September 13, 2010

Under The Knife

Not So Dangerous Times

by Will Carroll

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UTK Flashback: More Injuries?

If I had a FAQ, one of the top ones would be "Are there more injuries now?" This question is asked of me at the start of seasons, in the midst of seasons, after a major injury, and at other random intervals. The answer is "A bit more, but not nearly as much as you'd think." We remember current things more than we do things five, 10, or 50 years ago. The investment teams have made in players has led to some risk aversion and there's not as much of a stigma attached to being on the DL, until the injury-prone tag gets applied. Back in 2002, when I first got a look at the Redbook, the level of injuries hasn't changed significantly. Pitchers are still injured at around the 50 percent mark, position players are still reasonably predictable in the broad population but not predictable at the individual level, and there's still not much research trying to figure it out. (There are some teams doing some interesting work, most notably the Rays and Cardinals, though neither team has seen much of a change in the four years I know they've been working on it.) The DL dollars have gone up, but in line with salaries, which seems normal. What hasn't changed is teams' commitment to changing this. A majority of teams still have two full-time athletic trainers, when having more man-hours to do more preventative work is the easiest, cheapest way to make a difference. So are there more injuries now? Yes and no, but mostly no.

Johan Santana (sprained shoulder, ERD 10/4)
Santana is done for the 2010 season. The question is really the 2011 season. While the Mets fans gloom and doom it up like a Robert Pattinson fan on a shopping spree at MAC, there's an underlying question of how long Santana will actually be out. With a dearth of good comparables, I went to the experts at Kerlan-Jobe for some answers. Dr. Ralph Gambardella, explained the issue:

The anterior capsule is the front lining of the shoulder joint which then attaches to the labrum and then to the bone. The capsule is torn with the labrum often with an acute traumatic shoulder dislocation. However, in baseball with repetitive throwing the anterior capsule can just gradually stretch out and eventually give a thrower pain and a feeling of weakness and a velocity loss. This repetitive microscopic tearing and stretching injury ultimately is what the thrower may describe as a “dead arm” The type of surgery performed is very similar to the open surgery pioneered by Dr. Frank Jobe that was performed on Orel Hersheiser in the '80s, but now with advances the same surgery can be done arthroscopically. However, the healing concepts are the same and therefore the rehabilitation can be very long to get back to high level throwing. Certainly 6-9 months is not unreasonable.

Since the anterior capsule can be thin and relatively fragile at the site of surgical repair, a thrower can't be too aggressive with their motion immediately following surgery. Generally, the repair is protected by limiting motion for 4-6 weeks, then gradual stretching and strengthening, allowing a progressive throwing program to begin in at 4-5 months. Throwing is gradually increased, hopefully getting the player on the mound with full velocity in 9-10 months. 

So Dr. Gambardella is a bit more optimistic, but both agree that nine months is the most realistic time frame for a return to level. It's probable that we'll see Santana throwing during spring training, but the best case has him back toward April or May and the back end could be the All-Star break. The comparison to Hershiser is, I think, the best thing I've heard on this. Hershiser was able to return and was a similar type of pitcher in that he was about pitching and command, not just velocity. I hope ESPN decides to put Hershiser on one of its platforms to discuss this. We know that Santana can come back from surgery; he's done it three times in the past and always toward the low end of the expectation, but none of them was nearly as complex as this will be.  

Jimmy Rollins (strained hamstring, ERD 9/17)
The Phillies are being very cautious with Rollins, as they should be. The team initially said that the problem was cramping as a result of dehydration, but cramping can lead to muscle strains. A cramp is the body's reaction to some kind of problem, forcing the muscle to contract strongly and uncontrollably. As you can expect, that strong contraction could lead to some internal tearing, though even then, it's usually minor. The body is a smart system and tends not to injure itself, except as a measure to prevent greater injury. The Phillies have seen Rollins deal with a rolling series of leg problems this season, compounding issues by trying to come back a bit too soon, so it's no surprise to see them handle this conservatively. He'll have an MRI and a determination will be made after that stage on how long he'll be out, though sources tell me that this is "a mild strain." The team context will be important as well in determining when he'll be back. My guess right now is later this week, but we'll know more after the images are read.

Josh Hamilton (bruised ribs, ERD 9/20)
"No progress." That's about as easy a read as there could be, right? When it comes to Hamilton, it's not quite that simple, but close. Hamilton is a singular talent, but one of the issues with him is that it's always been very difficult to get a read on his healing times. Teams are careful with him due to his talent and history, plus how he plays the game. The most telling problem he's had, the wrist issue during his season with the Reds, is complicated by the fact that he was a Rule 5 player and some of his missed time might easily be considered "hiding" on the DL, not an atypical situation for a player in that situation, let alone Hamilton. With his ribs, back, knees, and other assorted dings and the lead the Rangers have, "no progress" isn't good, but it's not as big an issue as people are making it out to be. Bruises heal on a predictable timeline, but soreness/pain is very specific to a situation. If Hamilton misses another week and has no progress, that's going to be a much different situation. For now, this is only a problem for fantasy players.

Josh Johnson (strained back, ERD 10/4)
Mid-September is the point where some teams have taken that long look in the mirror and decided to start protecting their players, taking a look at some prospects, or both. The Marlins are at that stage now, made easier by a mild strain in the back of their ace, Johnson. They let Johnson keep working, but when he missed a weekend throwing session, everything started moving toward a shutdown. The final decision will be announced today, but the process was already rumbling down the tracks. The Marlins have already waved off his already pencilled-in Wednesday start, but sources tell me they'll go ahead and shut him down. It's a bit of a negative that he comes up just shy of 200 innings again, but really the "magic number" for longevity that I saw in my admittedly incomplete studies was 190 innings. Johnson is one, maybe two starts from that mark, but it's not worth any risk. Johnson should be back next year and can be reasonably expected to be back at this level.

Andy Pettitte (strained groin, ERD 9/19)
Maybe the Yankees just really want to win the Double-A title for their Trenton affiliate. Maybe they really do think they need to see more pitches from Pettitte. With the Thunder into the Eastern League finals, Pettitte will get another start for them tomorrow against Altoona. He's scheduled to go five innings, or 85 pitches, though like last time, Pettitte would finish out his work in the bullpen regardless. That puts him on track for a return to the Yankees' rotation the following Sunday. The speculation is already going that Javier Vazquez will be forced out by the move. Pettitte would be on track for three starts before the end of the regular season, plenty of time for Joe Girardi to make sure that Pettitte is his No. 3 starter. Yes, No. 3. Sources tell me that right now, Girardi would "split up" Sabathia and Pettitte with the right-hander Phil Hughes, who would also benefit from starting at home. 

Andres Torres (appendectomy, ERD 9/28)
While some are focused on missing Torres for the next two weeks, I focus on the fact that he might be back in two weeks. I can remember my appendectomy and it wasn't fun. I didn't feel like doing anything, let alone rushing back to a baseball team. I realize this is Torres' profession and the team is in a tight divisional race, but if there's any area where medical advancements have helped not only athletes, but regular people, it's in the development of surgical scopes. Arthroscopes led the way, in large part by Dr. James Andrews and Dr. Joe Randolph, and that use led to things like laproscopes. Laproscopic surgeries are making meaningful, quality-of-life type differences in thousands of medical cases. Keyhole surgeries for heart and lung issues are saving lives. Next time someone says sports don't contribute to society, remind them of this. Torres should be back by the final week of the season and would be available for the playoffs, though I'm not sure how "100 percent" he'll be at that stage.

Chris Young (strained shoulder, ERD 9/20)
The Padres need innings right now, as much as anything. Young hasn't given them any of those this year, but after 5 2/3 innings of work at Single-A, he might be just in time. No one seems to have high expectations for the tall pitcher, but just absorbing some innings, hopefully at something around league average, would be just fine. Any innings Young can take saves a bit off a pitching staff that is both young and overextended. Don't mistake "overextended" for "abused;" the pitchers are just in an area they haven't been and the results show. The fatigue, despite the closest eye of Bud Black and his staff, can be problematic. The problem with pitching injuries is that we have no way of determining what a pitcher can and can't do. Young has always been excoriated for his inability to go more than 180 innings, but if that's the only issue, isn't that a failing of usage and imagination rather than Young himself? Fitting players into roles has boxed more than one team in when maybe a bit more creative use of the 10-12 best pitchers might have worked better than 10-12 roles.

Justin Upton (strained shoulder, ERD 9/14)
Upton took batting practice and entered Saturday's game as a pinch-runner. He's getting closer to a return and hopefully further away from a trip to a surgeon to correct his lax shoulder. Nothing's final since the Diamondbacks want to see how Upton's shoulder holds up under game conditions. It's possible that all the rehab could be for naught, but by getting this test in, they'll know more in enough time to make sure that it's not there next season, if surgery is necessary. Look for Upton to be back in the lineup by tomorrow and to play every day for several days. The D'backs know that teams will likely test his arm—yes, the problem is with the non-throwing shoulder, but as with a pitcher, the glove-side arm is important to the process, especially when it comes to accuracy for outfield guns. They're OK with that, as it will just be more information. It's still about 50/50 as to whether he needs the surgery, but a run of games without problem would be a huge positive.

Quick Cuts: Carlos Gonzalez's "sore wrist" is not thought to be serious, but it's enough for Jim Tracy to get him out of the lineup here and there. ... Frank Francisco had an MRI. His back injury has his season in jeopardy, but that's mostly the calendar. No one's saying the playoffs are out. ... Brett Gardner will have an MRI on his sore wrist. The Yankees are trying to get this handled before they have to make playoff roster decisions. ... Jim Thome is back in the Twins' lineup, but still feeling a mild abdominal strain. ... Mark Rogers and Jeremy Jeffress are both up for the Brewers. Watching the two of them tells the story of the Brewers pitching—so much potential, so many things that can go wrong on the road from top pick to the majors. ... Carlos Silva was scratched from his next start with a sore elbow. He could be done for the season. ... I believe that biomechanical analysis is the key to preventing injuries. Here's one option for you, if you'd like to see it on a young pitcher close to you. It's not cheap, but neither is arm pain. I don't have a financial interest in this, but I can recommend the people behind this. Please, if your son is a pitcher, consider this or any reputable option.