that this happened, especially with the Mets playing well, but for a player with a long history of injury concerns, getting cute with the management of what should be a simple muscle strain is the wrong idea. Given the upcoming All-Star break and the available retroactive move the Mets have with Reyes, it makes even less sense. Still, the team does understand that if Reyes could play before the fifteen days of a DL assignment, that has a real value. It just doesn't match up well with the risk/reward. Obliques are pretty much a known quantity, and having a healthy Reyes back after the break is a much better outcome than the chance of a healthy Reyes affecting a couple games here and there along the way.

Quick Cuts: Brandon Webb will throw to hitters later this week. A rehab assignment should come quickly after, assuming all goes well. ... Shaun Marcum dodged a bullet. An MRI showed mild inflammation in his repaired elbow. The Jays will be careful with him in the second half. ... Felix Pie is expected back in the lineup early this week. He's missed time with a severe shoulder strain, so expect opposing third-base coaches to test him early. ... Rick Ankiel has re-started his rehab assignment and should be back after the All-Star break. His quad remains "tender" and will be "closely monitored." ... Placido Polanco is trying to avoid in-season surgery to remove bone spurs and chips in his elbow, but sources tell me it's all down to pain tolerance. Having surgery now might let him come back for September, so watch how he does when he tried to start things up later this week. ... Contrary to reports, Geoff Blum did not injure himself putting on a shirt. Instead, it was during that activity, one which can make any of us contort ourselves a bit, that Blum had a bone chip move to the wrong spot. He's been dealing with the chips for a while, but they lodged somewhere in there and have caused both pain and a severe hit  to his range of motion. ... Brett Anderson is throwing well, according to reports. He's expected back just after the All-Star break. ... Jordan Zimmermann had his first rehab outing and while he went his 25 pitches, sources say he looked "tentative" and "nowhere close." He has a month, barring setbacks. ... Brad Penny will throw a simulated game on Tuesday, and he could be back just after the All-Star break. ... Conor Jackson is headed for the DL; his hamstring hasn't healed up and the Athletics need the roster slot. ... Both Rich Harden and Derek Holland are scheduled to throw on Tuesday. The Rangers have used a lot of pitchers this year, but they had a lot of pitchers to do this with. There's nothing wrong with having a plan. ... Mike Lowell's hip problem is related to his hip surgery, but it's not the same problem recurring. This is more with the further deterioration of the area due to age and long-term usage. Calling it "arthritic" isn't technically correct, but it's close enough.