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August 2, 2010

Under The Knife

No Two Injuries are Alike

by Will Carroll

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Rehabbing an elbow is always a difficult balance, but in most situations, doctors will tell you that it's always better to try and rehab through something before having the surgery. A surgery, even something predictable like Tommy John, has a defined period of loss, currently between 10 and 12 months. Using the example of Twins reliever Pat Neshek, the lost time in rehab might look like a loss—Neshek even told BP's Dan Wade that it "was the worst thing I could do" because of perception and the machismo of the locker room—but if Neshek had been able to come back inside the 2008 or 2009 seasons, it would have been a big gain. You can use the same equation I gave you in regards to why the Mets didn't put Jose Reyes on the DL, though the numbers get a lot bigger and the risks are hardly as well known. For situations like Neshek's and the hundreds of others—no, that's not an exaggeration—that face elbow surgery at all levels each year, the "right decision" is a moving target. Is it just to get the player back in the quickest amount of time? That does play into it, but does that mean "rehab might get him back in three months or might extend him out if surgery is needed"?

Every decision is a gamble. Looking at data and trying to extrapolate any sort of one-size-fits-all decision process is going to create issues. If you walked into your doctor's office and he'd been replaced by a robot with a series of protocols, it might work for you, but I bet you'd be worried. No patient or doctor in baseball is a robot and with every situation, while they might have the same diagnosis or even the same surgery, there are far, far too many variables. Any question about what the medical staff, player, or agent might or might not have done simply can't be seen in the injury data, which is one reason I've been reluctant to publish that data in the past. What we see from the outside and can quantify in some way is only a very, very small part of what is often the biggest decision a player will ever be involved in. Let's get on to the injuries:

Ryan Howard (sprained ankle, ERD 8/6)
There are a couple things you can tell from this video of Howard's ankle injury. First, he needs to tie his shoes better. As the trainer tests his ankle, the shoe clearly shifts. Second, Howard tapped his toe on the injured side as he was kneeling at second base. By not protecting it, it's a pretty clear sign that while painful, it wasn't too damaged. X-rays showed no fracture, but the swelling was significant, so Howard is going to miss the bulk of this week, if not hit the DL. It's all going to matter on how Howard's ankle responds. With the significant swelling, it could go either way. I'll set the ERD at the midpoint, but know this could change quickly. There was also news that Howard had an x-ray of his elbow. He'd been hit by a pitch, and he was there, so they took the x-ray. It's really not much more than that. Any pain and swelling in the elbow is to be expected, normal, and will heal before the ankle gives it a chance to be an issue. It's injuries like this and the one suffered by Chase Utley (who's making slow, steady progress) that make it so difficult to repeat for the Dick Martin Award.

Ian Kinsler (strained groin, ERD 8/20)
Josh Hamilton (patellar tendonitis, ERD 8/4)
There are lots of whispers about Kinsler's groin strain, including some that would make "strain" a poor description of the injury. One of the earliest reports was that Kinsler had a sports hernia, but Evan Grant told me that he asked about that specifically and was told no. Remember that Kinsler had this previously, ending his 2008 season. That leads us to a fork in the road where either Kinsler has a severe strain or there's something more damaging going on. Whispers that there's a stress reaction—which is a stress fracture before there's a separation in the bone—also seem to be just rumors at this stage. Absent reason to believe the Rangers are hiding something, we have to work with the assumption that the strained groin is the problem.

Is there a way to reconcile everything? A talk with an MLB surgeon who has not treated Kinsler suggested that one possibility was a strain at or near the insertion, which might involve a possible reaction at the bone. An avulsion is when a tendon pulls a piece of the bone away, another possibility, though that would be more devastating in a case like this. Treating the injury as if it's a severe groin strain isn't going to change things for Kinsler—it's rest, control of any pain and inflammation, and strengthening the surrounding structure that's going to be his near future no matter what the actual diagnosis might be. There's also an issue of the pattern of injuries that Kinsler has had. August seems to be a real danger zone for him, which in most athletes would lead to conditioning questions, ones you really can't ask of a high-rev guy like Kinsler.

The Rangers are also watching Hamilton closely. As he chases the Triple Crown and MVP, Hamilton is very sore with a case of patellar tendonitis. He avoided an anti-inflammatory shot as long as he could, playing through it as long as he could using rest and treatment to get him through. He relented and had the shot yesterday, so he's likely out through midweek. This type of tendonitis is chronic and isn't going to go away without significant rest or even surgery, such as what Ryan Sweeney is having done. Hamilton is sui generis when it comes to a lot of things, so injury management is the same. Watch to see how Jamie Reed and Ron Washington work to walk a tightrope between productive and healthy. They'll look to buy him rest where they can and perhaps DH him a bit more. A big lead in the AL West is going to help with both these situations.

Randy Wolf (bruised forearm, ERD TBD)
Remind me again why pitchers don't wear protection of any sort out on the mound? I won't rant, but I will wonder because a simple, small sleeve might have helped Wolf yesterday. I don't think I've ever seen a trainer pull a player so quickly. Roger Caplinger took one glance at the wrist where Wolf was hit by a comebacker and had him headed for the showers and an x-ray machine. Early word out of Milwaukee is that Wolf has only a bruise and his response over the next couple days will determine whether or not he misses any time. It is the throwing arm's wrist, so even mild inflammation is likely to cause, at the very least, a delay. If his wrist didn't fracture, he's only lucky. At some point, we're going to need someone to be a pioneer. I don't want to say they'll need to be Jackie Robinson, but the reaction that David Wright got when he started wearing the new batting helmet gives you some idea. Whether it's one of the new protective hats or thin Kevlar sheets to protect the forearm and shin, it's not that the technology isn't there to help reduce these injuries. It's simply that the players, by and large, will not wear them. If we can't get them to wear cups, what can we expect for other parts of the body?

Justin Morneau (concussion, ERD 8/10)
Joe Mauer (inflamed shoulder, ERD 8/2)
Morneau is slowly making progress from his concussion. For this, we should congratulate the Twins medical staff for the handling of the situation. While Morneau is clearly a key offensive piece for a contending team, his long-term health is even more key. With all the money committed to Morneau, the Twins can't re-spend that if he's on the DL for a significant period of time or if concussion (or any other injury) ended his career. It's unlikely that Morneau, a player with a fairly significant injury history, has his contract insured. Morneau's current status is that he's still having some headaches after activity, but that he seems to be having less, more distant issues. Once Morneau is cleared to play, he won't be long on the sidelines. It's not out of the realm of possibility that he could be back this weekend, though that would be pushing it, something the Twins have smartly avoided. Of course, a winning streak does help mask other issues, like Mauer's sore shoulder. He was forced to have a cortisone shot to try to calm some swelling inside the shoulder, but reports yesterday had that failing to provide much relief. Mauer is going to play through it, as he has all season, but as Yahoo's Jeff Passan pointed out in his recent article, there's a point where Mauer's toughness is going to work against the Twins' long-term best interests.

Jason Bay (concussion, ERD 8/10)
Carlos Beltran (arthritic knee)
The Mets' medical staff took an amazing amount of heat last year because of what, in retrospect, looks like bad luck. From the outside, we'll never know enough to say exactly what happened, but the reduction in injuries this year shows that there was fluke to it. The injury to Bay shows us another issue. Bay bounced his head off the fence (Wall 1, Bay 0) last Friday, and while he was checked out, sources tell me that after that Bay immediately started saying he was fine. That's never something that a medical staff just takes at face value, but Bay hid his headaches and nausea until he got on the plane last weekend and the symptoms overwhelmed him. The medical staff will take a 15-day or more hit for his DL time, but the blame rests solely on the shoulders of Bay. The Mets as a team aren't known as the most open-minded, with a collection of players known for checking to see who's in the training room and harassing those that they think don't meet their code. Bay's symptoms aren't severe, but they have lasted, so he'll remain on the DL until he has proven that he's past any and all symptoms. While we're on the subject of the Mets' medical staff, they have to get a lot of credit for keeping Beltran in the lineup. I was clear in this column that I didn't think Beltran could last very long in center field, but the hard work that the medical staff is putting in is making me wrong, at least for now. I like being that kind of wrong and think that Ray Ramirez and his staff deserve a tip o' the cap.

Grant Balfour (strained intracostal, ERD 9/5)
Balfour wasn't arrested in the clubhouse, as one rumor this weekend had it. He was, however, headed for the DL. Are the two connected? I'll leave that one to the conspiracy theorists. Balfour was diagnosed with a strained intracostal, one of the muscles in between the ribs. These injuries tend to go like oblique injuries, so losing Balfour for the better part of a month seems to be the cost. The trade for Chad Qualls happened before the Balfour injury news got out, so the Rays dodged a bullet there. Balfour's strain is on the opposite side as his throwing arm, which makes this a rotational injury. For pitchers that rely on hip turn to generate a significant portion of their force (i.e., most of them) this is one that not only costs them time, it's one that makes reading it to prevent recurrence very difficult as well. The worst part of this is how it happened—in the clubhouse, not on the field.

Martin Prado (fractured finger, ERD 8/13)
Prado isn't going to be mistaken for Chipper Jones in any way, but he's helping to build the bridge from when Chipper was "CHIPPER JONES!" to next season, where he'll be Chipper Emeritus. (I'm convinced that Chipper is going to be this era's Jim Rice when it comes to HoF voting.) Unfortunately, Prado has also picked up Jones' habit of getting injured too often. Prado fractured his pinky near the knuckle on a slide and, as yet, he's not able to grip the bat properly. The medical staff is working hard with treatment and with several splints/braces to try and figure out if they can get him comfortable and, if not, how long it will be before he's able to get comfortable. The Braves will make a decision today on whether he'll need to go to the DL. If he does—and it looks likely now—he shouldn't miss much more than the minimum.

 (Not So) Quick Cuts: Jimmy Rollins came back Friday, but finally looked himself again Sunday. He had a steal that looked like Classic Rollins. I'm convinced he's going to be a massive steal in next year's fantasy drafts when people look at the raw numbers. ... Jacoby Ellsbury showed no problems in Triple-A and no signs of pain. There's some worry that even if there is, he'll cover to help get him back and back on the good side of his teammates. He's expected back later this week. ... In non-shocking news, Dustin Pedroia told the media he wouldn't be ready for the Yankees series later this week. I'm still sold on a 8/15 ERD for him. ... Matthew Leach of MLB.com tweeted that David Freese was doing some very aggressive running drills yesterday. He's getting very close to a rehab assignment. ... Wall 1, Dexter Fowler 0. Fowler has bruised ribs and a bruised hip after a collision with a wall on a fly ball. He'll be watched with an even chance he ends up on the DL. ... Andrew Bailey won't miss much time with his intracostal strain. He's expected back at the minimum, which would be Thursday. ... Carlos Pena's sore foot was said to be no big deal on Saturday, but there were some whispers in the clubhouse Sunday. This will take some watching. ... Armando Galarraga and Kris Medlen are both questionable for their next starts after getting hit by comebackers. Nah, we don't need any sort of protection for pitchers' arms or legs. ... Another concussion? Am I writing about MLB or the NFL? Ryan Doumit started his rehab assignment, but the Pirates will go slow with him after acquiring his replacement, Chris Snyder. Look for Doumit to play on the corners as well as catch, though the Indy Indians have been playing nearly two weeks with only one catcher. ... Scott Kazmir will begin a two-start rehab assignment early this week. The Angels will find a spot for him in the rotation when he returns, but a team source said, "He's bad enough to cut if nothing changes by Orlando." ... Geoff Blum is close to a return after surgery to remove bone chips from his elbow. ... I think the Buck Showalter move is the right one for the O's, but I'm more curious about what he'll do with the pitching coach job. Rick Kranitz is well thought of, but Showalter is used to having his own guys—usually Billy Connors. ... Homer Bailey had a solid outing in Triple-A, but he'll likely use the full 30-day rehab allotment before the Reds are forced to make a decision on him. Right now, they could end up in a modified six-man rotation. I'd rather see Bailey and Mike Leake in a tandem, but I don't expect that would pass muster under Dusty Baker. ... Jesus Flores had another setback with his shoulder, a major reason the Nationals were willing to trade Matt Capps to get Wilson Ramos. (Yes, prospect mavens, I know that sentence sounds odd to you.) Aside from that, there really wasn't much of an injury component to the trade deadline. You could argue that Capps was an answer to Joe Nathan, but half a season would argue against you. ... Football season is starting up, so for those of you that follow the NFL, I'll be starting up the Carroll Injury Report over at SI.com/fantasy this week. I hope you'll join me. Also, Football Outsiders Almanac 2010 is available. I contributed an essay on PEDs to this year's must-have NFL guide.

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