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April 25, 2011

Collateral Damage

Debriding Our Time

by Corey Dawkins and Marc Normandin

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Jared Burton, CIN (Right shoulder debridement surgery)
Debridement is a term that we hear at times when the word surgery pops up–usually in the upper extremities–but what does it entail? We have a general idea that it involves going in arthroscopically and cleaning up an area, but anyone with children–or in our case, past sloppy roommates–can attest, there are differing interpretations of what "cleaning up" actually means.

By definition, debridement is the act of removing dead, contaminated, adherent tissue or foreign material. This can include anything from battlefield shrapnel to the tiny pebbles in road rash. In baseball, debridement happens with everyday cuts and scrapes, but the ones that make the news involve surgeries that most often occur at the same time as other procedures (such as rotator cuff repair or labrum repairs in the hip).

In most cases of solely surgical debridement there are degenerative processes that cause different types of tissues to build up or break down. Bony changes—such as small spurs along the edges of the joints—or roughened edges of old bony depressions can damage surrounding tissues. In these cases, the spurs or roughened edges are smoothed out and any compromised tissue is removed.

When you hear about bone spurs being removed from someone’s elbow, shoulder, or any other joint, it's because one or more of these spurs has become enlarged. When a spur becomes large enough, it can also break off and become one of those pesky "loose bodies."

In the case of soft tissue debridement, changes from chronic inflammation or mechanical irritation result in painful or limited motion and can only be addressed surgically. Tiny shavers go in and remove all of this tissue until normal motion is restored.

In many cases involving professional athletes, surgery does not address the underlying cause of the debridement. Spurs and scar tissue don't just form on their own—they have underlying causes of their own, with microinstability leading the way in the upper extremities. In the ankle there can be soft tissue impingement from repeated sprains, but there can also be spurring from the constant impact of running day in and day out. Once the issues that initially presented are cleaned up by the debridement, the true origin of the abnormality often comes to the fore (and eventually needs to be addressed as well).

So what does that mean for Burton? Judging by the 43 cases of isolated debridgement surgeries in our database, his chances of returning in the same season aren't great. Most of the isolated surgical debridements occurred in the offseason, but of those that took place during the regular season, only one has led to a return in the same campaign.

Debridement doesn't sound that bad, but it takes time to recover from because of those aforementioned underlying issues that go unaddressed. The rehab process moves along very slowly because of the limited motion or instability in the area, preventing the player from bouncing back from the procedure as easily as he could from, say, a partially torn meniscus.

Burton underwent his surgery on Friday and will be sidelined indefinitely, but at least he can give Ramon Hernandez a little company on the injured list.

Aaron Hill, TOR (Strained right hamstring)
Jayson Nix, TOR (Left shin bruise)

After the hamstring troubles that plagued Hill last year, the last thing Toronto fans wanted to hear about was a recurrent strain in his right hamstring. Nevertheless, Hill had to leave Tuesday's game after stealing second base, and a subsequent MRI showed a strain in his lower right hamstring. Hamstring injuries have a tendency to pull again and again—we have 852 occurrences in the database, 119 of which are re-aggravations.

Unfortunately for Toronto, Jayson Nix went on the disabled list himself with a left shin contusion. X-rays and MRIs showed no fractures, but those are not the most sensitive tests for picking up on hairline fractures, so a more troublesome issue could still be to blame for his absence. Nix will miss at least the next two weeks, but if he does not start improving in the next several days, don't be surprised if the Jays move on to a CT scan to get a higher-definition image of the bone. In the meantime, John McDonald and his glove-oriented game will take over for Nix.

Franklin Gutierrez, SEA (Irritable bowel syndrome)
Gutierrez has been suffering from abdominal pain and cramps for over a year—finally, the diagnosis of Irritable Bowel Syndrome (IBS) was attached to the debilitating symptoms. This is a syndrome that is completely different from Inflammatory Bowel Disease. Not all of the causes of IBS are known, but some can be preceded by an intestinal infection.

Most patients don't care about the causes—they just want the symptoms, which resemble those common to constipation or intestinal flu, to stop. Treatment can involve certain medications, but it also usually requires dietary and lifestyle changes. Some changes, such as improving sleep habits, simply cannot happen for professional baseball players. In these cases more emphasis is placed on the dietary changes, as they are completely individualized, as well as medications that may need to be adjusted several times before finding one that works.

We don't have anyone in our database that has suffered from IBS, and we suspect that Gutierrez isn’t happy about contributing to science and the furthering of medical knowledge on the diamond by being a pioneer, although it is likely that some players have dealt with it over baseball’s long history without missing significant time. There is no timetable for his return, but hopefully the new medication will be a positive first step.

Jose Contreras, PHI (Right flexor-pronator strain)
Contreras's injury is just one more piece of evidence that the closer job with the Phillies makes grown men cry and their bodies fall apart. Philadelphia's problems with their closers date back to 2007. It's true that Tom Gordon, Brad Lidge, and Ryan Madson have accounted for the majority of Philly’s closer injuries, but it's almost as if no one wants to (or can) hold the job. Contreras, like Dante Hicks, wasn’t even supposed to be here today, but he is now suffering an injury that we will blame entirely on his role as fill-in closer.

We discussed the flexor-pronator mass previously when talking about Tommy John surgery. To summarize, this muscle mass lies directly over the ligament, but it also has the very important function of flexing and turning the hand from a palm-up to a palm-down position. This muscle is very important to pitchers because of its primary function in wrist and forearm movement, but also because it serves as secondary protection for the UCL.

The range of potential days lost for this issue is wide, extending from a few weeks to the end of the season, in large part because of the integral function of the muscle in pitching. Contreras is heading back to Philadelphia for an MRI, so we will have to wait for the results before any estimates of his return can be made.

Neftali Feliz, TEX (Right shoulder inflammation)
It's not easy consistently throwing a baseball near 100 mph. Ask Neftali Feliz, who first started to feel soreness behind his shoulder while in New York. The Rangers want to be careful with their young relief ace and are putting him on the 15-day disabled list with right shoulder inflammation.

Normally there wouldn't be any questions about the inflammation, but something just doesn't feel right with the description of his symptoms. Usually in the case of shoulder inflammation the soreness and pain are concentrated more in the front, top, and/or side of the shoulder, so there is a little birdie in our ear saying watch out for a minor rotator cuff strain (yes, the bird speaks perfect English and is well-versed in human anatomy).

Feliz missed 10 days in 2009 for shoulder soreness while in the minors, but there is not enough in his injury history profile to cause any great alarm at this time. Regardless, the pain cycle needs to be stopped, and putting him on the disabled list is the best way to do this.

Flesh Wounds: Justin Morneau finally returned to the lineup on Saturday after missing almost a week with the flu. It's definitely the sick season among baseball players. Scott Downs found this out the hard way, too, as he was placed on the 15-day disabled list with a gastrointestinal virus... Ruben Amaro is hopeful that Chase Utley can return before the end of May. That doesn't sound too promising, especially if you have ever tried watching Wilson Valdez play baseball… Scott Rolen strained his left shoulder and was placed on the disabled list. We didn't think he still had a left shoulder after all the surgeries and work done in the past, so this came as quite a surprise to us—it might be time to look into cybernetic implants... Ryan Kalish has a partially torn labrum in his left shoulder after diving for a ball this weekend. He is potentially facing season-ending surgery, so he'd better hope that Josh Reddick doesn’t take a step forward and replace him on Boston’s depth chart... Johnny Damon's finger isn't just bruised: he actually has a fractured tip of the left ring finger. No disabled list stint has been mentioned as of yet, as he is trying to play through the injury… In news no one could have predicted, Carlos Beltran has been the healthiest outfielder in New York, now that Angel Pagan is on the 15-day disabled list with a strained left oblique. #BlameBeltran, indeed.

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

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