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March 4, 2011

Collateral Damage

Missing the Meniscus

by Corey Dawkins and Marc Normandin

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There is no such thing as a small injury, especially when you're the injured party. Athletes at all levels are vulnerable to injury—there is no unbreakable Bruce Willis, although it would be pretty cool if that were the case. (That does not mean that we want you to make a sequel, Mr. M. Night.) Injuries can occur in an instant or from years of neglecting your body, improper mechanics, or sometimes just random chance. What is disturbing is the continuing trend of younger athletes requiring surgeries for injuries in numbers that were unheard of even 10 years ago. While an increase in overall participation is part of it, everyone should hope for the day where kids don't have to be seen by surgeons and instead can simply enjoy running around having fun, like, well, kids. On the other hand, having fun like kids do can often lead to seeing a surgeon. Vicious circle, that. On to the injuries:

Jason Castro, HOU (Right knee torn meniscus)

After suffering any injury while trying to avoid a tag on Wednesday, Jason Castro underwent an MRI. It was determined that he had suffered a torn right medial meniscus, and he will have surgery on Friday to repair it. The medial meniscus and lateral meniscus are two C-shaped wedges that are thinner toward the inner middle part and thicker on the outside. They sit on top of the tibia (shin) and consist of a pliable form of tissue called fibrocartilage, different from the white articular cartilage on the joint surfaces that is addressed with microfracture surgery. The menisci act as shock absorbers in the knee between the thigh bone and the shin bone to help protect the articular cartilage and improve the ease of movement. They also provide stability to the joint by cupping the femur, a shallower version of an egg crate. The articular cartilage is further strengthened by increasing its ability to heal itself through nourishment provided by the blood supply of the menisci.

The medial meniscus is located on the inside aspect of the knee and is the larger of the two menisci: the top of the tibia is actually wider medially than laterally. It is attached to the tibia by very small ligaments but also attaches to the MCL, making it much more likely to be injured than the lateral meniscus due to its relative immobility. This immobility, while providing improved stability, limits how much it can conform to the twisting forces applied on it.

The menisci are divided into two separate zones: the inner two-thirds are called the white zone and the outer third the red zone. What differentiates the two is the amount of blood supply that each receives. As its name implies, the red zone receives a much better blood supply than the white zone and therefore has a better chance of healing on its own or through surgical repair. If the tear in the red zone is large it is often stitched back together—saving the tissue—but when it's in the white zone it often needs to be trimmed out.

The menisci are injured through two main pathways, a sudden acute injury or a gradual degenerative type. Acute injuries are most often caused by sudden quick twisting, usually when bearing weight and with the knee bent. They are almost always painful and frequently accompanied by deep clicking or catching. In severe cases, there can be a flap-type tear that gets stuck in the joint and causes the knee to become locked. The knee will be swollen, which can make going down stairs difficult (more so than climbing stairs). Acute tears need to be addressed surgically and often can be sewn together, saving as much of the tissue as possible.  

Degenerative-type tears occur over a long period and can be the result of repetitive twisting or chronic instability in the knee. Often the torn tissue is not of good enough quality to be stitched back together, as the tissue is too frayed to get a good hold with the stitches. Degenerative tears are usually addressed by trimming the torn portion out arthroscopically.

The length of rehabilitation following surgery depends on the size, location, and surgical procedure. If the meniscal tear needs to be repaired by stitches, it will require about six weeks on crutches (or some other form of weight-bearing limitation) followed by more slow progress in order to allow the meniscus to heal itself. This occurs more often with younger athletes, in whom the tear is less likely to be degenerative in nature. If the tear is trimmed out, the procedure is called a partial meniscectomy and the injured party is on crutches for a very short period of time, if at all. In those cases, rehabilitation progresses much faster and the player can often return in about four weeks and sometimes even less than that. We'll know which situation Castro is dealing with after the surgery.

Lance Berkman, STL (Left elbow, left calf)

Not one, but two injuries for Lance Berkman already this spring. Berkman's elbow is still an issue and quite painful for him after his transition from first base back to the outfield. The longer throws have been putting more strain on his elbow. Remember that back in 2003, Berkman sprained his UCL and never underwent surgery. We're not saying that he's going to be undergoing Tommy John surgery anytime soon—this seems to be an inflammatory issue (such as tendinitis), but there may be an underlying microinstability causing undue forces on the tendons. The Cardinals were trying to ease him back into the lineup but then his left calf started tightening up on him. He still has plenty of time to heal before the season starts, so it makes no sense for the Cardinals to push him.

Francisco Cervelli, NYY (Left foot contusion)

We'll call it a left foot contusion for now—that's what the Yankees are calling it—but some things are not adding up. After fouling the ball off his foot, the medical staff immediately took Francisco Cervelli for an MRI. If it was a simple contusion it would be fairly easy to read on MRI, so it's somewhat ominous that the results are now being sent back to New York for further evaluation. Usually when this happens after a foul ball strikes there is something in the results that causes worry about a possible fracture that would require some time off—similar to what happened with Jorge Posada last year. The only other fracture Cervelli has in our database is a wrist fracture and subsequent surgery in 2008 following a collision at the plate during spring training. It's not like Cervelli is made out of glass, but as stated, we are a little worried.

Ubaldo Jimenez, COL (Infected right thumb cuticle)

When your mother told you not to pick at scabs, she was telling you for a reason. Ubaldo Jimenez learned his lesson after picking at what appeared to be an ingrown nail on his thumb—this allowed an infection to set in, along with (we assume) disapproving shaking of the head from Mama Jimenez. The thumb caused him pain while gripping a baseball and progressed to the point where he had to have it lanced and drained on Tuesday, which did provide him significant relief. All Ubaldo needs are some good antibiotics, some rest until his thumb heals, and a call from his mother to remind him not to pick. Even though there is no set timetable right now, he is planning to pitch on Monday.

Koji Uehara, BAL (Right elbow inflammation)

It's a new season, so of course Koji Uehara is injured. He had a cortisone injection for his right elbow, a treatment that is used only when there is significant inflammation present. Where the injection was would tell us a lot about the likelihood of further injury. In our database there are two other injuries to his elbow listed, both to the flexor pronator muscle mass that sits right on top of the UCL on the inside aspect of the elbow. Remember that the flexor mass helps to absorb forces when there is an insufficient UCL—this came up in the Wainwright discussion. If the injection was to the medial elbow, there would be significant concern that he has an underlying instability of the UCL. If the injection was to the outside lateral aspect of the elbow, most likely this was lateral epicondylitis, which, while painful, rarely leads to surgery.

Flesh Wounds: Another day, another Tommy John surgery: Cla Meredith had his on Wednesday... Jason Heyward has some left groin soreness and appears to be ready to take over for the daily injury role in Atlanta once Chipper Jones retires... Jordan Schafer has a mild left ankle sprain after twisting it on Wednesday… Brian Matusz will have a wart removed from his left middle finger and miss one-two starts. As Michael Cuddyer proved today on Twitter, wart removal leaves a bit of an ugly scene… Proving what separates professionals from amateurs, Troy Tulowitzki bruised his right heel on an awkward swing while our own Corey Dawkins broke and dislocated his thumb on something similar. Guess which one is the better athlete?

Corey Dawkins is an author of Baseball Prospectus. 
Click here to see Corey's other articles. You can contact Corey by clicking here

Related Content:  Surgery,  Elbow

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