Before long, spring training will be upon us, and we’ll be able to watch live baseball games again. Rounding up the usual injury suspects has been fun, and we’ll go into detail about several other injuries before putting the series on hold. However, injury news doesn’t stop being made at the end of the World Series, and since our last injury roundup, more than a few injuries have come to light. Therefore, we interrupt our regularly scheduled program to bring you this important news.

Nick Markakis, BAL (Athletic Pubalgia—Surgery)
News of Markakis’ surgery on January 5th was the inspiration for our recent article on athletic pubalgia. Following his operation, Markakis described soreness in his lower right abdominal area that has been occasionally bothering him for years. It reached the point that he had to take himself out of the last game of Baltimore’s season, which caused concern among many in the organization, but the problems that led to surgery started with a slide in September that was thought to cause a contusion.

After a period of rest and physical therapy in the early offseason, Markakis was still unable to continue with his normal routine. After several other tests were performed, he decided to undergo an operation at the hands of the expert athletic pubalgia surgeon Dr. William Meyers, who also operated on Placido Polanco and Hunter Pence. During the surgery, more damage was found than initially expected. The rectus abdominis muscle was torn, and the adductor groin muscle was injured. In addition, a large amount of scar tissue was present.

Markakis’ surgery will keep him out for about six to seven weeks, meaning he should miss only a small amount of time at the beginning of camp. The long-term prognosis is good, as Ian Kinsler, Josh Hamilton (first in 2009, then more recently), and Grady Sizemore (now twice) have undergone the same procedure and returned to action, but the problem can return within a few years, as evidenced by the experiences of Hamilton and Sizemore. Markakis should make a full recovery and hopefully maintain his 145+ games played streak.

Ian Kinsler, TEX (Ankle PRP injection)
Kinsler underwent an injection and surgical procedure on his ankle shortly after the conclusion of the World Series that he said allowed him to feel closer to normal than he has in a long time. Following his high ankle sprain in the spring of 2010, Kinsler felt that he did not have enough power in his ankle, even though he remained productive. The injured ligament began to heal in a lengthened position, but he also had scar tissue in the area that caused the ligament to function as if it were attached to a different place on the bone.

Some of this scar tissue was separated from the bone prior to the actual PRP injection. It was most likely done under ultrasound guidance, though a few other options are possible. One procedure, hydro-dissection, can separate the scar tissue from the surrounding tissues and, depending on his condition, may be all the athlete needs. In the video of hydrodissection of the ulnar nerve below, the needle comes in from the right-hand side, just underneath the “0.9.” Only a small amount of space is present at first, but as the needle slightly withdraws, small amounts of fluid are injected around the tissue to create more space and separation.

In Kinsler’s case, the clinician injected PRP material into the diseased portion of the ligament to promote healing in the ligament itself, taking care not to allow the PRP material to end up where the dissection occurred.

Alex Rodriguez, NYA (Right knee—Orthokine treatment)
Early last month, Alex Rodriguez went overseas to have a procedure performed on his knee to combat arthritis, and naturally, several questions arose. The name of the procedure is “Orthokine,” and it’s very closely related to PRP injections already approved by the FDA and recognized by Major League Baseball. In typical PRP injections, about 20cc of blood are drawn and spun down to separate the different components before the clinician injects the platelet rich plasma into the area.

In the Orthokine procedure, the 20cc are withdrawn, spun down, and incubated with interleukin-1 receptor (IL-1Ra), a natural antagonist to a protein responsible for degenerative joint disorders. After incubating for a period of time, the combined concentrate is injected into the joint to fight arthritic changes. IL-1Ra is taken from the patient’s own blood, so it’s still completely autologous—that is where the debate arises regarding whether a procedure is a therapy or a “drug” created by the combination of substances. It is the process of incubating the PRP material with IL-1Ra and then injecting it into joints that causes concern for the FDA, not the IL-1Ra itself. A commercially available recombinant version of IL-1Ra, Anakinra, is available in the United States. It is combined from several source molecules and used to fight rheumatoid arthritis, as well as other inflammatory disorders.

It’s not as if only one doctor who is admonished by the field is performing Orthokine therapy. Animal studies were used as a precursor to human patients for decades, and Orthokine is no different. With the promise it showed in animal models, its use among professional athletes is becoming more popular. For now, however, it is not approved by the FDA.

Regarding Rodriguez, only time will tell whether the treatment took hold and improved the degenerative arthritis in his knee. He will be ready in time for spring training, and the Orthokine treatment itself is very unlikely to make things worse.

Jason Castro, HOU (Left foot surgery—sesamoid removal)
As if recovering from ACL surgery was not bad enough, Castro ended up needing surgery on December 9th to remove one of the sesamoid bones in his left foot. He first noticed the pain during the Arizona Fall League championship game, and it persisted even after he rested it for a few weeks. His pain may be related to altered running mechanics after his return from ACL surgery. Sesamoid-related pain can debilitate catchers but can usually be treated conservatively with rest, physical therapy, shoe inserts, bone stimulators, and occasionally injections. Because they’re forced to crouch, catchers have a lot more pressure placed on the sesamoids than other position players and therefore can be much more difficult to treat. Because the bone is inside a tendon, recovery from surgery can take three months or more to allow the tendon to heal. Any delay in Castro’s rehabilitation may put his Opening Day availability at risk.

Al Alburquerque, DET (Elbow surgery—stress fracture)
Alburquerque is another player who has trouble avoiding injuries, and his latest involved having a screw inserted in the back of his elbow to stabilize a stress fracture. Before anyone jumps down our throats, stress fractures do sometimes require stabilization when they worsen or persist despite trying every treatment under the sun, including bone stimulators. Olecranon stress fractures are much more common in kids and adolescents, but they can crop up in professional baseball players. The screw is placed into the olecranon and extends up a bit, into the ulna itself. Alburquerque will not begin a throwing program until he reaches the three-month mark and likely will not be back with the Tigers during the first half of the season.

Flesh Wounds
Allen Craig’s
recovery from surgery to repair a non-union patellar fracture is progressing well, but he still may miss time at the beginning of the season. Recovery from this surgery ranges anywhere from four to six months or more depending, on the location and severity of the fracture in the patella. Since he had surgery on November 18th, the four-month mark would still keep Allen out of games until March 18th, at minimum… Mitch Moreland will begin hitting off a tee this week as he recovers from wrist surgery to remove the pisiform bone… Ryan Howard has started strengthening exercises and some weight-bearing activities, but a return before May is still more of a hope than an expectation… Blake Hawksworth underwent minor surgery on his throwing elbow on January 11th to have scar tissue taken out and a bone spur shaved down. Recovery is only four to six weeks, so he is expected to be able to pitch in spring training… Mike Adams had surgery on January 5th to repair an inguinal hernia—the type in which abdominal contents push through the torn tissue—but is already throwing again. He’s going to be a few weeks behind everyone else at the start of spring training but should be ready for the start of the season…. Hunter Pence and Placido Polanco are both coming along very well from surgeries on their sports hernias and are expected to be ready for spring training…. Bobby Jenks had two surgeries on his low back to remove bone fragments, one in December and one earlier this month. He will not be ready for the start of spring training…. Jimmy Rollins had surgery on December 8th to have a cyst removed from his left wrist and is expected to be ready for spring training.

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Any word on Travis d'Arnaud (thumb)?
Surgery and rehab has been going well so far. Should be ready for spring training.
From a fantasy perspective, what kind of impact does the howard rehad have on his power? When they say he's doing weight bearing, I assume he's fully active above the waist. Below the waist whats going on? 3-4 months without being able to do strenous lifting on one or both sides has to affect a guy like howard going forward right?
It definitely effects his power, to what degree is harder to determine. Surgeons have to protect this very carefully post-surgically so he is probably just coming out of the walking boot right about now. Only now can he begin gentle stretching and performing calf raises.

Don't be surprised if this takes longer than six months to recover from and his power is negatively effected. The good thing is that he's not exactly known for his speed so that won't be an issue.
In addition, to everything above, we find out today that Victor Martinez has torn his ACL and will reportedly be out all of 2012.

While missing the entire season may be a stretch at this point, it certainly is not out of the realm of possibility.
We found out today that Victor Martinez had microfracture and meniscus surgery and won't have ACL surgery for another six to eight weeks. After initially believing he might make it back in time if he had ACL surgery in January, his new timeline would end his season.
Would playing on a "Sprained Knee" for 2+ months have led to meniscus damage? ACL Damage? What was the nature of the August sprain?
Theoretically any increased looseness anywhere in the knee can increase the risk for an ACL injury but generally no not for the ACL.

It does increase the risk for meniscus damage because of the biomechanics in hitting and throwing. The rotational and sideways force increases the load on the meniscus when the MCL is a little loose.