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May 27, 2011

Collateral Damage

A Scalpel Full of Posey

by Corey Dawkins and Ben Lindbergh

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Some of the more gruesome injuries one sees on a baseball diamond take place within 90 feet of home. Batters are beaned, pitchers are hit by line drives, runners trip over first base, and collisions occur at home plate. Baseball is different from some other sports in that it permits little protection other than catcher's gear and batting helmets, which can slide around and fall off easily (but that's another story). On those plays coming from the right side, catchers are akin to the punt returners who are looking up in the sky knowing that someone is barreling down on them, but who still have to catch and hold onto the ball.

The NCAA—despite all the differences of opinion one can have with them—has generally done a good job in regards to player safety issues and has a rule regarding collisions at home plate. It doesn't eliminate contact completely, but it does penalize malicious contact with no attempt to reach the plate. Considering there have been major injuries to two of baseball's bright, young catching stars (Carlos Santana and Buster Posey), maybe it's time we start looking at those rules before it happens again. Eliminating all contact would probably be going too far, but maybe being more like the NCAA would be a good start. We feel dirty for saying that.

Buster Posey, San Francisco Giants (Left fractured fibula and sprained ligaments)
Corey mentioned on Twitter yesterday that things might actually be worse for Posey if no fractures were present. Ankle fractures in isolation tend to heal well, especially with surgery—except for rare cases like Kendrys Morales—but ligaments tend to be different. News came out yesterday that Posey will undergo surgery to repair ligaments on both sides of his ankle and possibly stabilize the syndesmosis with a surgical screw, which seems to confirm that difference.

The syndesmosis is the joint between the tibia and fibula, which is held together by several different ligaments. These ligaments are often injured during sudden external rotation, which occurs when the big toe ends up pointing away from the other foot. These syndesmotic ligaments are not the first ones injured, but they are the most important. During failure of those other ligaments, the stress then travels to the syndesmosis, often producing at least some degree of sprain. Once these syndesmotic ligaments fail, a third bone in the ankle (the talus) shifts, and in Posey's case, knocks into the fibula, producing a fracture.

Fractures tend to heal well. Some may require surgery, but often they do well without surgery, even when they look nasty on X-rays. Ligaments tend not to heal as well, especially the syndesmotic ligaments once they have failed to the point of instability. Normally the syndesmotic ligaments hold the tibia and fibula together and help prevent other injuries, like fractures and cartilage damage. They also provide a stable base for the muscles to be able to perform their jobs and for the body to balance.

Normally, as the body puts weight on the ankle (even standing still), the tibia and fibula strain to separate, and when the foot moves backward into dorsiflexion, these two bones are forced to separate even further. If there is instability at that joint, the biomechanics change throughout the entire lower extremity, and additional fractures, early arthritis, loss of motion, and loss of strength all can occur, not to mention the possibility of neurovascular injuries.

When torn, these particular ligaments often don't heal well in just a cast. Widening between the two bones occurs, and no cast would be able to keep the bones in good alignment without cutting off circulation to the foot. Therefore, the surgeon may have to put a screw through the tibia and fibula to hold them together in a stable, well-aligned position. This outcome is not yet set into stone for Posey, but it is one of the options being discussed.

Recovery from these surgeries does take a while. Some comps (Pablo Ozuna, Matt Williams) in the database show that it's generally at least three months, and more than a few have missed over 120 days while recovering from ligament surgery and associated fractures. That suggests that six to eight weeks is a little on the low side if the ligaments are going to be repaired. If there had been no surgery on the ligaments, then Posey might have been back in eight weeks, if not sooner. Any surgeon worth his salt will tell you there are no guarantees, but Posey's will have a much better idea after he has looked inside the ankle. We will get an update out after the results of the surgery are known.

R.A. Dickey, New York Mets (Right heel pain)
That description might not be very specific, but it does narrow down the source of Dickey's problem to a degree. The pitcher stumbled going to cover first base and was clearly limping afterward. He had to be helped down the dugout stairs, and after his exit the Mets pinpointed the location of the pain as the bottom of the foot and heel. Multiple ligaments and the plantar fascia are in that area and could have produced Dickey’s pain. He's going to be reevaluated at the Hospital for Special Surgery today, but based on his reaction, he will likely end up on the disabled list.

Rafael Soriano, New York Yankees (Right elbow inflammation)
It's not often that teams are happy to hear that a player will miss "only" about six to eight weeks. The Yankees were able to relax a little after Soriano paid a visit to Dr. Andrews and ruled out more significant injuries that may require another surgery. It has been some time since Soriano last missed significant action during the regular season, but all good things come to an end. It's probably going to take a few weeks of minimal activity to get the inflammation under control, after which Soriano will have to go through a modified throwing program before being activated, so the six-to-eight-week estimate seems reasonable.

Flesh Wounds: Homer Bailey had to leave his start with shoulder issues, though Dusty Baker said his current problem is different from the impingement Bailey suffered earlier this year... Jesse Carlson had surgery on his left rotator cuff performed by Dr. Andrews and will miss the rest of the 2011 season... Matt Maloney is the latest player to end up on the disabled list with an oblique strain... Darnell McDonald was placed on the disabled list with a left quad strain... Kevin Slowey doesn't appear to have a hernia after all, but he was placed on the disabled list with an abdominal strain... Shawn Kelley is making his way to Dr. Andrews for an elbow inspection. There has been no news of a setback, but Dr. Lewis Yocum spearheaded Kelley's partial Tommy John surgery last September, so the switch in super sports doctors is curious.

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

Related Content:  Surgery,  Fractured Ankle

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