July 6, 2010

Under The Knife

The All-Star Effect

by Will Carroll

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Starting in early June, it seems like nearly every injury story is going to have the phrase "the All-Star break" in it. A player is coming back just before it, while another player is expected back after it, and yet another is hoping to rest over the break in order to be ready for the second half. The problem is, it doesn't appear to work that way. The break is three and sometimes four days when a player doesn't have games. It's the only scheduled break like that during the long grind of the season, no doubt, but three days is seldom enough time to heal something minor, let alone be able to have some sort of medical breakthrough.

I spent several hours sifting through UTK columns and injury data over the last seven years, and while this is no scientific study, it appears that the break is nothing special. There's no increased rate of return; in fact, the opposite is true. The arbitrary break often leads teams to bring players back just after the break, artificially extending the days lost. This is just accounting and perception. It also happens at the start of months, returning to a homestand, and more noticeably at the beginning of series, though these obviously happen more often than the other events. The All-Star break is nothing more than an artificial construct that we can use to put things in relation to others.

As for the rest, it helps for some minor things, but the real value is mental. One MLB athletic trainer said that he often debates sending his guys home rather than continuing treatment. "I've seen those guys every single day since February in some cases," he told me. "I'm sick of them, they're sick of me, and we're both sick of the process. Unless it's something where a gap in treatment is a big issue, I'd rather they go home. I can tell them to ice or heat, but I think getting away, seeing the family—that's where the value is. Recharging, not healing."

The other side is for the All-Stars themselves. If most of baseball is getting a few days off, does it hurt players not to take that time off? Many players do, opting out of the event for various reasons. There are some players who have slower second halves, which some will point to and say "worn down." This has become very common for those participating in the home run derby, notably Josh Hamilton; some is simple regression to the mean, and some might have happened anyway. One thing that's notable in going through game logs is that the managers and teams don't seem to think three days off solve anything. Aside from injuries, none of the All-Stars in the last three seasons were given their own created break. A couple of teams seem to have made efforts to buy some rest, giving their All-Stars a game off before or after an off day, but not once that I can find (and I'll admit, there may be some I missed) did a team give an All-Star both the day before and after a scheduled off day off, absent an intervening event like an injury.

The effect on pitching is even more difficult to judge. I'm no statistician, but the same kind of eyeballing showed much the same effect, or lack thereof. Taking the time off didn't suddenly make a pitcher better. Even in aggregate, there's no sudden rise in Game Scores in the week just after the break. If three days off worked, teams would do it. If a pitcher going an inning in an exhibition game hurt them, no team would allow it. When it comes to injuries and fatigue, the All-Star Game doesn't count.

Joel Zumaya (fractured elbow, ERD 10/4)
One guy I skipped yesterday was Zumaya, largely because I wanted a lot of information before saying anything about it. I'm not sure I have the complete story here, but enough so that I can comment on it. Zumaya went down last week, and it looked like his arm had exploded. My first thought was Dave Dravecky, while most others thought Zumaya was headed for Tommy John. It turns out neither appreciation was close, but we do have a much better idea of why Zumaya has had so many issues over the years. What Zumaya did specifically was fracture the olecranon. It's not a bone, but a section of a bone of the ulna, one of the two bones that make up the forearm. The olecranon has a lot of things going on back there. There is a bursa which can be irritated and is the cause of almost all elbow bursitis. There are attachments for muscles/tendons and ligaments. There is also a fossa where the upper arm and forearm come together, which some have speculated at some point was a ball-and-socket joint like the shoulder or hip, back when we used our arms for walking.

So how did it break? We've known for years that, especially in youth athletes, the olecranon would impact with the humerus during the pitching motion if a pitcher did not pronate to allow for a smooth follow-through and dispersal of the energy. You can try this at home easily: pretend that you have a hammer in your hand. As you strike down at a nail, you plan so that the hammer hits the nail before your arm is fully extended. The energy goes into the distal impact (hammer on nail) rather than the proximal (bone-on-bone inside the elbow.) Now, try taking the same swing (not too hard!) and having there be no nail or board to hit. You'll feel the elbow tighten and, in the back, you'll feel the elbow impact slightly as it "locks out" in full extension. That's likely what Zumaya did—he hyperextended the elbow during a pitch, causing the olecranon to break when it impacted the humerus.

There's a second possibility that two orthopedists I spoke with mentioned. That is, that Zumaya put so much pressure on the bone during each pitch—not just the one we saw—that it worked like a stress fracture and finally gave way due to a wearing down rather than a sudden, singular impact.

In fact, both could be true; a weakened bone could snap more easily. The fact is that Zumaya simply does things that few other pitchers do to their elbows, shoulders, and bodies. I've always wished that Zumaya would have been sent to Birmingham, just to see how much force he's putting on various areas of his arm. Now, that won't happen for a while. Instead Zumaya is headed for surgery for a simple procedure of fixating the bone in one of various ways. Doing the surgery will allow Zumaya to do more in a more timely fashion. I can't imagine asking him to do nothing with the arm for a period of weeks would be good, let alone the possibilities of deconditioning and loss of motion. It's impossible to say that Zumaya can or can't come back from this, because there simply are no comparable precedents. Even though olecranon fractures can and do happen in baseball, it's fair to say that no one similar to Zumaya has done this. There's certainly a chance he comes back from this and pitches normally, but that's assuming that the bone heals well—which it should. The worry here is the forces involved, something no one has a handle on. Can anyone handle this kind of force without negative consequence?

Erik Bedard (post-surgical shoulder, ERD TBD)
After a couple of good starts in the minors, Bedard went to Triple-A Tacoma on Thursday and put up decent numbers in a four-inning stint. The M's seemed impressed enough to put him on the schedule for a return today, but something's happened, and reports now have Bedard being scratched with "shoulder stiffness." If Bedard wasn't recovering well, it should have shown up in his rehab starts, but there was no public indication of that. While he wasn't on a strictly normal schedule, he was making his next starts, showing his normal stuff, and even some increases in velocity. This isn't a game to get him more rehab time, because he wasn't up against the clock there. As is normal for Bedard, it's a wait-and-see situation. No one seems to have panicked here. There's no talk of doctors, images, or even another rehab start.

Edinson Volquez (sprained elbow, ERD 7/15)
Aaron Harang (strained back, 7/6)
The Reds announced that Volquez would make one more rehab start, allowing them to sort their rotation a little bit in the meantime. There's no setback, just a combination of roster rules and keeping Mike Leake rested. The Reds have a really tough balance down the line, which is one reason they've been kicking the tires looking at the available starters, including Cliff Lee and Dan Haren. Whether they want to give up Yonder Alonso or not starts and ends that particular discussion, but there's value to the Reds in finding someone—anyone—who can put up 8-10 credible starts. That can be one guy or two, especially if one of them could shift to the pen come playoff time. The Reds have enough offense to make a league-average guy look good, if Walt Jocketty and his staff can find the right guy at the right price. Volquez will be a big help for the staff, essentially splitting a role with Leake (first half/second half) once he returns. His velocity and movement have already been at major-league quality, so all that's left to see is where his stamina is.

The Reds also have a bit of a worry with one of the guys they're not used to worrying about. Aaron Harang missed his last start and now his Tuesday return is in a bit of jeopardy. He's seeing a chiropractor in hopes that will get him comfortable enough and functional enough to make his next start, but a decision will be made when he gets to the park today. If Harang can't go, it shuffles everything above with Volquez in regard to how the Reds will set their rotation. With the break coming up and the retro move available, Harang could miss as little as one more start (three total) if need be. Right now, things are 50-50 on Harang, but for a rotation already in trouble with innings, this could be the first domino on a lot of actions.

Aramis Ramirez (bruised thumb)
Ramirez was back in the Cubs lineup on Monday after missing the weekend. There was no visible change to Ramirez's bats, grip, or any sort of splinting, so the assumption here is that the team gave him some time off to let the bruise heal a bit. The problem here is that it recurred at all. Bruises are painful and his is in a location—in the "v" of the thumb—that is nearly impossible to uninvolve completely. Since this has recurred, then gone away, we can make some assumptions. First, the thumb is affected negatively by batting. We don't know if it's something specific, but it can and has recurred. Second, we know that it's not so bad that a couple days off doesn't get him back to function. Knowing that, there's no way to say whether or not it will happen again and certainly not when. It's not something that has a predictable deleterious outcome, like a wrist injury, so Ramirez just adds some uncertainty to his normal mix.

Omar Vizquel (bruised knee, ERD 7/8)
Ah, another bruise. This time it's Vizquel, who fouled one off his kneecap. Everyone can understand why this one is painful; maybe we haven't all fouled a major-league pitch off our knee, but we've banged it into a table or something and cursed. What's more interesting here is that Vizquel is so seldom on this report. A bruise is a bruise, but for an older player like Vizquel, there's a clear "survivor effect" in place. No one gets to play baseball at I'm-a-man age or higher without something special. I've often said that health is a skill and for an older player, it's even more true. There's exceptions to this rule, sure, but whether it's genetic or something else, we don't know how to predict it. Time whittles away at some players and seems to let others slide by. The first team that figures this out will have such a massive advantage that the Yankees' checkbook will seem small. Then again, the research budget for all 30 teams in total is less than what Drew Storen signed for last season. Vizquel should be back by the end of the week.

Dallas Braden (strained elbow, ERD 7/20)
No-hitters are hard, sure, but Braden has always been as fragile as he has been talented. After that 109-pitch outing, he's only been over 100 twice, and has had three starts of 85 pitches or less. Some of that has been because he's been a bit off, but I think we have to step away from blaming the stress of the perfect game for any of this. Braden's elbow is structurally sound, so pushing him to the DL is as much about the roster spot as it is the rest. The Athletics are cycling through pitchers in something akin to a "pitch-and-ditch" strategy. In discussing it, one front office type described it a bit differently. "It's a Bunny Ranch rotation," he said. I begged his pardon, sure I hadn't heard it correctly. "Bunny Ranch," he said again. I heard him correctly, but wasn't sure what he meant... and frankly wasn't sure I wanted to. For the sake of you, the reader, I asked what that was. "You can't just work a bunny week after week. Last thing you want is a worn-out [girl] So they have something like 10 girls 'active' and another five or so 'on the bench.' They get a rest and come back hoppin'." So, Athletics fans are hoping that Braden's hopping after the All-Star break ... or something.

Asdrubal Cabrera (fractured forearm, ERD 7/31)
Cameron Maybin (sore shoulder, TBD)
Yesterday, there were a couple "WATG" comments after an oversized UTK was posted. I won't rant about how much I hate those comments, but I guess I should take them as a compliment rather than thinking about Bill James' "I'm not a public utility" essay. So what is going on with Cabrera, "tommybones" asks? Good things. Cabrera has not only been taking grounders, he's started swinging a bat. The Indians think he'll be ready for a rehab assignment just after the All-Star break and could be back by the end of the month. That's a darn good result for a broken arm, and shows both how smart it was to plate it and how hard Cabrera and Lonnie Soloff's staff have worked to get him back.

"Leites" asked about Maybin's shoulder. Maybin had labrum surgery in the offseason, so it's definitely not good news that he's having to have it looked at again. It's not unusual, since this is a similar pattern to what we've seen with B.J. Upton and others. The question is whether it's normal soreness, an adjustment period, or a recurrence. He's obviously not been playing well, ending up back in New Orleans rather than locking down center field for the Loria-disappointing Marlins. He was scheduled to have an exam with Marlins doctors in Miami on Monday, but at deadline no details have been released. The Marlins will be looking to see if any of his performance can be pinned to the shoulder issue or whether this might just be a comfort/mental issue that he's going to have to push past, whether that's at Triple-A (where he's on the DL for now) or Miami.

Quick Cuts: I was on Baltimore radio with Glenn Clark this morning, and he pointed out just how good Cliff Lee has been since coming off the DL. I knew he'd been good and coveted, but I'd missed the numbers—and the impact. Lee's season matches his Philly second half and perhaps exceeds it. So what changed? … Carlos Ruiz is scheduled to meet with a concussion specialist. If he is cleared, he'll head out on a rehab assignment soon. ... Lots of people around the O's seem to think Kevin Millwood is headed for the DL, despite no mention of a specific injury. In the Pitch-FX era, will "lost velocity" become enough of a diagnosis? ... I mentioned Dave Dravecky above, but it remains one of the great mysteries of sports medicine as to why Dravecky, Tony Saunders, John Smiley and Tom Browning all had their arms fracture. They're all lefties. ... Oliver Perez is scheduled for a rehab start today. He got knocked around a bit, but showed some velocity last time out. ... Kyle Lohse has started a throwing program, but we're at least a month away from seeing anything resembling real pitching. It's still an encouraging step that he's out there so quickly after surgery. ... I missed the new Steel Train album that came out last week, but I'm catching up on some very good stuff. ... Matt LaPorta left Monday's game with what the Indians called a "head contusion." That's reasonable, given the hard contact between LaPorta's head and Elvis Andrus' knee. He had a CT scan after the game due to concussion symptoms. ... Scott Olsen is a little ahead of the rest of the pack of rehabbing Nats. He's expected to be back in late July, giving him a chance to make an impression. Now the question is whether Olsen et al will be enough to fill in the rotation or if the Nats still need to acquire some innings to protect Stephen Strasburg .... Jeff Novitzky is palling around with Floyd Landis suddenly. I guess if his $75 million dollar quest to get Barry Bonds has failed, he'll need another windmill to waste your money on.