April 4, 2011

Collateral Damage

Checking into the Holliday Insides

by Corey Dawkins and Marc Normandin

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Matt Holliday, STL (Appendicitis/Appendectomy)

Matt Holliday got through spring training unscathed, unlike so many others, but after just one game he developed accute appendicitis and underwent an emergency appendectomy. Appendicitis is not necessarily rare—coincidentally, Tim Stauffer, the starter Holliday faced in his first game of the season, dealt with it last year—but it has not been explained well in comparison to some other injuries and conditions. The appendix itself is a small closed-end tube located off of the large intestine. It is finger-shaped and unnecessary for normal digestive function, and it often extends out of the abdominal cavity into the pelvic cavity. The wall of the appendix does contain lymphatic tissue that helps the immune system produce antibodies to fight off infections, but this function can be replicated by other tissues in the lymphatic system following appendix removal.

The exact cause of appendicitis is not 100 percent known. It is thought to stem from blockage between the intestine and the appendix, either as a result of a viral infection or—and this part is icky, folks—from stool entering the appendix. Not all cases of appendicitis require surgical intervention, but often they do end up requiring surgery. This can cause localized inflammation of the appendix, in turn increasing the risk of infection, a blood clot, or rupture. Most commonly the appendix becomes inflamed and infected. It begins to produce diffuse lower right abdominal pain at first, then advances to the degree that the pain and tenderness can localize in one area called McBurney’s point, roughly halfway from the navel to the hip bone. Fever, nausea, and vomiting are also common symptoms associated with advancing appendicitis.

Once tenderness develops in McBurney’s point, surgery is usually required, but further diagnostic tests need to be performed before the surgeon starts an incision. There is no one particular diagnostic test that can definitively confirm appendicitis, but there are multiple tests that can be run: a white blood cell count, urinalysis, focused CT exam, abdominal x-ray, barium enema, or diagnostic ultrasound. The only definitive way to confirm appendicitis is via a laparoscopy, a procedure that is similar in many ways to an arthroscopy.

Once the tentative diagnosis is made through the various tests above, an appendectomy is usually recommended. Previously, an appendectomy was performed in an open manner with a two-to-three inch incision, but thankfully this type of operation is becoming much less common. It is now generally performed laparoscopically, meaning that a very small incision—approximately one centimeter in length—is made so that a laparoscope can be inserted to directly visualize the appendix and surrounding structures. Other portals of similar length are made to allow other instrumentation into the body to remove the appendix.

Before the removal of the appendix, the surgeon carefully evaluates the entire area to ensure that the symptoms are the result of appendicitis and not due to another condition. Once it’s confirmed that the appendix is the problem, the surgeon removes it with specialized instruments—one of which looks like a miniature butterfly catcher that closes—and then sutures the hole of the intestine where the appendix was attached. The incisions are then closed and the patient is placed on antibiotics, if they were not initiated prior to surgery.

Laparoscopy offers several advantages to an open procedure, including but not limited to quicker discharges from hospitals, faster return to full activity, and much less post-operative pain. Patients are often discharged 24-36 hours after surgery, as compared to five days following an open procedure. Because of the minimally invasive nature of laparoscopy, there is less damage to healthy subcutaneous tissue, including the muscles in the area and the lining of the abdominal and pelvic cavities on the way to the appendix.

Considering that the Cardinals have not put Holliday on the disabled list and that he made an appearance at Busch Stadium over the weekend, he most likely underwent the laparoscopic procedure. In our database, the average days lost for non-pitchers in the last eight years is approximately one month, but there is a range from 12 to 55 days (although this is not differentiated by open versus laparoscopic procedures). Once fully healed, however, there should be no effect on his ability to play baseball at his normal level—for example, Andres Torres, who had his own appendix removed in September of 2010, returned after 12 days and batted .267 with a .441 slugging percentage in the eight regular season games and three playoff series that followed, numbers close to his .269/.346/.476 line prior to the procedure.

Evan Longoria, TB (Strained left oblique)

It was originally thought that Evan Longoria would miss no more than one week, but his placement on the 15-day DL ended that optimism. In fact, manager Joe Maddon expects that he will be out roughly three weeks in total. Oblique injuries occur most often in March at the major-league level, but the next most common month is July, not April. A lack of proper baseball conditioning plays a role early on, but the focus switches to fatigue around the All-Star break. If not treated properly, these oblique injuries can linger—that’s the last thing the Rays need, as we detailed in the Rays’ Team Injury Projection. Expect three weeks, but hope all he needs is the DL minimum—the depth and versatility of the Rays’ roster allows them to cover for a Longoria injury with minimal shuffling, but Sean Rodriguez is no Longoria on either side of the ball.

Justin Duchscherer, BAL (Minor lower back surgery—ablation)

How can a procedure that sounds like medical Armageddon possibly be considered minor back surgery? This procedure isn't performed on the major stabilizing structures of the back, such as the bones or the discs. Rather, it involves heating up and destroying the nerve endings that the surgeons feel are involved in his lower back and hip pain. It is a relatively minor procedure and is minimally invasive (to the point that it is often completed within an hour, although it can last longer depending on the number of nerves involved). The nerves do grow back, as all nerves do—it’s just a matter of how fast they return. In the case of the lower back, pain may or may not be relieved for 9-to-15 months—sometimes longer, sometimes shorter.

One of the issues with this procedure is that it treats the symptoms rather than the true cause of the pain. Often several weeks pass before the nerve endings are completely dead and the pain dissipates. If the Orioles and Duchscherer are just trying to give him one last chance to skirt this seemingly constant pain, then ablation seems to be a reasonable measure. He will have to take it easy until the pain goes away, but then he can begin his therapy and continue his throwing program in hopes of being of use to the Orioles this season.

Jair Jurrjens, ATL (Strained right oblique)

Jurrjen’s strained oblique did not respond well to rest, earning him a spot on the 15-day disabled list retroactive to March 25. This pushes his earliest return date to April 16, following a minor-league refresher start. As mentioned before, oblique injuries can be difficult to manage in a sport where rotation of the trunk is of paramount importance. The Braves believe that Jurrjens’ is a minor strain, and that he should be back at full strength as soon as he is eligible to return.

Brian Matusz, BAL (Strained left intercostal muscle)

While originally thought to be a possible latissimus strain, Matusz had an MRI which confirmed an intercostal strain instead. The latissimus dorsi has received more attention over the last several years, but the intercostals are just as important. While they normally offer minimal mechanical advantages to the throwing motion, strained and painful intercostal muscles can cause drastic changes to the delivery. The Orioles are going to play it safe with their young left-hander and ensure that he is fully healed prior to returning. Their estimate is three-to-six weeks, one we think is accurate. Having rookie Zach Britton around in the meantime should lessen the sting.

Mike Stanton, FLO (Left hamstring strain/tightness)

Regardless of whether you want to call it tightness or a mild strain at this point, it is concerning that Stanton has suffered injuries to both legs already this year. After missing so much time in spring training with a strained right quadriceps, it appeared that he was in the clear starting off the year. Then, on Friday, Stanton did not let manager Edwin Rodriguez know that his left hamstring was tight prior to the game, and it worsened to the point that he had to be removed. While neither Rodriguez nor Stanton expects a move to the disabled list, Rodriguez is taking it carefully with Stanton, preferring to get him to the warm weather before putting him back in the lineup. This does not automatically ensure that he will be in the lineup at home on Tuesday—he’s still considered day-to-day.

Phil Hughes, NYY (Drop in velocity)

This is not the first time there has been concern about a drop-off in Phil Hughes’ fastball velocity. In late 2007 and early 2008, there were similar concerns, which ended up being both warranted and predictive to some extent. At the end of 2007, after coming back from a major hamstring strain, Hughes admitted that the hamstring was at least partially to blame for the decreased velocity as he compensated for the injury. In 2008, his velocity dipped as low as 86 and averaged around 89-90 in his first couple of starts. News came out that he was suffering from a stress fracture of the rib shortly thereafter, and he ended up missing close to four months that season. Most recently, Hughes was in the mid-to-high 80s throughout spring training, and he sat at 87-89 mph in yesterday’s start, with a top speed of 91 mph.

We’re not insinuating that he’s going to miss four months of the season, but rarely does the average fastball velocity drop to this degree and stay there without an underlying injury (one Hughes may not even be aware of yet). His arm strength could get to where it needs to be in the next week or two, and this early-season issue could blow over, but until we see something to believe in, the outlook is dicey.

Flesh Wounds: Luke Scott left Saturday’s game with a right groin strain and expects to return on Wednesday. ... Johnny Damon woke up with a tight right calf and was scratched from Sunday’s game. He's day-to-day. ... Shane Victorino’s left calf kept him from starting Sunday’s game, but he was able to get in as a pinch-hitter later on. ... Andrew McCutchen sat out Sunday after experiencing soreness in his neck after diving for a ball on Saturday. ... Ubaldo Jimenez still has issues with the cuticles on his thumb and may miss at least his next start. ... Jorge De La Rosa left Saturday’s game with a blister on his middle finger and is considered day-to-day. ... Rajai Davis twisted his right ankle on Friday and has been out since.

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