August 3, 2010

Under The Knife

On Will's Mind

by Will Carroll

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In the last 24 hours, I've had three men I really respect discuss three topics with me. One asked about pain and baseball. Another asked about the dangers of wall vs. player collisions. The last one asked about the cost of injuries. This is a bit of a change of pace for UTK, but it's all related, so I wanted to share the type of things I think about on a day-to-day basis.

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What's the worst pain you've ever had? I asked that question to my Tweeps and here's some of the answers, so start cringing:

"Ruptured appendix at age-17."

"Gallstones."

"Pouring rubbing alcohol onto a punctured ear drum."

"Fouled in a pickup hoops game and my collarbone popped out."

"Severely broken left ring finger. Required surgery and a plate."

"2009, Little Rock, AR, 4^th inning, 3-2 slider, shoulder blow out."—that one is Michael Schlact, who's rehabbing from the injury now in the Rangers' system.

"The time I got Huston Streeted by a soccer ball."

"Shattered patella" - Kevin Goldstein, explaining why he's a 20 speed player.

"Catheter after ankle surgery. Nothing close."

"Dry sockets—all four—after wisdom teeth removed."

"Three litre bottle of Coke thrown squarely to the balls when I was 14."—I don't want to know the rest of that story.

"When I lost my fingernail at football practice."

"Almost completely torn hamstring requiring 6 weeks of PT but no surgery. Still aches 15 yrs later."

"Burning, searing, mind altering pain from hip to knee thanks to a herniated disc."

"Meningitis headaches."

"Torn plantar fascia." - Colin Wyers. Our company softball team is going to suck.

"The day after surgery for my ACL."

"Horse trampling—cracked 2 ribs and fractured my forearm."

"Shingles, on the left side of the face including eye."

"Q-tip stuck up my penis. (Yes it was a medical procedure)."

"Last summer I had three kidney stones at the same time."

"Getting hit on the end of my finger by a softball. Resulted in a partial amputation and a 5hr surgery to save my finger."

"Having my ulnar compound fracture reduced." - BPro's Dan Wade. We're hard on interns around here.

"Physical therapy for shoulder labrum reattachment. 1000x worse than actual injury."

So how do those compare to a Carl Crawford, Tyrone Proethroe, or Jacoby Ellsbury—three injuries I'm imagining that those athletes might describe as rating a 10 out of 10. The answer might surprise you. Doctors often ask you to measure pain on a scale of 1 to 10 no matter what the situation is. Last time I was at the doctor, in what led to surgery last season for a torn abdominal muscle, I was asked that question and I kind of perked up, knowing the reason. The fact is that the worst is the worst. One man's hangnail "10" is the same as a compound fracture "10." While individual responses to pain are very different, the disabling nature of pain is the same. That doesn't make it "right" or "wrong"—it just is. 

Study after study has shown that measures of pain—nerve conduction, blood pressure, even brain scans—aren't much more accurate than a simple question. Which leads us back around to how players respond to pain. Some might fight through it, the way Joe Mauer has done all season. Some might shut it down, electing to have the surgery that will end the pain (Ryan Sweeney), while someone with the same injury might be able to play through it (Josh Hamilton.) That doesn't mean one is more or less painful or that one of them is a "better teammate" or "more man." Once baseball fans and baseball media understands this, we'll all be better off.

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Over on Twitter, a discussion started up about padding on walls. I started thinking about it and my immediate solution was "more padding." Some smart people questioned whether that would work. "Of course it would work," was my reply... but it did get me thinking. Was it the best solution? In auto racing, one of the key innovations of the last decade, largely due to deaths of Scott Brayton and Dale Earnhardt, was the SAFER barrier. I wondered if there could be some variant of the SAFER system that might work for baseball. A couple calls over to IMS, where SAFER was developed, and the answer was "probably not." 

Then someone brought up Peltzman's effect. For those not familiar with it, it's the "law" that states that safety advances often cause more reckless behavior, canceling out any benefit of the safety enhancement. Which got me thinking about two "quirky" stadium sections: Tal's Hill in Houston and the monuments that used to stand in the field of play at old Yankee Stadium. 

Tal's Hill has, to date, never caused an injury, though many (including myself) thought it would be a hazard. Between the 420 and 436 mark and with a near 40-degree slope, there have been several dramatic plays, but I wondered how often they could even come into play. It's impossible to answer, but using Hit Tracker's data, the distance isn't the real problem. It's hitting it that distance into a relatively small area in dead center. 

So what if instead of warning track and wall, as we have now, we used a dirt embankment? Would knowing that, as an outfielder, you were about to run up an angled embankment slow things down? It's not practical, mostly for structural reasons, nor is it clear that it would reduce injuries. Dirt is pretty low in cost, but construction and maintenance make it a bit less reasonable, especially compared to the relatively low cost of foam padding. As for those monuments in Yankee Stadium, Steven Goldman, our resident old-timer, says that he's not aware of any injury out there, due to their sheer distance. 

That raises a final question: Does a known hazard keep players from getting hurt? I don't know that Aaron Rowand or Jim Edmonds aren't going to slam into a brick wall as hard as they do a padded one. It's seen occasionally in Wrigley Field to this day, as well as other less-protected areas of other stadiums. The idea of last year's Rick Ankiel vs. wall collision, sans pads, might have been worse than it turned out to be makes me pale. I'm always one to suggest that pads or protection of any type, but in this case, I'm not sure that Peltzman isn't on to something. 

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Here's a question I don't have the answer to, but that should be reasonably easy to answer: Do teams get more with deadline trades (on average) than they lose to injuries (on average)? It would take some GIA-style calculating, but I think that the data is there to make it. My guess is that injuries are significantly more costly than even the best-case scenario for trades. Trades sometimes work and sometimes don't, much in the same way that injuries seem to have a random element to them. They can even go together, in a case like Mark DeRosa last season. I asked the trade guru herself, Christina Kahrl, for her take on the value that a team could generate at the deadline.

"For best cases for hitters or pitchers, these things seem to generally run around 4-5 WARP generated, using Manny Ramirez or Mark Teixeira from 2008, or CC Sabathia '08 and Randy Johnson '98 as best-case examples," she explained. "But that's what they accrue, not the net gain, which would be lower. More usually, I'd aim much lower, maybe a win net if you're lucky."

Yet even with this, teams will spend far more time and effort on trades and scouting than they ever will on injury prevention. 

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Carlos Santana (injured knee/leg, ERD TBD)
It's never good when you hear things like "Call a surgeon" on the wild feed of MLB.tv. It's never good when you can say, "Well, best-case scenario is it's just a broken leg." Both came true on what Alex Speier of WEEI called a "Theismann moment" for Santana. Santana was blocking the plate—well, you can watch, if you're not squeamish. It was a clean slide by Ryan Kalish that impacted high enough up the shin to hyperextend Santana's knee and something gave. Literally, it knocked him out of his shoe, but amazingly, he held on to the ball. It looked like it was the tibia, but it was unclear from even multiple angles and very good camera work while Santana was waiting on the cart. I originally thought that the shoe coming off might have saved him, but Manny Acta was quoted as saying that the spikes "stuck" and was the root of the problem. If the shoe giving way—or, rather, the foot moving out of it—allowed some of the shock to be taken by motion rather than by bone or joint, that's at least a bit less shock he absorbed, but Acta is right in that the impact had likely done the worst by the time the shoe eventually gave. Some reports have him "testing well with trainers," though these tests seem focused on the ligaments. He's headed back to Cleveland for tests, but it sounds like he may have avoided the worst-case scenario. We likely won't know what all this means for a day or so, but the fact that I even need to put a TBD up there rather than the more definitive "10/4" is encouraging.

Ryan Howard (sprained ankle, ERD TBD)
Howard is headed back to Philadelphia to consult with team physician Michael Ciccotti. This is a normal move; the Phillies like consistency of care and like their players to see Dr. Ciccotti quickly in cases where there's an issue. The key here is that the players understand this and hop on the plane. We saw this several times during spring training, so you can't read anything into this for Howard. What does give us some new information is Howard himself. He's still on crutches and the ankle was described as "sore" and "very swollen" by Howard. The DL sounds increasingly likely. Remember that Howard needs the ankle as a base, and he's not much for mobility. He's a better runner and fielder than he used to be, but neither of those is predicated on speed. He should be able to play through some instability, so this one is going to be more about pain management and avoiding recurrence.

Kevin Youkilis (sprained thumb)
Things with the Red Sox seem to be descending a bit when it comes to health. There have been a lot of injuries, but most have been traumatic, much like the "jammed thumb" for Youkilis yesterday. There's nothing a medical staff can really do to prevent things in situations like that, but the Sox seem to be in a crisis of confidence. A second opinion is almost an automatic, and the trust between the players and the staff is strained, if not broken. Youkilis' injury is usually a quick description of what turns out to be a mild sprain—painful, but usually mild. Still, getting back on the field quickly is going to be used against others who are "slacking" on their way back from other injuries. Youkilis is human, feels pain, and is at risk of injury as any player. He's a heck of a hitter and that beard... but he's not a Platonic ideal, which is how he's often portrayed. The injury's mechanism makes me think more of a bruise, along the lines of what Aramis Ramirez dealt with, so we'll have to watch and see how, if at all, this affects Youkilis at the plate.

Mike Cameron (strained abdominal, ERD 10/4)
It's a bad time to be injured in Boston. With Jacoby Ellsbury's saga and the contrasting "heroism" of Wes Welker—look, he's coming back from ACL surgery in a normal timeline, not rescuing puppies—there's a continuing parade of people calling the Sox "soft." Some of it is from the clubhouse, but most is from people who have never had an injury more serious than a paper cut (or a bad haircut). Cameron was able to play through an abdominal strain up to a point, but the pain was very literally disabling. Cameron could have kept going out there, fighting the injury, but it had rendered him unable to be a better player than the option, which the Red Sox decided was Ryan Kalish. Cameron is likely to head for surgery, which was always where this was going to go. Everyone had just hoped that it would happen after the season—or after the playoffs. 

Carlos Silva (cardiac evaluation, ERD 8/30)
Many questioned Silva's heart when he walked off the mound Sunday. Turns out, they were right. Silva left with an elevated heart rate that didn't return to normal long after he left the mound. Some reports have Silva suffering from a condition known as PVST, which is controllable. Sources tell me that Silva is a regular drinker of energy drinks, especially prior to a start, which makes it possible that he just "overamped" in his preparation, with a combination of adrenaline and caffeine acting counter to what Silva had hoped. The Cubs placed him on the DL so that he can undergo tests and adjust to medication if necessary. I can only hope Silva didn't watch the Cubs get crushed last night. That couldn't be good for anyone's heart. Maybe he can share with Lou Piniella. Because the Cubs are out of it, expect Silva to be given as much time as necessary to return, which is why I'm setting the ERD a bit long. 

Quick Cuts: Joey Votto has some mild tendonitis in his wrist. Watch over the next week to see if his power numbers suffer any. ... Joe Mauer is going to be limited to DH for much of this week, due to his shoulder inflammation. ... Martin Prado went to the DL, but as I said yesterday, it was more of a roster decision than any reflection on his finger. He'll be back at the minimum. ... Images showed no fracture of the wrist for Randy Wolf. He's lucky, but there's no word about when his next start might happen. ... David Freese seemed to have a setback in his rehab game yesterday, according to several reports. No details yet. ... Todd Helton is hitting well on his rehab assignment, but the Rockies don't seem in a rush to get him back. ... In something of a surprise, Jordan Zimmermann was optioned to Triple-A after being activated off the 60-day DL. Reports have him getting "several more starts" before returning to Washington. ... Gil Meche has decided against shoulder surgery, given it would end his 2011 season as well. He'll try to pitch out of the bullpen if he can rehab back to some effectiveness. ... The Rangers are going to use Josh Hamilton's absence to get a couple other guys some rest. Again, the big divisional lead helps. ... Steve Pearce will have season-ending knee surgery. The rehab didn't work. ... Jeremy Hellickson? He's good. It was very nice to see David Price and Matt Garza greeting him after every inning, talking to him throughout his start.