June 24, 2011

Collateral Damage

First Baseman, Heal Thyself

by Corey Dawkins and Ben Lindbergh

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Ike Davis, NYN (Left ankle sprain and cartilage damage)
Davis' ankle has been much slower to heal than either the Mets or Davis expected (or at least than they let on to expect). The first baseman’s ankle injury was always more serious than a simple bone bruise, as it was classified originally. It was also more serious than the ankle sprain and bone bruise that were later divulged to the media. An underlying cartilage injury, either unseen or undisclosed, has limited him in his recovery and now threatens to end his season.

Before mobs arrive at the gates of Citi Field demanding the collective heads of the medical staff on a stake, realize that Davis' care was appropriate at every step along the way, even if the Mets didn't disclose all of his injury information. In order to understand why it was appropriate, we need to review the mechanics of the injury itself.

With the sudden twisting of the ankle experienced during ankle sprains, the talus (the central bone in the ankle joint) can be driven upwards and inwards toward the corresponding articulating surface of the tibia. A compressive and shearing force of the hard cartilage on one or both bones can result in injuries to the cartilage and the underlying bone. In the more severe cases, the force is transferred through the cartilage and into the bone, resulting in swelling in the underlying bone. In addition, the blood supply can be compromised by the force of the injury itself, although that effect is seen more often in young athletes.

Avascular necrosis (AVN)—the death of bone cells stemming from a shortage of blood—occurs at many different locations throughout the body, not just at the ankle. Bo Jackson's career was derailed after he suffered from AVN in his hip, and it's also commonly seen in the shoulders, elbows, knees, and even certain wrist fractures.

Back on May 10th, Davis' ankle was clearly injured and would not allow him to walk normally, so he required some level of immobilization. Given that no fracture showed up on the initial exams, casting did not make sense, due to the secondary atrophy of the muscles that occurs following immobilization. A walking boot was more appropriate, because it could be removed to perform physical therapy and range-of-motion exercises at home.

To say that staying in the walking boot created this injury would simply be misleading. The injury to the cartilage and underlying bone occurred back on May 10th, not over the course of the weeks that Davis has spent in the boot. Davis wasn't just sitting at home with his leg up on an ottoman playing Playstation 3 all day, but it's not like he was performing strenuous activities in the boot, either—he removed the boot for hours each day to perform motion and strengthening exercises in physical therapy sessions.

So what do Davis and Mets fans have to look forward to? He's going to give rehabilitation three more weeks in hopes of having the area heal. Healing can still occur this far out from the injury without surgery, though with each passing week without progress, the chances of this happening decrease.

Assuming the area does not heal on its own, a microfracture-type procedure where the “dead” area is drilled to promote bleeding and produce a fibrous clot can be performed. This area must be then protected from impact activities for several months in order to allow the clot to stabilize and transform into a substance that is similar—but not exactly the same—as normal cartilage. Since we’re already approaching July, such a surgery would essentially end his season.

Brandon Lyon, HOU (Right shoulder surgery)
Lyon's issue isn't only with the subluxing biceps tendon, or the partial rotator cuff tear, or the labral issues. It's the fact that he has all three at the same time, which makes a prognosis impossible at this point. Surgeries have been performed on subluxing biceps tendons before, but never on a major-league pitcher.

Instability of the biceps tendon causes inflammation that sometimes just won't go away without surgery, no matter how much physical therapy or rest is prescribed. Essentially, a groove for the biceps tendon to sit in has to be recreated from either soft tissue or a small bony flap. If the bony flap is used, the bone is smoothed out and a substance called bone wax is applied to ensure as little friction as possible.

Lyon may need more than just that. One major reason why the biceps can become chronically inflamed—and as some theorize, eventually subluxed—is an incapability of the rotator cuff to stabilize the shoulder. Therefore, Lyon's partial rotator cuff tear may also need to be addressed during the surgery next Thursday. Dr. Andrews will also look very carefully for any labral tears that may be contributing to Lyon’s continued pain and relative instability.

No one is sure when Lyon will return to pitching, because the surgery hasn't been performed yet. Once Dr. Andrews finishes up inside Lyon’s arm, we'll learn approximately when Lyon will be able to step back onto a mound in a major-league game.

Roy Oswalt, PHI (Low back tightness)
Oswalt left last night's game with lower back tightness, which is concerning in light of his history of low back problems. Having already missed almost three weeks earlier this year with a low back strain, and having been diagnosed with disc injuries back in 2008, Oswalt is reaching a point where it becomes more and more difficult to maintain the core strength necessary to protect the spine. At his age, injuries to the discs do not heal and often manifest themselves as tightness or spasms in the back. Given Oswalt's history of back problems, do not be surprised if his next start is pushed back.

Josh Willingham, OAK (Left achilles strain)
Willingham is also reaching a point at which it becomes harder for the body to heal itself, even though he’s only 32 years old. He had been battling inflammation in his left Achilles tendon for almost a month before finally being placed on the disabled list with a strained left Achilles tendon. As the body ages and the wear and tear of years of activity finally catch up to it, the tendons lose their elasticity. If the Achilles tendon cannot adapt to the stresses placed on it with each step, inflammation starts to set in, eventually followed by strains.

Willingham was not able to run at 60 percent without pain, so the move to the disabled list was necessary. He believes he can return in the minimum and be activated from the disabled list on July 3rd, though considering his symptoms’ staying power prior to the strain, it is certainly not out of the realm of possibility that it could take a few weeks longer.

Jose Contreras, PHI (Right forearm strain)
Continuing the trend of older players getting injured, Contreras re-injured his arm over the weekend and landed on the disabled list with a forearm strain, retroactive to June 20th. Contreras missed over a month earlier this year with a strain of the flexor pronator mass, and he's expected to miss another four to six weeks as a result of his most recent injury. With each injury, it becomes more likely that a longer period of time will be required before returning to the mound.

Shaun Marcum, MIL (Left hip strain)
Marcum's left hip was feeling fine at the start of his game against the Devil Rays, but then he had to face David Price. While batting against the opposing pitcher, he felt something pull slightly, and he eventually came out of the game after the end of the third. While his outing was scheduled to be short, it is certainly somewhat concerning that he has experienced ongoing hip pain, especially after batting.

The internal rotation of the left hip at the plate could be placing stress across a small labrum tear. In the case of a small labrum tear, the hip flexor can often become inflamed and behave similarly to a hip flexor strain. Unless Marcum has continued difficulties with the hip, there is no reason to pursue an MRI. The Brewers are maintaining that he will make his next start, but there has to be at least some doubt about that at this point.

Flesh Wounds: J.P. Howell has been suffering from gout, a painful type of arthritis. Once the flare-up eases in a few days, he should be able to return without any problems...David Wright has been cleared for baseball activities and should return in about two to three weeks... Joe Mauer is battling back soreness again... Eduardo Sanchez is still at least a week away from throwing off a mound... Colby Lewis pitched through a stiff neck on Wednesday. He's expected to make his next start... Cole Kimball had to halt his throwing program after experiencing pain in his shoulder during a recent light throwing session. He's going to be shut down for two weeks before resuming activity... Torii Hunter bruised his ribs after making a great catch and running into the wall... Jake Arietta is dealing with elbow inflammation resulting from a bone spur that he has known about for some time. He may need to have the spur removed after the season.

Corey Dawkins is an author of Baseball Prospectus. Follow @CoreyDawkinsBP
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Ben Lindbergh is an author of Baseball Prospectus. Follow @benlindbergh
Click here to see Ben's other articles. You can contact Ben by clicking here