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June 27, 2011

Collateral Damage

Twin Killing

by Corey Dawkins and Ben Lindbergh

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Delmon Young, MIN (Right ankle sprain)
An in-depth history and clinical evaluation are often as accurate, if not more accurate, than many of the diagnostic tests typically ordered to determine which structures a player has injured. Young was diagnosed with an ankle sprain after going back on the ball and crashing into the wall, but it didn't appear that he’d really twisted the ankle inward, as is the case with most common sprains. His ankle was forced into sudden dorsiflexion, and the concern shifted from the ligaments on the outside of the ankle to other structures. Injuries commonly seen in these cases include fractures, medial ankle sprains, syndesmotic injuries, and ruptured tendons.

The video above reveals that Young immediately reached for his calf and lower leg, not necessarily his ankle. As mentioned above, fibular fractures can occur in combination with syndesmosis sprains. Given Young’s mechanism of injury, his reaction, and his inability to bear weight, it would not surprise us at all if he also suffered a small fracture. We've seen time and time again that simple x-rays don't show small fractures, but a fracture would not be the worst thing.

Severe syndesmosis sprains generally don't heal without surgery, even in the absence of fractures. A screw is implanted through the ends of the tibia and fibula to ensure that the bones will not spread apart, thereby allowing the ligaments to heal. The screw is eventually removed to allow normal kinematics of the ankle to resume.

Young will undergo more tests to determine the true extent of his injuries over the next couple of days.

Shin-Soo Choo, CLE (Left thumb fracture)
On Friday night, one pitch by Jonathan Sanchez changed not only Choo's season but possibly that of the Indians as well:

As the pitch struck Choo's thumb, a compressive and shearing force was easily transmitted to the bones, which was just too much to absorb without injury. The resulting displaced fracture will probably require surgery to correct the alignment and allow the optimum healing environment. The size and type of fractures would determine which hardware would be used for surgery, which in turn would dictate the length of time missed.

Justin Morneau, MIN (Neck surgery)
At this point, Morneau would probably like a time machine to take him back to a season when he was healthy. Currently on the disabled list with wrist inflammation but also suffering from neck stiffness, Morneau will undergo a procedure on Wednesday to remove herniated disc fragments and relieve pressure on a pinched nerve.

The wrist inflammation is partly the result of his neck problems, which caused weakness in his arm and numbness in his hand. Morneau is expected to miss at least six weeks to allow for proper healing in the neck, during which time the wrist will also benefit from rest.

Roy Oswalt, PHI (Bulging disc)
The Phillies removed all doubt about whether or not Oswalt would make his next start by placing him on the disabled list for a bulging disc. As we discussed in Friday's Collateral Damage, Oswalt's low back injury history is nothing new. His bulging and herniated discs have been recognized for several years, as has an overall diagnosis of degenerative disc disease.

Complicating the difficulties caused by the disc injuries is a thickening of the facet joints, which is a nice way of saying that Oswalt has early arthritis in that area of the spine. Early arthritis is not unheard of for someone of Oswalt's age and activity level, but it’s not normally quite as limiting as it is for Oswalt at this stage of his career.

Oswalt is relieved that his season isn't over yet, but he’s hardly out of the woods. Doctors are recommending a regimen of different injections and physical therapy aimed at decreasing the inflammation while simultaneously strengthening his core, but that may not be enough to decrease his symptoms. The problem is that it's not as simple as prescribing a treatment and waiting for the area to heal, since the damage is already done. The herniating and bulging discs will not get noticeably smaller, and the arthritis around his facet joints will not go away. When Oswalt does return, he’ll be at risk of aggravating the injury every time out.

Jed Lowrie, BOS (Left shoulder nerve contusion)
Lowrie has been having trouble since colliding with Carl Crawford back on May 29th. His continued soreness and difficulties with the shoulder culminated in a subluxation on a swing on June 16th. After multiple tests and a second opinion from Dr. Yocum, it was determined that the continued soreness and weakness was the result of a deep bruised nerve that occurred during the original collision with Crawford.

Nerves can become bruised, and depending on the severity, symptoms can persist for several weeks, months, or in extreme cases, even longer. Rehabilitation needs to be structured very carefully, since setbacks are common when players are pushed too hard, too fast.

Ryan Madson, PHI (Right hand inflammation)
In another unusual diagnosis, Madson was deemed to have inflammation of the small muscles in the hand, caused by being struck by a comebacker on May 20th. After experiencing ongoing soreness while throwing pitches in the wake of the incident, he had an MRI of his hand, which was negative.

Continued pain while gripping certain pitches led him to a hand specialist, who discovered the inflammation. The affected muscles, while small, are invaluable for fine motor skills. Without proper functioning of these muscles, pitchers are unable to grip the ball properly and impart the correct spin on the ball.

Anti-inflammatory medications were prescribed, and Madson also received an injection to knock out the inflammation faster. He will throw a side session tomorrow to see how his hand feels, after which we'll have a better grasp on the timeline for his return.

Dustin Pedroia, BOS (Knee)
Several weeks ago, Pedroia was concerned that he might need surgery for a knee that had been sore ever since he fielded a ball on May 16th. Dr. Tom Gill looked inside the knee in a minimally invasive procedure and determined that it was safe for Pedroia to continue playing. At that time, we briefly talked about the chance of injuring the cartilage underneath the kneecap, where Pedroia does have at least some damage.

Viscosupplementation injections are used to decrease the friction in arthritic joints or joints with cartilage damage. Since Pedroia had a second viscosupplementation injection—almost like an oil change of the joint, with one more coming to complete the series—we have evidence that something is going on inside the joint. The knee may need to be cleaned up at the end of the season or even further in the future, but for now it is holding up well.

Elvis Andrus, TEX (Left wrist sprain)
Andrus sprained his left wrist on Friday after sliding headfirst into second base and has already missed the weekend while recuperating. Wrist injuries can be tricky, but generally mild ones do not have any long-term repercussions, and Andrus does not appear to be headed to the disabled list. Management thinks he could be back as soon as tomorrow, but Andrus thinks his return might come later this week.

Flesh Wounds: Huston Streetis day-to-day with groin soreness... John Danks and Grant Balfour are the latest members of the strained oblique club, and while Danks was placed on the disabled list, Balfour is still considered day-to-day... Even though Jose Tabata was carted off the field with a left quad or hip flexor strain, he will undergo more tests today to ensure that there was no damage to the hip joint or proximal femur... Jonathan Sanchez was placed on the disabled list with left biceps tendinitis, which could explain his recent ineffectiveness... No decision has been made about placing Marcus Thames on the disabled list for his left calf strain, and he will remain day-to-day... J.R. Towles was cleared of any concussion, but he did need 11 stitches to close up a nasty gash on his chin caused by a pitch that bounced in the dirt... Jonathon Niese was removed from his start with a rapid heartbeat, but he was checked out and allowed to return to his home on his off day. The scare was likely just the result of environmental conditions, but his condition will continue to be monitored nonetheless.

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

13 comments have been left for this article.

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Future Shock: Monday M... (06/27)
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