February 25, 2011

Collateral Damage

Springing for Surgery

by Corey Dawkins and Marc Normandin

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A few rare injuries for pitchers mixed with one that is all too common make up the bulk of today's installment. Pitcher injuries are generally depressing, given that so much of what hurlers do depends on the health and strength of their shoulders and elbows, but not all is lost when major surgery is necessary—today's lead story proves that point.

Adam Wainwright, STL (Torn elbow ligament–Tommy John Surgery)

News leaked out on Wednesday that Adam Wainwright was due to miss significant time thanks to elbow pain. Christina Kahrl covered the roster implications for the Cardinals while we covered the time line of events and injury history. While throwing batting practice on Monday he felt a “tug” according to some reports ("stiffness" in others) and was sent for further testing and evaluation. After a second opinion from Dr. Lewis Yocum, it was determined that Wainwright would indeed require Tommy John surgery—his second, as the procedure was also performed on him in 1998, when he was in high school—and will be out for approximately 12-to-15 months. There is some precedent for multiple Tommy John procedures—Jason Isringhausen has had a pair, as have Hong-Chih Kuo and Chris Capuano.

The surgery has been performed on athletes for nearly 40 years now, so in general, everyone has an idea about what this reconstructive elbow surgery entails. TJ involves harvesting a tendon from elsewhere in the body—usually the opposite wrist or a tendon from the foot—and reconstructing the damaged ulnar collateral ligament (UCL) on the inside aspect of the elbow with it. This procedure is used to address elbow instability that usually starts with a gradual decline and finishes with an acute event.

You may be asking, "Just what is instability?" and "How do you know when instability would lead to surgery?" Instability is more than just laxity (looseness) as plenty of people have laxity in their ligaments and aren't unstable (well, the ligaments aren't unstable—we don't want to generalize about the people). A joint is unstable when the looseness causes symptoms such as pain, inflammation, dislocation, or muscular weakness resulting from mechanical changes. This instability can be caused by any number of factors including, but not limited to, fractures, tendon ruptures, labrum/meniscus tears, or ligament damage. When a ligament is injured it never heals exactly like it was, but it can regain a large proportion of its former tensile strength once scar tissue heals over the partial tear—assuming the tear isn't too large.

 In pitchers, the UCL often very slowly tears from the inside out, starting with the deepest layers of the ligament. The majority of the fibers could still be intact and there might be very slight looseness, but it can still be stable. By strengthening the muscles surrounding the joint—specifically the flexor pronator mass that lies directly over the UCL—forces that were once transferred directly to the ligament can be decreased as they are absorbed through other structures. This can be done with very small tears, often with positive results for many years.

That seemed to be what happened back in 2004, when Wainwright suffered a partial tear of his ligament. It is likely that it partially tore on the undersurface, but it wasn't loose to the point of causing further injury to either the ligament or other structures in his elbow, and thus was deemed stable. It was this combination of scarring, strengthening, and proper mechanics explained above that allowed him to return to pitching at a very high level—as mentioned Wednesday, Wainwright threw nearly 900 innings after suffering this small tear.

Earlier this week, Wainwright likely tore the scar tissue and then increased the size of the original tear. Now the tear is large enough that it is impossible to strengthen the area to the point of stability he needs to stay on the mound, or to avoid putting other elbow structures at risk (most notably the ulnar nerve and the flexor pronator mass). Hence his elbow will going under the knife this time around.

Mark Prior, NYY (Shoulder)

It's been a long time since Prior has pitched in the big leagues, but he's in Yankees camp and looking to try once more. Prior has undergone several surgeries in his career, including one in 2008 to repair a torn shoulder capsule. This was a more serious injury than was expected when the doctors went in and poked around in his shoulder. The injury that Prior had back in 2008 was a humeral avulsion of the glenohumeral ligament (HAGL). In English: one of the ligaments—which blends into the capsule in the shoulder–ripped off of the bone.

His latest comeback (which should, at the least, tie him with Rocky for attempted returns) was rendered even more improbable by a report that the torn capsule was never actually repaired. It's highly unlikely that the surgeons did not to repair an injury like that, as it causes instability in the shoulder. If it is true, then it is amazing that Prior could return to pitching at all.

The capsule is basically a balloon with thickenings (the glenohumeral ligaments and the coracohumeral ligament). It’s normally watertight, producing negative pressure during movements to enhance stability. When the capsule is torn, it no longer has enough negative pressure to keep the shoulder stable. The shoulder is more prone to further tearing of the capsule, labral tears, or rotator cuff problems due to having to compensate for this loss of pressure.

Such an ailment would make it difficult to pitch effectively, especially with a HAGL injury. The HAGL injury involves the ligament that is a major stabilizer in the position of abduction and external rotation—basically, right when the pitcher starts to accelerate the ball while coming out of his windup and pushing off the mound. Prior may never come back from this, but it's clear that at this point he's going to keep trying.

Vicente Padilla, LAD (Elbow surgery–Nerve entrapment)

Padilla underwent surgery on his elbow yesterday to free an entrapped radial nerve on the outside aspect of his elbow and the thumb side of his forearm. Radial nerve entrapment can occur for multiple reasons: overdeveloped muscles, increased muscular tension, or scar tissue buildup around the nerve. The radial nerve supplies (i.e., tells what to do) most of the extensors—muscles that straighten a limb. In order to free the nerve there will be a very careful incision and a cut of whatever is pushing on the nerve. Because of the rarity of this procedure and the unknown extent of the injury, there's no definitive time line, but the hope is that Padilla can start throwing in about a month and be ready by midseason.

Jonathan Lucroy, MIL (Pinky finger surgery)

During a normal blocking drill, Lucroy first felt like he jammed his pinky, but subsequent X-rays showed a fracture. There are multiple reasons for surgery in this situation: too much angulation (deviation of the bone from a straight line) or any rotation would precipitate a procedure. Lucroy will have a pin inserted to stabilize the fracture and allow it to heal. He's expected to miss about four weeks, so there is a chance that he won't go on the disabled list to start the season.

Mat Gamel, MIL (Oblique)

Gamel may want to start considering skipping spring training after getting injured in camp for the second straight year. This time around, he went down with a strained right oblique during batting practice. We've seen an increase in these injuries both to pitchers and hitters over the last several years. There are two distinct muscles on each side, the internal and external obliques, and they work in conjunction with the opposite sides to attain movement. As an example, the left internal oblique and the right external oblique muscles would work together to rotate the body and move the right shoulder towards the left hip. We aren't sure whether he strained his internal or external oblique, but Gamel is expected to miss approximately one week either way.

Flesh Wounds: Mason Tobin experienced soreness in his arm on Wednesday, but neither the club nor Tobin appears to be worried about it, since the soreness is in a different area than last year's Tommy John surgery... Brian Roberts underwent X-rays of his neck after waking up with pain, and they came back clean. He will treat the spasms in his neck and should return in a few days… B.J. Upton took an Adam Russell fastball in the ribs and was down for a few moments yesterday during batting practice. He appears to have suffered only a bruise, and was able to hug it out with new friend Russell immediately afterward... Franklin Gutierrez is heading back to Seattle to undergo more tests to diagnose the mysterious stomach ailment he has been suffering from since last year. We hope the doctors find that Gutierrez has just been looking at the Mariners' lineup card too often, and that it isn't anything more serious than intense nausea.

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