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June 3, 2011

Collateral Damage

Sciatica State

by Corey Dawkins and Ben Lindbergh

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Hanley Ramirez, FLA (Low back pain and left leg sciatica)
Usually athletes don't disclose much information about injuries during media interviews, but Ramirez's interview earlier this week was the exception. The shortstop revealed one potential reason for his decreased production so far this year: his back has been bothering him for about a month, and he has also experienced numbness and pain shooting down his left leg. That’s close to a textbook description of sciatica, a common injury to the sciatic nerve in both active and sedentary people. Approximately one-third to one-half of the general public experiences sciatic pain traveling down the leg, but less than one percent of people suffer from associated numbness or muscle weakness.

The sciatic nerve is the largest nerve in the body—approximately the width of a thumb at its widest point—and is composed of a bunch of nerves that intertwine and become the sciatic nerve at the level of the piriformis, a muscle deep in the glutes. It then pierces through the piriformis muscle before traveling down the leg and branching off to various smaller nerves. An injury to the nerve and its resulting symptoms can occur anywhere along its length, from the spine on downward.

Symptoms can include any combination of pain, weakness, numbness, or tingling traveling down the leg as a result of injury or compression on the sciatic nerve. Finding the root cause of these symptoms is difficult due to the wide range of possibilities and locations. Injuries to the intervertebral discs—which can become herniated, bulging, or degenerative—as well as bony changes, such as spurs or other irregularities, can cause sciatic symptoms traveling down the leg, as can stenosis, or narrowing of the spinal canal. Muscular strains and/or spasms throughout the low back and hip can exert pressure directly onto the nerve, mimicking a disc injury. One other potential cause of sciatica—although not the cause of Ramirez’s condition—is falling directly onto one’s rear and causing a contusion of the sciatic nerve itself without other injuries.

Sciatica symptoms are different for each person and range from mild pain and numbness to symptoms so severe that the person cannot move or get out of bed. Sounds familiar, right? The ailment usually involves only one side, but it can cause symptoms in different areas of the same leg. For instance, a player can experience sharp pain in his low back and the back of his thigh but only numbness past the knee. These symptoms can also worsen with various activities. For some people, sitting is worse, while others suffer more severe pain at night. Sneezing can contribute to increased pain, as can walking even a few yards.

In order to figure out what exactly is causing the sciatica, X-rays and MRIs of the lumbar spine (low back) are usually ordered to rule out any disc injury or narrowing of the spinal canal. If these initial tests are negative, doctors may move on to testing of the nerve itself by EMG or nerve conduction studies, in which small needles are placed to the nerve to measure how fast the impulse travels between the two points. This can pinpoint the level of the injury and which nerves further down the leg are affected.

Treatment depends on what is causing the injury to the sciatic nerve. Unless there is a major disc injury, surgery is not the first option for herniated or bulging discs. If physical therapy and oral anti-inflammatory medication offer no relief, epidural injections containing stronger anti-inflammatory medication would be considered and are tolerated well. Only if traditional measures fail is surgery considered. Muscle strains and spasms in isolation usually respond to therapy, except in the rarest of cases.

In Ramirez's case, there still hasn't been any further information about the underlying cause of his symptoms as of Thursday night, but further information will likely be revealed today. Manager Edwin Rodriguez said that a decision concerning the disabled list would be coming shortly, because Florida’s roster is limited as presently constituted.

Matt Holliday, STL (Left quad strain)
Kyle McClellan, STL (Left hip flexor strain)

Groin, hamstring, and oblique strains are known to be repeat offenders and lead to longer recoveries, but quad and hip flexor injuries can also prove resistant to healing, albeit to a slightly lesser degree. There are many different muscles that act as hip flexors, but the major ones are the iliacus, psoas major, and one of the quad muscles. Since each attaches at a slightly different location, these muscles all have slightly different actions, but they all flex the hip to some degree and position.

Once a player has been placed on the disabled list with a quad or hip flexor strain, the likelihood of a repeat strain requiring another disabled list move is low. This is what differentiates flexor strains from the recurring groin, hamstring, and oblique problems we see throughout the season. Holliday has been fighting with his problematic quad for several weeks, and the strain had reached the point at which the muscle needed rest before it could make a full recovery. McClellan, on the other hand, strained the hip flexor in the first inning of Monday's game and was placed on the disabled list a few days later. Both are expected to miss the minimum, which seems a little more likely in Holliday's case than McClellan's.

Ryan Doumit, PIT (Left ankle fracture)
Catchers are taught certain techniques to limit the likelihood of injury on plays at the plate. Sweep tags are commonly seen, but there are times when the plate needs to be blocked to prevent the runner from scoring. If the catcher is going to try to block the plate with one leg, he risks injury to his foot, ankle, and knee if he puts too much pressure on any of them when the runner slides. Catchers instead are taught to put almost no pressure on the leg itself, let the leg kick back on contact, and then fall on the runner to slow him down before reaching the plate. In a game where every millisecond counts, that could easily be the difference between the runner being safe or out.

Doumit appeared to be caught in between on the play at the plate on Monday. As the throw was coming in from right field, he was positioning himself to do just as he was taught, but he was a split second late. As a result, a little too much pressure was placed on his foot, and his leg didn't whip out from underneath him. He suffered a non-displaced ankle fracture and a sprained ankle without significant ligament damage. He's going to be out for a month or so, depending on how quickly the fracture heals.

Daisuke Matsuzaka, BOS (Tommy John surgery)
Rich Hill, BOS (Left elbow/forearm injury)

After submitting to multiple examinations, including one in Japan, Matsuzaka will undergo Tommy John surgery performed by Dr. Lewis Yocum next week. The Red Sox—and reportedly Dr. Yocum as well—felt that there was a good chance that he could rehabilitate the elbow and be effective. Matsuzaka felt differently, and ultimately it's his elbow, as well as his decision to pursue surgery. The downside of that choice, of course, is that he's going to miss the rest of 2011 and probably a large part of 2012.

Rich Hill also appeared to be heading for season-ending surgery on his elbow/forearm after leaving the mound in pain on Wednesday. While Daniel Bard told the media that the ligament passed the clinical exam, the forces applied in the athletic training room don't come close to those experienced on the mound. Hill's tenderness and pain with certain tests were suspicious enough to send him off for an MRI, which confirmed the seriousness of the injury. No further details were released about what particular structure was injured as of Thursday night, but it appears likely that Hill is done for the year.

Clay Hensley, FLA (Right shoulder pain)
There hasn't been any official word on what Hensley suffered in Wednesday's game, but in general, whenever a pitcher says he felt something “pull” in the top of his shoulder, it's not a good sign. There are surprisingly few problems that could fit that description in the top of the shoulder. Most likely Hensley strained his rotator cuff or biceps tendon, or tore his labrum, with the biceps tendon obviously being the least worrisome of the three. It is unlikely that his fractured scapula on the left side caused a direct cascade-type injury in the right shoulder, but it may have played a very limited role. Since there hasn't been any official word on what structure was injured, we can't be sure how long he will be out.

Ike Davis, NYN (Left ankle sprain and bruise)
Davis' left ankle has been slow to recover, and the Mets are now calling it an inversion ankle sprain as well as a bone bruise. This type of ankle sprain is the one almost everyone gets when they twist their ankle and have swelling on the outside of the ankle or foot. According to Terry Collins, Head Athletic Trainer Ray Ramirez has never seen this type of injury take this long to heal.

Davis is likely suffering from something more than a sprain and a bone bruise; as we've noted multiple times, the line between a small fracture and a bad bone bruise is surprisingly thin. One way to evaluate the integrity of the bone is to have a focused CT scan, which should provide a definitive answer as to whether or not there is a fracture. It doesn't appear that Davis will undergo a CT scan soon, but if his symptoms persist, that may be the next step. The first baseman will avoid any impact activities for the next three weeks and limit his baseball activities to playing catch and swinging a bat.

Flesh Wounds: R.A. Dickey has a partial tear of his plantar fascia and is continuing to pitch through the pain. He may require a DL stint if the pain worsens... Alfonso Soriano strained his left quad, extending his history of leg problems over the last several years... Dan Haren had to cut his bullpen session short due to low back tightness... John McDonald pulled his left hamstring and will be down and out for at least a few weeks... Brandon Webb’s rehabilitation has been halted, thanks to renewed inflammation in his shoulder... Cameron Maybin was placed on the DL with inflammation in his right knee... Francisco Liriano was placed on the disabled list with inflammation in his left shoulder... Liriano’s teammate Jason Kubel was placed on the disabled list with a left foot sprain... Alberto Arias will go under the knife again after experiencing continued pain following his labrum, rotator cuff, and calcium deposit surgery from last April.

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:  Injury,  Sprain,  Year Of The Injury,  Fractured Ankle,  Quad-a

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