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August 15, 2011

Collateral Damage

Beware of Batted Balls

by Corey Dawkins and Ben Lindbergh

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Al Alburquerque, DET (Concussion) [AGL: 56, ATD: -.056] (Explanation)

Not only do pitchers have to worry about line drives while pitching, they now need to worry about batting practice. Alburquerque was in the outfield warming up before the game on Friday when a line drive off Robert Andino's bat struck him near the left temple. He never lost consciousness but was writhing in pain before medical staff reached him. He was taken to a local hospital, where his physical exam revealed a concussion—concussions can't be diagnosed by x-rays, MRIs, or CT scans—and a CT scan revealed a small amount of internal bleeding, likely the least dangerous kind, epidural hematoma.

An epidural hematoma is where blood collects between the membranous covering of the brain (dura mater) and the skull. Subdural hematomas—the more dangerous kind—involve blood collecting between this membrane and the brain tissue. Intraparenchymal hematoma is extremely dangerous and arises when blood collects inside the brain tissue itself.

Alburquerque was kept for observation—since hematomas can be very slow-forming—and given anti-seizure medication as a precaution before being discharged Saturday and driving home to Detroit on Sunday. Flying with any sort of bleeding in the skull, even in the mildest form, can be extremely dangerous because of pressure changes and the inability to be transported to emergency facilities quickly if symptoms worsen.

It's impossible to predict when Alburquerque's symptoms will disappear, but most resolve within seven days to two weeks. The internal bleeding adds another piece to the puzzle and demands that additional precautions be taken, likely keeping him from being activated from the seven day disabled list when first eligible.

Tommy Hanson, ATL (Right shoulder tendinitis) [AGL: 84, ATD: -.025)]
Looking at Hanson's performance since coming back from the disabled list earlier in the year, it's clear that he was not fully healed upon his return. The inflammation itself likely disappeared, but the root cause of the inflammation did not. This can easily happen during the season, when time is an issue and teams in contention are eager to get their best players back.

Inflammation is the symptom of a problem that is structural or dynamic in nature. Structurally, the rotator cuff can become inflamed based on the anatomy of the shoulder. Weakness in other areas and muscular imbalances can cause the humeral head to elevate abnormally and decrease the subacromial space. Most anatomical reasons are easily detected by the variety of diagnostic tests available today.

Dynamic reasons are both harder to diagnose and harder to rehabilitate. Often an imbalance between the muscles surrounding the shoulder causes a cycle that is almost impossible to escape within a few weeks. In the absence of an acute injury to any part of the body, the single root cause develops over several weeks to months, if not years, prior to the inflammation popping up. Poor posture, weak back and scapular muscles, and soft tissue tightness feed off each other, often gaining momentum until there is a significant loss of function.

Just as these problems aren't created overnight, they can't be solved in a very short time, either. It is true that gains can be made in the short-term that allow the athlete to return, but therapy is continued even after coming back from the disabled list. It is a balancing act between returning too early or too late that all too often culminates in another trip to the disabled list.

Hanson may return when eligible, but considering the difficulties he had coming back from the first time, he likely won't be fully healed. If we start the clock when he was first placed on the disabled list in June, 84 games lost would put him out until around the second week of September.

Justin Smoak, SEA (Fractured nose and maxilla) [AGL: 23, ATD: -.018]
Smoak's first game back from a thumb injury did not go as he expected: he left early with a fractured nose and maxilla. Jarrod Saltalamacchia hit a hard ground ball that took a ferocious hop and hit Smoak in the face, resulting in a broken nose and fractured maxilla. Smoak was looked at by the Mariners’ athletic trainers and team physician Edward Khalfayan before eventually walking off under his own power while holding a towel to his bloodied face. The non-displaced fracture of the maxilla will not need surgery, and fractured noses usually don't require surgery unless the airway is compromised. Smoak should be able to return in the minimum.

Jason Marquis, ARI (Fractured right leg—fibula) [AGL: 37, ATD: TBD]
A rough weekend for the Diamondbacks got a little rougher on Sunday afternoon, when Marquis went down with a broken right fibula. Even though the fibula is the smaller of the two lower leg bones, it remains important to the function of the lower leg. Numerous muscles and ligaments attach to the fibula, which helps to protect the neurovascular structures as they travel down the leg into the ankle.

Angel Pagan smashed a ball right into the lower leg of Marquis in the third inning, but Marquis remained in the game. Oddly enough, it wasn't until the next inning, when he hit Josh Thole in the leg, that Marquis was unable to continue. What likely happened was that the line drive caused a hairline fracture that worsened or excited the pain nerves to a greater degree when he threw the pitch the next inning. Most fractures of the fibula take four to six weeks to heal, which likely puts Marquis on the shelf for the remainder of the year.

Xavier Nady, ARI (Fractured left hand) [AGL: 32, ATD: -.001]
Nady suffered the fracture in his left hand after being hit by a pitch from Dillon Gee on Friday in the second inning. Nady was able to tough it out initially and stayed in the game, but Paul Goldschmidt replaced him in the top of the third. Nady's hand started to swell and turn black and blue almost immediately, indicating that the injury was likely more than a simple bruise. A fracture was diagnosed after imaging and will keep Nady out four to six weeks.

Derrek Lee, PIT (Fractured left wrist) [AGL: 45, ATD: +.003]
Almost 10 days after being plunked by Carlos Marmol, Lee still couldn't swing painlessly. A CT scan Friday evening revealed the fracture in his left wrist, which had escaped notice during two x-rays and an MRI. As we discussed on Friday, you can't rule out a fracture until a CT scan has been performed. The degree to which Lee delayed healing by playing through the pain can't be known at this point, but most fractures of this type heal within four weeks.

Jason Repko, MIN (Left shoulder bursitis) AGL: 17, ATD: +.086]
For the second time this season, Repko ended up on the disabled list after an MRI revealed bursitis. Several bursa are located throughout the shoulder, but it is the subacromial bursa that is most often involved. Subacromial bursitis can be the result of infection, rheumatoid arthritis, or gout, but is most often the result of subacromial impingement. The rotator cuff, biceps tendon, and subacromial bursa can all become inflamed from compression between the humeral head and acromion. Subacromial impingement can be the result of bone spurs, downward sloping acromion process, or rotator cuff or periscapular weakness.

Flesh Wounds: Mike Pelfrey is lucky to have only a bruised right elbow after being hit by a line drive in Saturday's game...Alexi Casilla aggravated his right hamstring strain and is back on the disabled list... Michael Cuddyer felt a pop in his neck while swinging in batting practice on Friday and has not played since. The Twins are calling it a strain and dealing with it on a day-to-day basis... Andres Torres fouled a ball off his right shin on Friday and was placed on the disabled list with a contusion... In another instance of a pitcher getting hit by a batted ball, Brandon McCarthy suffered a bruised right knee and is still day-to-day... A.J. Pierzynski was hit by a pitch on Friday and has remained out with a right wrist contusion. Reports are that he will return tomorrow... Kevin Youkilis missed two games with low back stiffness but was back in the lineup yesterday... Huston Street was placed on the disabled list with a mild right triceps strain... Jose Tabata is expected to be activated from the disabled list today... Justin Morneau was activated from the disabled list on Friday despite not being able to feel his index finger. The most important factor is strength, which in Morneau’s case is reportedly back to normal... Juan Uribe will see a specialist in the next few days to determine the cause of his continued left hip pain, specifically whether it’s a sports hernia or labral injury inside the hip... Sergio Romo has soreness in his right elbow, which is concerning given his history of an elbow sprain in 2009... Romo’s teammate Barry Zito sprained his right ankle during his latest rehab start and is expected to miss some time... Cole Hamels admitted to a dead arm during Friday's start, but manager Charlie Manuel said he also had trouble getting his shoulder loose before the game. We will keep an eye on this situation over his next few starts.

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:  Back,  Hit List,  Broken Wrist,  Fractured Ankle

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