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Stan Conte is the Head Athletic Trainer for the San Francisco Giants.
Stan Conte: Welcome, let's get started.
steve S (Davis, CA): I read that when you had Jesse Foppert pitching in simulated games in June, he was under a speed limit for his fastball(raised from 80 mph to 85 mph in mid-June). Do you still have him under a limit as he is pitching now in minor league games, or is he free to "air it out"?
Stan Conte: We have been very careful with Jesse's rehab program because he is such a young player with very high potential in the major leagues. Presently Jesse is in minor league rehab games and doing very well. He could be ready before September 1st but most likely will not be activated from the DL until the roster limits are expanded on September 1st. However we are moving Jesse's program along with increase pitch counts per outing so if he were ready and the team needed him, he could be ready before that time.
We rehabbed Jesse a little different in regards to his throwing program than past Tommy John players. We started him throwing earlier as very submax throws on flat ground. As soon as he was able to throw normally we had him throw down to a catcher on flat ground to mimic the downward motion even though he was not on the mound. As he progressed we incorporated some of the new research out of ASMI that showed less stress on the UCL ligament with throws under 80 mph with the use of speed gun. This allowed us to get him on the mound earlier but keeping his velocity down. During the last month we have slowly increased his velocity from initially 80-85 mph and now he has progressed over the last month to his normal 90-92 mph.
Cris E (St Paul, MN): How many MLB organizations have you worked in? It seems trainers get moved out less often than managers or GMs, and that there are a bunch of guys who spend a long time with one team. Is that changing at all?
Stan Conte: My background is different than most Head Athletic Trainers in baseball. I am a Physical Therapist as well as a Certified Athletic Trainer and had my own private clinic. Over the years the SF Giants sent many of their players on the DL to my clinic for rehab. I eventually started working at Candlestick and simply keep progressing through the system. So I have only been with one organization.
Up until recently Athletic Trainers would spend their entire careers with the same team and seem to stay as long as they wanted. We saw teams were the owners, managers and General managers were fired by the trainer remained. Over the past several years the trend has changed and some trainers are getting fired like the managers.
I am under the belief that the Head Athletic Trainer is responsible and therefore accountable for all injuries that occur. Therefore if the team has a consistent, year after year high injury rate, the trainer must be held accountable. If the injury rate does not change, then the club should make a change in its Medical Department. Until recently, I believe clubs did not think the trainer was important enough to fire. New GM's are now recognizing that healthy or injured players equate to wins and losses. Is it the Trainer's fault? No more or less than a manager who is responsible for wins and losses. We all know that the manager does not play the game and many times it is not his fault for losses but if he accumulates enough of them, he is held accountable and fired. The same rules should apply to the trainers.
sdshelby (Davis, CA): During the season, what role, if any, do you play in overseeing the health of the Giants' minor league players, particularly the young players who might be considered among the organization's top 15 prospects?
Stan Conte: My job entails managing the medical departments in the Minor Leagues as well as the major league. The first thing I do each morning is check my email for the daily injury report that is sent to me by our Rehab Coordinator. It shows any new injuries and the progress of the players who have been injured. This is not just for the top prospects but for all players. We do our best to try and treat every player like he was Barry Bonds in regards to their medical coverage so there should be no differences. Many times I will call an individual trainer or the Coordinator to find out additional information or give direction as to what should be done to manage that particular player's injury.
I must admit that I keep a little closer eye on the minor league players this year because my son, Nick, is a catcher in Rookie ball so I have a special interest now. In fact, I may have been inaccurate when I say the first thing I do is look at the injury report. I usually look at the Salem Keizer Volcanoes box score to see how he did the night before.
Mark (Toronto): The Jays are supposed to be one of the better organizations at protecting minor league pitchers however their top pitching prospects : Rosario, McGowan, Perkins, Arnold, have all been struggling with injuries. Is it coincidence? Do pitch counts matter?
Stan Conte: I am unfamiliar with the Toronto minor league organization so I can't comment on those players or Toronto.
I do think pitch counts do matter; the question really is how and to what extent. We at the Giants are looking more and more into the area of pitch counts and if there is a cause and effect relationship. There is a lot of anecdotal information out there about how high pitch counts cause injuries but very little scientific studies. The best one that I have read is Keith Woolner's articles in BP on Pitcher Abuse Points (PAP^3) especially the second part on relationship to injuries. I believe I will have to go back and get my PhD in statistics to fully understand what he is saying but he has some interesting data.
Each organization has its own philosophy on pitch counts. Some limit all their pitchers to a certain number. These numbers vary all over the board. I believe it is not as simple as a pitch count number. Other factors come into play such as stressful innings. We track all innings over 25 pitches as a stressful inning. Some pitchers may only throw 100 pitches but throw them in four innings. So on the surface it looks like their count was not high but they put a far amount of stress on their arms if they throw 35 pitches in one inning.
More work needs to be done to see if lower pitch counts in the minor leagues actually do prevent injury. In addition, nobody seems to be talking about the relievers and the number of appearances they have and it relationship to injuries. That is another field in and of itself.
Southpaw (Seymour, IN): Forgive my ignorance, but are you related to BALCO's Victor Conte? I'm not trying to imply anything, I just had to ask given the same last name.
Stan Conte: Thanks for the question. I am absolutely not related to Victor Conte. Since the Balco thing broke I have been swamped with questions about the fact that we have the same last name. It is unfortunate for me and my family but it is an understandable question since some of the Giants players are involved with the Balco scandal. I have never met Victor Conte and frankly hope I never do.
I have been a staunch supporter of drug testing in MLB and leveling the playing field in regards to illegal use of drugs in baseball. There is no place for this in baseball. Not only is it illegal and unfair to the athletes who are competing without drugs but it is unfair to the game itself. I believe that MLB is moving in the right direction with the drug testing. I only hope that it the testing in the major leagues gets to be comparable to the one that is now implemented in the minor leagues.
Cris E (St Paul, MN): MRIs are tremendously costly, and yet they seem to be darn useful. Is there some point at which a team would go halfsies on a machine with a hospital or clinic just to get cheap rates and easy scheduling? Wouldn't that make it easier to justify more in the way of preventative or wellness scans? What is SOP these days, just billing it back to insurance or paying cash on the barrelhead or what?
Stan Conte: MRI's are costly as well the expense of many other diagnostic procedures. Sometimes we do get some "volume" discounts from companies but the cost of owning and staffing an MRI center is a lot more than we would pay for a year of MRI's. The MRI's, like physician visits, physical therapy and other diagnostic tests are usually paid by Worker's Comp Insurance since almost all of the injuries occur at "the work place".
The use of MRI's is common place in baseball but the interpretation of them is sometimes controversial. There is a fair amount of variability to the reading of them especially in the throwing shoulder. Some radiologist will read then differently than others so we have all our MRI's read by one radiologist, Dr. Charles Ho at California Advanced Imaging. Over the years, we compared Dr. Ho's reading to what we see in surgery and found them to be very accurate and consistent.
Sometimes MRI's confuse the issue more than clear it up. There are now at least two documented studies on professional baseball players who had no symptoms of shoulder pain but their MRI's showed significant tears of the rotator cuff and labrum. The Giants are in the process of doing a study with all our newly drafted pitchers in which we do MRI's on their elbows and shoulder, whether or not they have pain or symptoms. The radiologist then reads them without knowing who has pain or who does not. Although we just started the study this past June, we are finding that the MRI's are being read as showing damage even on the players with no pain or history of problems. Some of these finding may in fact be natural adaptation to the throwing motion or it may be early signs of problems to come. We plan to follow all of these players throughout their careers and see which players develop problems. .
Cris E (St Paul, MN): The Giants seem to be one of the more open teams when it comes to player injury information. How's that play in the locker room? And how has HIPAA affected your approach to medical information and the media?
Stan Conte: How medical information is reported through the media is highly variable from team to team. Many times the manager or general manager reports to the media. For the Giants, I have been the one responsible for talking to the media regarding injuries. I think it is important for the team to give out accurate and timely information to the press for several reasons. First, if you do not give out any information, the media will get it from fringe sources or simply make up something themselves. Second, I think the media wants accurate information and is a great source for educating the public into the diagnosis, treatment and care of professional athletes. I see a far amount of inaccurate information in the press and this confuses the general public about their own injuries and how they should be cared for.
In regards to the players, it can be very tricky. Sometimes management wants to put a certain slant on an injury such as down playing it as being minor. This can be for many reasons including the possibility that the team may be trying to trade that player. The player may want you to make the injury look worse than it really it because he has been playing bad and wants the public to know he is trying to play with the injury but may not be producing because of the injury. Almost always, I talk with the player ahead of time about what I am going to say to management and the press. That way there is no misinterpretation within our team. Sometimes the player does not like what I am going to say but as long as it is the truth, I have never had a problem.
The Hippa rules are sometimes confusing as to who can say what to whom. We have had MLB lawyers give us guidelines as to what can and cannot be done. All players sign a waiver that allows us to give information to the press. To date we have never had a problem but we are careful to work within the guidelines set by MLB's legal team.
brevare (KS): What do you recommend for resistance training, as well as flexibility training for baseball players?
Stan Conte: There has been much discussion about what the right type of conditioning program a baseball should perform. Many have blamed weight lifting and resistance training on the increase in injuries. I do not believe that weight training causes injuries but rather ONLY weight training causes injuries. What I mean, is that many players in the off season spend the majority of their time doing heavy weight lifting and nothing more. We believe that a balanced program of flexibility, strengthening with weights as well as other methods, running and baseball activities are the key.
I have been asked many times if there was only one thing you could do to prevent injuries in baseball what would it be. First the answer is that there will never be just one thing but if I only had one, it would be running. Players hate to run in the off season so they avoid it. They would rather do Stairmaster or Precor type activities. I tell my players when they put a Stairmaster on first base then we will start doing more of it. The running has to be baseball specific. This means high intensity sprints must be brought into the program during the off season. We see a lot of leg injuries early in spring training and in the beginning of the season because the players have done sprints at 80% and during game situations they are required to go a near 100% intensity. They have trained in one way but are being asked to perform in another. This is a set up for injuries. We also have them run the bases because of the curves involved. We discovered that running in a curve helps strengthen the groin and prevents injuries in this area.
Finally, we believe that if baseball activities such as throwing and hitting are incorporated at the same time of the weight lifting program, the normal flexibility is maintained and players to not get "tight" from the lifting.
Jason Schmidt (San Francisco): According to reports, you watch me closely when I pitch, even in the outings where I throw enough pitches to make Jim Andrews salivate. Could you tell me what you look for and how closely you work with Dave Righetti?
Stan Conte: Jason:
Unfortunately I watch you more than I ever care to think about. For those people out there, I watch his mechanics but also his velocity and location. A tip off that Jason is "losing it" is that his fastball is up in the zone. Sometimes this is because he is trying to throw harder and "reach back for more" and this causes him to throw the fastball up higher in the zone.
Gideon (Reno): I heard awhile back that you closely monitor the mechanics of starting pitchers and have them pulled if they show signs of fatigue/bad mechanics. Is this true?
Stan Conte: The answer to this questions is Yes and No. Yes I do monitor the mechanics of the pitchers during the game. What I look for is changes in their normal delivery that may indicate fatigue and therefore a chance of injury. I will relay what I see to Dave Righetti, the pitching coach and/or Felipe Alou. Usually the change in mechanics and fatigue influences the pitchers ability to get batters out so many times the pitcher is removed for that.
No, I don't pull pitchers out directly. That always is the manager's job. I will voice my opinion to them but you have to remember that objective is to win the game and the manager may feel that the pitcher on the mound is the right one for the next series of batters. This takes precedence over a change in mechanics
dave (boise): Can you suggest any changes (equipment, field, strategy, etc.) that could be made in the game of baseball to prevent injuries without compromising the quality of play?
Stan Conte: The most important field changes that many trainers have suggested is the proper padding around the ball park. Just several weeks ago a player was injured when he slid into a concrete block while trying to make a catch at Busch Field in St. Louis. This is an area that is unpadded around the lower part of the fences. It is the same concrete that fractured the knee cap of Bill Mueller two years ago.
Along those lines, many minor league fields need to have safety checks to see if they adequately protect the players. Some of those fields are not held up to major league standards because of costs.
dave (boise): In your opinion, are pitchers who have forearm flexor injuries more susceptible to subsequent UCL failure since both structures resist the valgus stresses in the throwing motion?
Stan Conte: Excellent question. We were faced with this question last year when we discovered that Jason Schmidt had a tear in his flexor tendon. After MRI and multiple physician exams, we felt that much of this tear was old but were concerned about whether we were putting his UCL at risk by letting him continue to pitch. There is a general belief that the flexor tendons on the medial elbow can prevent valgus stress and therefore protect the UCL. This is one of the reasons we put effort into strengthening the flexor muscle mass. However, there is not a lot of science behind that idea. After consulting with many physicians and trainers around the country, we decided that it was a reasonable risk to take. We were actually more worried about increasing the old tear than the UCL. In any event, we let him pitch and he had no problems. The flexor tendon was repaired after the 2003 season and he has pitched all year without problems
geer08 (Birmingham, AL): Is Alou just playing mindgames with Herges, making up arm fatigue for him and hoping a rest will clear his head and make him believe he can be a closer, or is there really something going on with Matt's arm?
Stan Conte: Matt Herges appeared in quite a few games during the first half of the season. His results indicated that he was not pitching the way he should. Is this a medical problem or a fatigue problem? That is difficult to say. He had no clinical problems so there was no obvious medical issue but fatigue could have been a part of it. I believe that Alou was giving him a mental as well as a physical break. As the season continues we will see if he was right.
Vic (Walnut Creek): What qualifications are necessary for someone to be considered for a trainer position with a major league club? Do any go right to the majors?
Stan Conte: To be considered for a minor or major league athletic training position, one must be a Certified Athletic Trainer. Certification is done by the National Athletic Trainers Association (NATA) who administers a comprehensive exam. To sit for the exam, one must complete a Bachelor's degree in athletic training which includes practical hours on the field.
Almost all major league trainers spend years working their way up via the minor leagues. They take the same long bus trips and bad food. They make very little money and their jobs are usually under appreciated by all except the players they work with. Just like players, they may never make it to the big leagues. Barney Nugent, my former assistant, spent 18 long years in the minors before getting the opportunity to move up in 1993.
Greg Tamer (Indianapolis): You're a trainer and unfortunately, there's only one source of medical information. So tell me - does Will Carroll really have a clue?
Stan Conte: I have known Will Carroll for several years now and yes, he does have a clue. He probably has done more than any single person to highlight the importance of sports medicine in baseball. I have just recently finished his book and enjoyed it. I don't necessarily agree with everything he says but I am sure he doesn't agree with me on all things too.
His information on BP is far more accurate than anything you will see in the newspapers
Mark (Bethesda, MD): Following up on a question someone posed in the recent Alan Schwarz chat here. We're so accustomed to hearing about pitchers breaking down in the middle of multi-million dollar contracts, with the event is generally viewed as an unfortunate caprice handed down from the baseball gods. But couldn't many/most of these injuries actually be anticipated if you were routinely monitoring what's going on inside the shoulders and elbows of these guys? An MRI machine costs about $2 million dollars (not counting the staff to maintain and run it). It strikes me that any team that at least rented time on one would end up with a huge return on their investment. Why hasn't it happened (or has it)?
Stan Conte: I think that it seems logical and common place that players breakdown in the middle of multi-year contracts. However, a recent study by American Speciality Insurance Company who publishes the annual Redbook for MLB showed this not to be true. In fact they showed that on 3 year contracts, there was a higher injury rate on the 3rd year than the previous two. The theory is that the player may be trying to extend himself to get his next contract and actually end up hurting himself.
That is the beauty of stats, sometimes what you think should be the case is disproved by the numbers.
The predication of who gets injured is going to be developed more and more in the coming years. Right now there is no good database to predict who is going to get injured and who is going to stay healthy. Keith Woolner's PAP articles are the best I have seen as trying to figure out a way to predict which starting pitchers are going to get hurt. I sure am following that closely to see how accurate his system is.
Blake (Chicago): Stan, thanks for chatting. In your opinion what is the most preventable injury? The easiest to rehab?
Stan Conte: Probably the most preventable injury is the lower leg strain such as hamstring, quad and calf pulls. I say this because through proper conditioning and flexibility, the muscle should be protected. That is not to say that all of these can be prevented because there will always be strains and pulls.
In 1997, the Giants decided to try and new conditioning program that was designed to prevent injuries. We relooked at the physical requirements of the game and designed the conditioning program accordingly. Along with other things, we were able to reduce our DL 65% in the first year and keep it down there for the subsequent six years. So we know that injuries are preventable.
Probably the most simple and predictable to rehab is a fracture of the hamate bone in the wrist. This is caused when a batter swings and the knob hits the bone at the outside of the wrist. It requires surgery to remove the broken piece but the player should be able to be competitive in 4-6 weeks.
JC (SBC Park): Do you think MLB may move toward requiring a head trainer be a PT (physical therapist) and ATC?
Stan Conte: Being a PT/ATC, I am in favor of more physical therapists being involved in baseball. Today there are 3 head trainers that are PT/ATC's.
However, just being a PT does not give you all the requirements to be a good Head Trainer. The understanding of the athletic training aspects is equally important. In addition, the individual has to understand the game of baseball from a biomechanical basis.
Most physical therapist I know, do not want to go to the minor leagues to get that experience but hopefully more will want to in the future.
Dave (Chicago): How does Dustin Mohr tear his biceps and keep playing? The same injury put Frank Thomas on the DL for a year. Is Mohr a freak or is Big Hurt a Big Wuss?
Stan Conte: Dustan Mohr had a different injury than Frank Thomas. Mohr tore the long head of the biceps from its attachment in the shoulder. I believe Frank Thomas tore his from his elbow. Totally different injuries. Mohr's injury probably will not require surgery in the off season and he is essentially pain free now. They sound like similiar injuries but they are apples and oranges.
Bill Johnson (New Mexico): You've received several Qs, and given several answers, about all the following you do of minor-league players, particularly pitchers. How deep into the organization does that go? Is it really worth your time to keep a close eye on guys in the rookie leagues, most of whom are never going to be close to major-league players?
Stan Conte: Excellent question.
I think the idea that the "suspect" is not worth the time but these days no one really knows who is going to get to the big leagues. For example Marvin Benard and Armando Rios. Although not big impact players in the big leagues, they did in fact make it. Benard was a 50th round player and Rios was not drafted at all. Rich Aurilia was a 22nd round pick.
Other than the ethics of treating everyone the same way, which is an organizational standard, the fact remains the players that the medical department assesses as marginal may be in the major leagues at some point. That is if they stay healthy.
Also, Rookie League is nothing but prospects, many of which already have millions of dollars in their pockets from signing bonuses.
Now does that mean we treat Barry Bonds the same as a rookie level catcher at Salem-Keizer? Well, in that case, the catcher gets treated better.. (refer to previous answered question)
davekirsch (Chicago, IL): Some pitchers - including Jason Schmidt and Curt Schilling - seem to be able to pitch deeper into games frequently. (Some would call it abuse - that's a discretionary term.) What kind of things have you identified that may be linked to having greater endurance and/or avoiding injury as a pitcher?
Stan Conte: I am running out of time here but want to answer as many questions as possible. Sorry if I don't get to everyone's. I am typing as fast as I can.
I think that proper and good mechancis is a major key. If those are off, then the pitcher is ineffecient and therefore will fatigue quicker than others. The other thing is that he has to be a good pitcher. If he struggles to get outs with every inning, then his pitch count will increase and he will fatigue. This is one of the reasons we are looking at stressful innings (pitch counts over 25). The other is general conditioning as well as pitching conditioning. A pitcher who throws 110 pitches per game year in and year out, conditioning himself to throw that many. If pitcher throws only 85-90 and then is asked to throw 115, he usually fails or gets hurt because he is not conditioned to that many.
HB (Boston): Without asking you to name names or even numbers, how much of a problem is steroids in baseball? There hasn't been a positive test in 2004. That seems fishy to me. Is it more steroids or are there other drugs that players have moved to?
Stan Conte: I think that steriods has been a problem in baseball as well as other sports. That is shown in the 5-7% positives last year in the drug testing. I believe that it is less of a problem now since the drug testing has been mandated this year. Drug testing has just been started during the second half of the year so that is why you have not heard of any positives.
Unfortunately, I think there will be athletes in all sports that will try to cheat. I hope all of them get caught so there can be as level a playing field as possible.
Doom Service (Toronto): What do the Giants do in the area of vision? I get the feeling, perhaps wrongly, that most teams treat it like dental care rather than an essential part of every player's performance.
Stan Conte: The Giants do take vision very seriously. We also take dental care seriously too, by the way.
All players including the minor leagues get annual vision checks in spring training. We try to identify those that need more extensive follow-up. Our team has two excellent doctors, Dan Goodman and Michael Carson who do most of the work with the players.
As most other teams, we have ventured into the Lasik surgery world. Many of our pitchers have had Lasik surgery and a few of the hitters in the past year or two as well. Most of these were having difficulty with contacts and needed an option. These have worked out very well for us.
Christian Sumner (Dallas, TX): Hi Stan,
Thanks for taking questions. My question is about Brett Tomko. Prior to heading to the DL a month ago, Brett seemed to be struggling mightily. After returning, he has pitched very well, even going deep into ballgames. Was his injury solely attributed to his problems earlier, or is he just "finding it" recently?
Thanks!
Stan Conte: Brett Tomko was having a minor problem with his elbow that was effecting his pitching performance. His mechanics were getting worse with each outing. After numerous diagnositic tests, nothing serious was revealed. It was decided to give him a rest via the DL. This allowed him to recover from some minor inflammation and work on his mechanics. It has been successful so far.
Stan Conte: Thanks so much for allowing me to try and answer your questions. I am disappointed that I have to stop but we are playing a game in San Diego and I have to go to the ballpark. Sorry for those questions I couldn't get to. Maybe next time. Thank you.
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