March 23, 2011

Collateral Damage

Show and Patella

by Corey Dawkins and Marc Normandin

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With the exhibition season drawing to a close, the optimism surrounding many a player's return is dwindling. Despite all the talk about hope springing eternal, injuries have cropped up from the outset, and some players will need to begin the season on the disabled list.

Chase Utley, PHI (Right knee tendinitis)

Chronic patellar tendinitis can be a difficult and frustrating injury to treat, as evidenced by the ongoing spring training saga of Chase Utley. His right knee did not respond to the usual treatments of physical therapy, modalities, and corticosteroid injections, and for some time it looked like he would end up in the operating room before all was said and done. Yet, despite appearing to have made no progress at all, Utley did take some swings in the batting cage after visiting a rehabilitation specialist. How is this possible?

The patellar tendon isn’t actually a tendon at all, but a ligament that runs from the bottom part of the kneecap and attaches to the top of the shin. We will refer to it as the “patellar tendon” for simplicity's sake, but there is an important distinction between the two. There are several different portions of the patellar tendon. The tendon itself is prevented from rubbing against the bones by a fat pad closer to the patella (yes, literally a pad of fat) and a fluid-filled sac called the bursa near the top of the shin bone. The patellar tendon can tear or rupture, but most injuries to the part arise from overuse.

These cases used to be called tendinitis, which implies inflammation—a biological reaction to harmful pathogens, dying or dead cells, chemicals, or other irritants. Research suggests that they are actually examples of a degenerative condition and should therefore be termed “patellar tendinopathy” or “patellar tendinosis.” There are several factors that can cause the degeneration, but the usual suspects involve repetitive jumping or extended stair-running (think running entire stadiums for a few days in a row). These chronic conditions are caused by mucoid degeneration, meaning that the tendon turns softer—similar to a gelatinous substance—which can lead to local discomfort and increase the odds of a rupture. As the degeneration progresses, some of the areas actually turn necrotic. Once this happens, the tendon cannot heal itself without some help.

How these cases are treated depends on where they are in the degenerative process. If caught very early, they can usually be treated by rest, modalities such as ultrasound and stim units, and specific strength and flexibility exercises designed to keep the kneecap moving smoothly and in proper alignment. Some bracing can be used to help with the alignment or change the mechanical pull of the tendon. Cortisone injections can be used, but they are not injected into the tendon itself, since injections into the tendon can weaken it further. Instead, the injections are oriented so that the outside of the tendon is bathed in the cortisone, quieting the pain-producing nerves and inflammation surrounding the tendon. PRP injections can be used if traditional treatment fails, and surgical debridement could be considered.

Utley was leaning in the surgical direction for a while, but it looks like there has been at least some progress following a visit to a rehabilitation specialist (who likely broke up some adhesions in the area). There is still no definitive timetable for his return, which places Opening Day in jeopardy. Throughout the rehabilitation process, Utley will have to alter his workout regimen, since squats and lunges can aggravate his condition and retard the healing process.

Ramon Hernandez, CIN (Right elbow)

Ramon Hernandez’s elbow has been sore for the past couple of days. While Dusty Baker is saying that it's structurally sound, something is not quite adding up in his full explanation. Baker and Hernandez have been quoted as saying that the elbow improves once it warms up and stiffens between innings, but the key is that Baker also says that Hernandez has trouble extending it at times. A few possibilities include loose bodies, muscle strains, bone spurs, and a condition called valgus extension overload (VEO). VEO is commonly seen in throwers, and refers to a condition in which bone spurs can form, elbow extension can be lost, and the UCL can be compromised to some degree. This doesn’t automatically mean that surgery will need to be performed for someone with valgus extension overload, but it is a possibility if the loss of motion persists. If it is VEO and the UCL is not too compromised, Hernandez will likely try rehabilitation first. He will visit with Dr. Timothy Kremchek on Thursday to determine a diagnosis and prognosis.

Frank Francisco, TOR (Right pectoral)

See, not every visit to Dr. Andrews ends with a scar. The famed surgeon evaluated Frank Francisco’s shoulder and chest and found no structural damage. It wasn’t specified which pectoral muscle was involved (major or minor), but either way, that's good news. The pectoralis major is the large muscle on the front of the chest. It also happens to be a strong internal rotator of the shoulder that helps accelerate the ball while pitching. The pectoralis minor helps to stabilize the shoulder blade, prevents impingement, and provides a stable base to serve as an attachment point for the posterior muscles. Without frank tearing of the muscles, this is rarely a surgical condition and can be addressed through focused physical therapy. Francisco will start the season on the disabled list, just to be safe, and he should be back by mid-to-late April.

Johnny Cueto, CIN (Right shoulder inflammation)

After being forced to leave Saturday’s start, Cueto was further evaluated in Cincinnati and diagnosed with right shoulder inflammation. He previously suffered from both elbow and shoulder inflammation in 2008 and 2009. The reports of biceps stiffness or soreness could be the result of direct inflammation of the long head of the biceps, or they could reflect the body’s attempt to protect the shoulder from further injury. Cueto will be shut down for approximately a week before beginning a throwing program. He’s ticketed for the disabled list, but it appears that he should return in mid-to-late April as well.

Jason Donald, CLE (Left hand fracture)

Whenever a thrown ball hits any bone there is a chance for a fracture: it doesn’t matter if it’s the hand or the ankle. Donald found this out the hard way after a pitch from Gavin Floyd caused a very small fracture at the base of the index finger on his left hand. He’s going to be restricted from baseball activities for at least another 4-7 days and will likely have to begin the season on the disabled list. These injuries tend to heal well: most of the smaller bones heal in roughly six weeks' time, putting him in line for a mid-April return.

Flesh Wounds: After being carted off the field on Tuesday, Eugenio Velez was diagnosed with a grade II (moderate) ankle sprain. He is going to be down for at least 3-5 weeks. ...Another day, another Yankee with an oblique strain. Curtis Granderson and Joba Chamberlain now have something to talk about. ... Mike Baxter will have surgery to reconstruct his torn left thumb ligament. ... Kendrys Morales is experiencing pain on the ball of his left foot and is being seen by a foot specialist. He was already having a rough time this spring recovering from last year's fractured leg. Prognosis details have not yet been released. ...John Jaso still hasn’t played in a game since taking a foul ball to the groin in Saturday’s game.

Corey Dawkins is an author of Baseball Prospectus. Follow @CoreyDawkinsBP
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