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December 5, 2003

Under The Knife

Trading Risks

by Will Carroll

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Like Willie Garson, there's a lot of chips being pushed toward the center of the table, and the cards are players. There's about $20 million in this pot, but each of the cards in this flop are injured. How does a team risk millions on a shoulder, a knee, or a wrist? Either very carefully or very foolishly: It's knowing the odds and what you can afford to lose that will make or break these deals.

  • The Yankees aggressively pursued Javier Vazquez, making him an early target of the Hot Stove/Cold War between the Bronx and Boston. Vazquez has always been someone who is both coveted and worrisome. Despite never being officially diagnosed with a significant injury, Vazquez has often run into a wall, but has always recovered quickly with a short rest. Over the last four seasons, he has been able to pitch over 200 innings with effectiveness. Given he started that streak at age 22, one could look at Vazquez's history as a ticking time bomb or as proof that we have a new member of the Abuse Sponge Club (Livan Hernandez, Proprietor). Vazquez is also the poster child for V-Loss. After any long rest, his velocity and movement on his fastball recover quickly, pointing to fatigue, not injury, as the culprit in his occasional lapses. Vazquez is not without risk--he's likely a bright yellow light--but the Yankees know how to deal with fragile pitchers.

  • On the other side of the deal, Nick Johnson has been among the most tantalizing of prospects. Heading into arbitration, it speaks volumes that "prospect" is still often the word used to describe him. The second-most used is "injured." Johnson is one of several young sluggers to develop mysterious wrist problems. There are as many theories about this spate of injuries as there are injuries, but the best I have heard is a combination of young, muscle-bound sluggers and whip-handled bats combining to create so much force that the wrist cannot handle the load. Hee Seop Choi, Jason Stokes, and Travis Hafner are some of the better-known names that have experienced similar problems. Reports from New York indicated that the Yankees believed Johnson's bones may be the root cause, but there has been no confirmation of this from sources. One would expect the medical records must be thorough for the Expos to take Johnson without a special physical, so that gives hope to Expos fans.

  • The trade of Eric Milton to the Philadelphia Phillies in return for Carlos Silva, Nick Punto, and a MLTBNLATRFD (minor leaguer to be named later, after the Rule 5 draft) is one fraught with medhead angst. Milton, of course, is coming off a season defined by and almost completely lost to an extensive knee surgery. Is this surgery the reason that the Twins were willing to move him, or was his 17-inning audition at the end of the 2003 season enough for the Phillies to be satisfied that he can move into a rotation that may lose ace Kevin Millwood?

    Like most instances where baseball and medicine meet, the answer is "both." After Milton's late-March knee surgery, details came out about the severe deterioration that was found despite his relatively youthful age of 27 (he's now 28). His surgeon, Dr. Thomas Rosenberg had operated earlier in 2003 on Tiger Woods, but unlike Woods' relatively simple surgery, Rosenberg found Milton's knee required much more extensive work. In the procedure, Rosenberg removed more than 30 discreet pieces of cartilage from both the medial and lateral meniscus. He was also forced to debride what was described as significant osteoarthritis from the knee both above and below the joint. As you can see from this illustration and description of similar procedures, Milton's knee likely looked like that of a much older person that may at some point be a candidate for complete joint replacement in order to maintain function.

    The six-month recovery and involved rehabilitation that Milton went through in order to return to the game went according to plan, according to Twins sources. Once he began to pitch again, both in drill and during a brief minor league rehab stint, it was clear that at least in the short term, Milton was able to return to his previous level of pitching. There is, however, a significant worry that his knee will continue to degrade over the course of a full season, endangering his ability to contribute as expected. It's one thing to pitch 17 good innings and quite another to the reach the 200-inning level for which the Phillies are paying.

    Milton's injury is similar to, but much more advanced than that of fellow lefty Randy Johnson. Johnson was able to come back after injections of synvisc, a synthetic lubricant that seeks to reduce bone-on-bone friction in the absence of normal, natural shock absorbers. There is a great deal of disagreement over which, if any, technique is more effective in the long-term, but sports medicine often takes an odd perspective on both efficacy and function. There is clearly room for interpretation and individuality. Where both techniques returned the respective pitchers to function, both are also likely to be walking around with their children and grandchildren on a replacement joint. It is one price of professional sports that we seldom see.

    The Phillies receive a pitcher with significant risk of recurrence who will likely pitch--and walk--with some level of pain. It is Milton's pain tolerance and the abilities of the Phillies' medical staff that will decide his effectiveness on the mound. The team takes on a one-year risk, which given the usual timeframe for recurrence, is only slightly elevated over a normal pitcher of this age. They also deal with a known quantity: By knowing the level of damage, the Phillies' staff will be able to come up with a plan to keep Milton as healthy as possible, something they were unable to do in Minnesota before the problem showed up.

  • Heading to Minnesota is Carlos Silva, a 25-year-old who could slot into the back of the Twins rotation or, more likely, will move into the role vacated by LaTroy Hawkins. Silva has been more effective in relief while in the majors, and his poor mechanics do not bode well for his being able to succeed and stay healthy in a starting role. While Punto, the PTBNL, and the $9 million owed to Milton for 2004 were more significant to the Twins than talent in this trade, the team actually didn't reduce its injury risk significantly.

    I'll leave the rest of this deal to the performance analysts and PECOTA, but from the medhead angle, there's no clear winner in this deal. Medheads might not fold on this go-round, but I'm not raising either.

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