Heralded Twins prospect Brusdar Graterol was recently shut down and placed on the IL for ‘shoulder impingement’. This is concerning given how promising a start to the 2019 season Graterol has had and what it could mean for his future.
So what is ‘shoulder impingement’? And when might it need surgery? Let’s see what we can figure out:
[Disclaimer: I am not a team physician for the Twins. I have not treated or examined any Twins players. The information I am using is only that which is publicly available. My goal with these posts is to provide some education to TD readers around general injuries that are peculiar to baseball players.]
Question 1: What is shoulder impingement?
Shoulder impingement is a sort of catch-all term that can be used to mean a number of different things depending on the specifics of the situation. It Is a term that is often used in application to patients who have pain in their shoulders, often without any specific structural damage or a particular injury. Most frequently, people have pain in their shoulder area that gets worse when working above chest level. It is often treated with physical therapy, activity modification, oral medication and occasional cortisone injections. It is uncommon for these patients to require surgery, but it is sometimes needed after the preceding treatments have failed to provide adequate relief. Some also refer to this condition as shoulder bursitis. It involves irritation of the rotator cuff and the bursa, which lies between the rotator cuff tendons and a part of the bone of the shoulder blade (called the acromion). You may have friends or family members who have been told they have ‘impingement’- this is a fairly commonly used diagnosis. More specifically, this condition is referred to as ‘external impingement’.
Shoulder impingement in pitchers, however, often means something entirely different than what is described above. Whereas external impingement occurs between the rotator cuff and the acromion (outside of the ball and socket joint of the shoulder), pitchers more commonly have problems with what is called ‘internal impingement’. This occurs specifically in overhead athletes because of the tremendous motion that is necessary to hurl a baseball 90+ mph accurately. During the course of throwing, the arm is cocked back, placing it in an awkward position. In this position, part of the rotator cuff can get pinched between the bone of the ball and the bone of the socket (also often including pinching of the labrum). This may not seem like a big deal, but over time this repetitive motion can begin to take its toll. Experts agree that some changes/damage to the structures of the shoulder are likely normal and adaptive in pitchers rather than problematic. In some cases, however, these structural changes progress down the spectrum and become an issue- causing pain, lack of velocity and/or control and fatigue of the shoulder.
There is not perfect agreement amongst experts about why exactly these athletes begin to have pain in some cases. Regardless, it is likely a very complex combination of factors ranging from subtle changes in mechanics to core strength to gradual loosening of shoulder ligaments over time (and many others). Each individual case is likely different, and treatment needs to be tailored to the specifics of the athlete.
Question 2: How/when did this injury occur?
Typically, this is not an injury that results from a single trauma (though theoretically it can happen that way). It is much more typical for this to be the result of an accumulation of ‘microtraumas’ over a long period of time.
Question 3: Does this injury always need surgery?
No. As mentioned above, painful shoulder impingement in throwers is likely related to a complex set of factors. Because of this, treating any ONE thing with a surgery is somewhat unlikely to be effective. As a result, treatment is almost always begun by trying to calm down inflamed tissues. This typically involves rest from throwing. It may also involve oral medications and in some instances, cortisone injections. There is some discussion around PRP and so-called ‘stem cell’ injections (what orthopedists refer to as Bone Marrow Aspirate Concentrate or BMAC) for these types of problems, though this is not yet something I would consider standard of care.
During this time, the athlete is also likely to undergo physical therapy to work on improving some of the other factors mentioned above- core strength, range of motion, rotator cuff strength, etc.
As the pain and inflammation improve, the athlete is likely re-examined by trainers and physicians. This can take anywhere from a week or two to several weeks depending on the case. When things have improved sufficiently, the athlete is likely to begin an interval throwing program, which involves progressively more aggressive throwing sessions. Once they have completed this, they would likely return to the mound and begin throwing from there. Once appropriate progress has been made (and of course presuming no setbacks are encountered), they are likely cleared to return to play.
The success of non-surgical treatment for these types of problems is all over the map in the literature. There are ranges from percents in the teens to 70%+. Again, it likely depends on a large number of factors which makes prognosticating nearly impossible.
Question 4: How do we tell which cases of impingement need surgery and which do not?
This can be among the most difficult decisions to make when dealing with pitchers. One of the problematic elements is that surgery to treat this problem is comparatively not very successful. As noted above, in general there are likely a number of different structural abnormalities in the shoulder that are in play with this injury. Some of them are adaptive and are considered ‘normally abnormal’ for pitchers. Others are problematic. Separating these two is something about which even experts readily disagree.
It is difficult (and perhaps foolish in this setting) to quote surgery success rates, but in general they are not the best. There is a reason behind the old saying that for pitchers “If it’s the elbow, call the surgeon. If it’s the shoulder, call the preacher.”
Question 5: What is done during surgery?
This is widely variable depending on the specific structures that are injured, and (quite honestly) the particular views of the operating surgeon. I was recently watching a lecture on just this subject that featured a panel of a number of the preeminent North American surgeons that treat these problems. The differences of opinion and differences in strategy between surgeons were substantial. Yet another reason to make significant efforts to make non-surgical treatment successful.
Question 6: How concerning is this for Graterol?
This is hard to know from the information available. As stated earlier, the term ‘impingement’ can mean a wide variety of things- some more concerning than others. One of the positives in this case would seem to be that Graterol was pitching very effectively quite recently. Thus, this doesn’t seem to be something that has been festering for months. Hopefully that means they’ve ‘caught it early’ and can get things back on track sooner than later. I would imagine he will be out for a few weeks at least, but I would be surprised if he required any surgery in the near future.
Overall, many pitchers have occasional blips on the radar with things like this that are improved with rest and rehab and don’t recur in the future. Predicting the future is difficult for anything- and this type of issue especially- but hopefully Graterol can get back on the mound throwing gas soon.