February 24, 2012
The DL Kings: Chad Fox
As we have seen in previous installments of the DL Kings, there are many ways in which a career can be shortened by injury: There can be a single, recurring injury as we saw with Kelvim Escobar, or there can be a multitude of different injuries, as was the case with Alex Escobar. We have said that a player needs to have talent to be high on this list—otherwise teams would just cut loose after a few signs of trouble, and this holds true for Chad Fox, who holds the list’s infamous top spot.
Fox was originally drafted by Cincinnati in the 23rd round of the 1992 draft, and through the 1995 season, he was almost exclusively a starting pitcher, where he demonstrated a mid-to-upper 90s fastball and a good slider. Fox was traded to Atlanta for outfielder Mike Kelly after the end of the 1995 season; He pitched for the Richmond Braves the following season, increasing his strikeout (from a 6.3 K/9 to 8.39), and dropping his walk rate (from 5.85 BB/9 to 4.73) . Alas, elbow trouble forced him to the disabled list and he underwent Tommy John surgery that July.
Fox made the majors in 1997; while recovering from the Tommy John procedure, he was converted into a reliever. There is precedent for unsuccessful minor league starters to transition to being a dominant reliever; Lee Smith is a prime examples. In this role, Fox struck out over a batter an inning and was more effective against left-handed batters than right, although small sample size rules apply. After the season, Fox was traded from the Braves to the Brewers.
For a while, it appeared as though Fox would be able to put the elbow surgery behind h>im and continue on and have a productive major-league career. In April of 1998, Fox appeared in 13 games and threw over 19 innings, allowing just one earned run with a K/BB ratio over 7:1. In mid-May, he developed shoulder inflammation; his high number of appearances over the first month of the season were likely a contributing factor. Fox returned from his first appearance on the major-league disabled list 52 days later, and was nowhere near as effective in April, but managed to stay healthy the rest of the way.
Fox was able to avoid surgery in 1998 despite the time missed; the same cannot be said for the 1999 season. After only six appearances, he was placed on the disabled list because of soreness in his right elbow and was diagnosed with an elbow sprain. After unsuccessfully trying to rehabilitate the elbow, Fox underwent a second TJS operation on July 27th, making him one of the earliest to have a revision TJS.
During the next spring training, Fox was throwing a bullpen session when he felt a sharp pain in his elbow; further tests revealed the concerned ligament was ok, but that he had suffered a hairline fracture in the joint instead. In the adult population, these types of fractures are usually preceded by events that weakened the bone first—a stress fracture, a bone tumor (benign or malignant), a bone cyst, previous surgery, for example—anything that changes the structure of the bone and weakens it. In Fox's case, it was likely a combination of biomechanical changes from previous surgeries and the increased stress from pitching. Whatever the cause was, it had to be fixed. Dr. Andrews did the procedure, taking out some loose bodies, and inserting three screws into the area to stabilize the fracture site. As a result, the complete 2000 season was lost—or a total of 181 days.
Between 1998 and 2005, there was only one year in which Fox didn't end up on the disabled list—that year was 2001. Fox was able to put together his best year, striking out 80 in 66.2 innings, and he was also was named the Brewers Most Valuable Player.
Fox had already amassed 399 missed days between the 1998 and 2000 seasons, but whatever respite might have been provided by the 2001 season came undone in the following year. In spring training, he suffered a sprain of his TJS graft; it became an issue that haunted him for the rest of his career. Fox was able to make it through his rehabilitation and came off the disabled list at the end of May; the reprise, however, was short lived as he strained his rotator cuff about one week later and was placed on the disabled list for the remainder of the year.
Compensatory injuries don't get enough attention because it's hard to definitely link one injury to another, and it is near impossible to reliably obtain the necessary information and evidence of that link. For example, we would need to know the pitcher’s available range of motion, functional strength, and proprioception (ie, where the body senses the body part in space). Range of motion is easy enough to measure between measurements in clinic and on video, but the latter two prove more problematic. With current technology, it’s impossible to get a reliable direct measurement of the joint and muscle forces, and it’s also impossible to measure proprioception when the injury occurs.
A saying in medicine attributed to Dr. Theodore Woodward, MD around 1940 goes like this: When you hear hoofbeats behind, don’t expect to see a zebra. Given Fox’s previous history of elbow and shoulder injuries, it certainly seems that his shoulder was a compensatory injury. There was no obvious “zebra” (such as a tight left calf causing his balance problems which changed his biomechanics to the point of injuring his shoulder). True, some minor shoulder damage may have been present in 1998 but the combination of that with his elbow injuries could have caused the strain and inflammation. At the end of 2002, he lost over 176 days, good for over 97 percent of the season. He was released by the Brewers and signed with the Red Sox
In 2003, Fox added a left oblique to his list of injuries. He missed over two months in the first half of the season and was released by Boston on July 31st. The Florida Marlins signed him to a minor league contract on August 8th, and recalled him on August 12th, to replace Tommy Phelps after the latter was placed on the disabled list. That would be the last bit of good news for Fox for a while.
After the 2003 season, there was no way that Fox could shake the "injury-prone" tag , but there was still a chance he could remain a productive pitcher. As before, Fox was able to make it through roughly the first month of the season before before the ulnar nerve in the elbow, the so-called "funny bone", became inflamed, causing Fox to reacquaint himself with the disabled list. There can be many reasons for ulnar neuritis, including a lax or loose elbow. Fox had injured the TJS graft in 2002, which left the elbow a little looser than before; this can change mechanics and stretch the ulnar nerve for a brief period of time during motions such as pitching, which will lead to inflammation. The continued pain and inflammation meant that Fox was able to return in 2004; he would miss 160 days.
Somehow, Fox convinced the Cubs to sign him during the 2004-2005 offseason, but before the first month of the 2005 season was over, his career was in jeopardy. On April 25th, he came in during the ninth inning; the temperature was around 50 degrees, but a 25 mph wind with gusts created a wind chill below 40 degrees. After releasing a pitch, Fox felt a pop, instant pain and knew something was wrong.
The prevailing concern was for another ligament injury, and Fox’s main symptoms were similar to an acute injury to the ulnar nerve and/or the breaking up of scar tissue in the area. He had burning pain and numbness that ran into his fingers, and after being seen by Dr. Andrews, Fox apparently wanted to try to rehabilitate it and not go through with another operation. There was no definitive “he needs surgery” because it appeared that the ligament in question was not acutely injured. There are one or two reports that he had surgery, but they don’t describe what structure was injured or repaired, so the overwhelming evidence – unless I can get a chance to look at his actual medical chart – points to it being treated non-operatively. Fox lost the remainder of yet another season, the damage this time being 159 days.
The amount of injuries Fox suffered could take a toll on any person, both physically and mentally. Fox sat out the 2006 and 2007 seasons and opened a sports complex, but the pitcher tried to make a comeback in 2008. He signed a minor league contract with the Cubs on January 11th, and it would be a bumpy road back to the majors: he was soon on the minor league disabled list with a strained triceps. Fox recovered and returned to Chicago’s roster in early May, but his oft-injured ulnar nerve became painful while playing catch with Scott Eyre, leading to a return to the disabled list once again. Fox did not return in 2008 and missed another 139 days.
Fox decided to give it one final try in 2009; he was now 38 years old. He started the season in the minors, getting called up at the beginning of May. In his second major-league appearance of the season, he described feeling as though his elbow was getting hit by a hammer. Once again, inflammation of the ulnar nerve resulted in a trip to the disabled list, and Fox remained sidelined for the rest of the year. After 148 days, his career was over.
With 846 days on the disabled list, Fox is the reigning king of the disabled list with the most days lost since 2002. Every player has a different path in their career; this also holds true for those who have spent enough time on the disabled list to earn a spot on the DL Kings’ throne. If one factors in Fox’s stints on the disabled list with Milwaukee pre-2002 (and outside our 10-year time frame), he has 1063 days missed in his career. Quality pitchers were at such a premium that teams were willing to take a risk on anyone with a career K/9 of over 10, and Fox was always willing to try until his elbow raised the white flag and told him that it could no longer pitch at the major league level. Eventually, the teams figured that out too—quite possibly the only reason why the number of missed days is not even higher.