Heezy1323

If you had to choose, you would likely choose the non-throwing shoulder (obviously). But an injury to the front shoulder of a hitter is also not ideal, depending on the part of the labrum that has an injury. There is more flexibility required of the front shoulder when swinging and this type of surgery can sometimes alter the flexibility- hopefully temporarily until rehab is complete.

Im sure most here are aware that Royce Lewis strained his hamstring last night during the Twins vs. Reds game. It looked like he may have been a bit hobbled running to first earlier in the game, but returned to hit in the 8th inning. During the at bat, he appeared to aggravate the hamstring and had to leave the game. The Twins are calling this a day-to-day injury at this point. In 2018, Dr. Chris Camp (the Twins Head Team Physician) and others published the following report: This article and it's appendices give us great information about a wide range of different injuries to MLB and MiLB players over a period of several years. The injuries in this article span from 2011-2016 (as noted above), so there may be some changes over the past handful of seasons. But I believe the information is still relatively valuable. Here is what it has to say about Hamstring Strains (which happen to be the #1 most common injury during this time period): You can see the mean number of days missed is 14.5, with the median at 9. The majority of these occur while running (56%). Here is some additional context: Certainly unfortunate for Lewis and the Twins. The have 13 days until a likely playoff opener on 10/3. Let's cross our fingers and hope Royce is ready to go. (Cover photo credit Jeff Dean, Associated Press)

I agree with most everyone's thoughts on Paddack, Alcala, Stewart and Gordon. Not sure I have any meaningful insight there, from a medical standpoint. As far as Buxton… it's hard to know. It sort of depends on if we take the information at face value or if we 'read between the lines'. At face value, there can be an in-folding of the joint lining called a plica that can sometimes cause discomfort in the knee. It can rub along the edge of the femur and cause irritation and pain. In my experience, it is uncommon for this to be an issue of any significance, but it is possible. If we are reading between the lines, I am somewhat skeptical. If there had been a plica in Byron's knee, and it was anything of significance, I would think it would have been removed during his procedure last year. It is possible a new plica formed since surgery, I suppose. My speculation (emphasis on speculation) would be that the issue continues to be the surface cartilage issue that has been previously discussed. Cortisone injections can be used to treat both of these things (cartilage issue and plica). The idea being that the cortisone decreases inflammation within the knee, hopefully thereby helping swelling and pain. Other types of injections, such as platelet rich plasma (PRP) can also be used in a similar way (though there is less available data to support their use). I believe he has had PRP injections in the past as well. What I personally take away from this is that the Twins/BB are trying all possible avenues to get Buxton's knee settled down to something resembling normal in time to contribute for the playoffs. By all accounts, Byron has an exceptional determination to play, despite his injury ledger. However, given his history, I am skeptical his knee will suddenly 'turn the corner' to the point that he can withstand significant time in CF. That said, I will be the first to say that I have no first hand knowledge of his situation. There could absolutely be important details I am missing. I hope I'm wrong. There's nothing I'd love to see more than Byron running down a line drive in the gap or legging out a triple in October. But I have to say it will surprise me if I do. *insert sad face emoji*

I appreciate the kind words. I'm never quite sure when to 'chime in' vs not. Please feel free to tag me in future posts if you have questions, and I'll do my best to answer back. I don't read TD every day, but try to check here often. Between the Athletic and the Gleeman/Geek podcasts, there's so much great twins content.

I have heard rumblings (I have no specific information or anything like that) that the issue in his knee is as you say- damage to the surface cartilage. I have heard the area is in what's called the trochlea, which is the area in the front of the knee where the patella (kneecap) glides. You are mostly correct about the current technology. We do have some different methods to 'replace' the cartilage, but none of them make it 'good as new'. And there have not been too many instances where these procedures have been able to stand up to the rigors of professional sports for any considerable length of time. Some people, for reasons unclear, can tolerate even large cartilage lesions in their knee with minimal or no symptoms. Other people can have significant symptoms from even a small area of cartilage injury. It's highly variable. With the majority of these lesions in elite level athletes, we often attempt a 'clean-up' type procedure first, which is what I suspect Buxton had last year. This includes shaving some loose cartilage away and removing any floating pieces, etc. But this procedure does not 'fix' the root cause of the issue. The irregularity of the gliding cartilage remains. In many cases, people do well despite the irregularity (I don't always understand why it happens that way, it just does sometimes). In other cases, people continue to have trouble with the area, in which case the choices get more difficult. You can treat with rest/rehab/injections (as he has been). You can try to repeat the same surgery hoping for different results (always risky). Or you can try one of a handful of types of cartilage restoration surgeries. Without knowing the details on exact size, location, depth and several other factors, it's hard to say which of these would be best for someone like Byron. But they all require fairly lengthy recoveries. (A recent athlete with something like this is Lonzo Ball, who will miss the entire upcoming NBA season). From my perspective, it's also hard to know if this current issue he is having is actually patella tendinitis (totally possible from trying to ramp up activity) versus 'he is having pain in the front of the knee, and we are going to use the term 'patella tendinitis' to report it, but in reality he is having pain due to the cartilage damage area.' These two things will often result in similar symptoms, and it can be hard to differentiate which is the true cause of pain. In any case, a big bummer for Byron. I sure hope he can get things settled down and get back to roaming CF at 100mph like we all love to watch him do. As always, that's my $0.02. I am not a Twins team physician and have not examined Byron or seen any of his imaging or anything like that. This is purely speculative on my part.

I largely agree with you @Lucas Seehafer PT. Allow me to play devil's advocate to some degree. What do you think is the SPECIFIC question being asked of the consulting doctors (Dr. Anderson et al.)? I think it is most likely something along the lines of "Do you see anything on this imaging study (xray/MRI) that would indicate that there is the chance of Carlos developing an ankle problem that limits his function in the next 10-12 years?" I don't believe that is a question you can answer using the 'functional model' you are describing. The MD isn't being asked about how he is currently performing or how he has performed in the past. Everyone involved knows the CC of today is an incredible player. If the MD says, "Well, I see some arthritis on this MRI, but he is currently functioning fine," the response is going to be- "OK great. What does that mean for his future?" As such, the MD is essentially forced to make a prediction. Are predictions always correct? Absolutely not. But I don't think that the argument that "He is functioning just fine today" satisfies the question being asked. Also, the MRI here is not 'predicting future injury' to use a term you used. It is, more precisely, 'documenting the current state of the ankle'. This may seem like semantics, but I don't believe it is. The injury isn't being predicted- it is already there (presuming my assumption of some ankle arthritis is accurate). What is being predicted is how this ankle will hold up over time given the amount of arthritis currently present. Now, is there some room for subjectivity as to how an ankle with some arthritis will hold up over time? One hundred percent yes. This is likely (IMHO) where the MDs differed in their opinions. Or, perhaps the MDs said similar things, but team officials chose to utilize that information differently. I don't think we can say for sure. In any event, I thought your article was a very good synopsis. I agree entirely with the last 2/3 of it. Well done.

How do they know exactly what he said? All they know is that the Giants deal seemed to hinge on his feedback about the MRI. Not exactly what the feedback was. Allow me to phrase another way. Why NOT ask him? What is to lose by collecting all available information? You can always choose to disregard it. For $300 million, I am of the opinion that a 15 minute phone call is reasonable.

I think this is a great read of the situation. I agree entirely.

You don't believe the Mets spoke (at minimum) with any of their own physicians? I think this is tremendously unlikely.

Why is it that you find this weird? He is the preeminent foot/ankle physician for professional athletes in the world. The "Dr. James Andrews" of foot and ankle. Essentially every high level athlete seeks his opinion after an injury. I don't think it's weird at all. I would want to know what his concerns were. I may or may not choose to abide by his recommendations, but I sure as hell would want to know what he had to say. He didn't get to his level by accident.

IMO, this is VERY unlikely to be the case. These plates/screws just don’t suddenly come loose after 8 years. If something happened at the slide, the most likely disaster is fracture of the bone directly above the plate (which obviously didn’t happen here). I still like my theory of low-grade arthritis stemming from his original injury. Other possibilities exist, for sure.

I didn't intend my reply to come across as snarky. I certainly didn't take your response disrespectfully. Mine was simply an honest take (as I see it): This was, for all practical purposes, a one year deal. I'm guessing the team reviewed his medicals at hand, but did not require repeat imaging of *all* prior injured areas (again, due to this being effectively a 1 year deal). IMO, this is because anything that is not recently/currently bothering Carlos is unlikely to become important over the course of one year. To be clear, I'm not endorsing this approach as foolproof or the most ideal approach. I'm only giving my thoughts on what may have happened. I don't think I'm able to comment intelligently on what threshold exists for *standard* due diligence and *extreme* due diligence. I think most people would agree that a different level of scrutiny is necessary for a 10-year and what is effectively a 1-year deal.

IMO, this wasn’t a 3 year deal. It was a “3 year deal” in which essentially everyone involved knew it was a one year deal absent extraordinarily unusual circumstances. You’re welcome to disagree with my reasoning. I have no idea if I’m correct or not. It’s just the most plausible explanation to me given what we know.

Here's my $0.02: (I have no insider info) I think the most likely scenario is that Correa fell into the Twins lap quickly last year, and everyone recognized it was most likely a 1 year arrangement. So the level of due diligence required by the medical staff is lower. Imaging of all prior nicks/bruises isn't necessary in that case. This time around given the commitment of 10+ years, teams were being more diligent and likely getting new imaging of any body part that had ever been treated for an injury (surgically or not). My guess is that the imaging of his ankle shows some early arthritis related to the ankle fracture that was fixed 8 years ago. This is something that is essentially impossible to "fix" in the traditional sense. And it may be mild enough at this point in time that it isn't causing him any significant symptoms (hence no issue made of it last offseason). But imaging can still show some early signs of arthritis, even before a person has symptoms. My guess is that the Giants docs saw this, and said something to the effect of, "This ankle has some early arthritis. This is something that generally is going to get worse over time, at a rate that is impossible to know. As it worsens, it is likely to affect Correa's ability to perform quick movements and may require a position change. Worst case scenario, it could be progress more rapidly and be a significant hindrance to him playing at an effective level." There are certainly other possible explanations. This is the one that seems to fit the circumstances best as I think about it. Merry Christmas/Happy Holidays all.

I appreciate your further explanation. My response was perhaps a bit unfair, in that there were a few posts that questioned the aptitude of the medical staff, and I just chose yours to quote. My response was probably a more generally directed response to that notion, rather than a specific retort to your post. IMO your concerns are valid, and also highlight the incredibly complex nature of this type of decision-making. These are tough problems to solve. I would argue that they are even tough problems to 'measure' in any consistent or meaningful way, much less 'solve'. Thanks for your response.

That's an interesting question. My assumption has been that the force generated at the wrist is primarily from the swing itself, not necessarily the contact with the ball. But I would say I don't honestly know the difference in forces across the wrist on a swing and miss vs. a swing that makes contact. My best guess (and I would call it a guess) is that the gloves probably wouldn't make a difference unless they were quite thick/cushy, in which case they probably aren't realistically useful for an MLB hitter. Would be an interesting study...

I understand the frustration with injuries on the Twins. I understand the tendency to look for systems or people to blame. But the unfortunate truth is, it just doesn't work like that. The WWII analogy would be great, if baseball players were made from identical parts on an assembly line and reacted exactly the same way to the same adverse conditions. But the challenge of medicine, sports science/performance and similar fields is that there are hundreds, probably thousands of unknowns. And not just unknowns that exist because they haven't been studied- unknowns that cannot possibly be known under any circumstances. Is it possible that the medical and/or training staff of the Twins is underperforming? Sure, I suppose that's possible. I am not a Twins physician, but I know those who are. They are admirable docs, among the brightest in the field. Isn't it also possible that there is bad luck involved? Or that the scouting department is choosing to draft or trade for players who are prone to injury? Or not weighting the input from the medical team heavily enough? Or, is it possible… juuuuuuuuust possible, that this stuff is really frickin' hard. And despite having brilliant people working tremendously hard to solve these types of issues- some injuries are inevitable. I'm not trying to carry water for the Twins or anyone/anything else here. I have no vested interest in others' opinions of Twins or their team physicians. But I am familiar with the challenges of solving these types of problems- I do it on a daily basis. It's hard. An in my opinion, assuming it is due to incompetence undersells the difficulty of it by a substantial margin.

I'd be speaking out of turn if I said I am intimately familiar with the rehab of this surgery, but February puts us about 7 months from surgery. I think that's a very reasonable time frame for something like this. It's possible I'm wrong here, and there's more to it than I know, but I feel comfortable with that timeline.

I can assure you this is not the case.

I would humbly suggest that this part is actually the easy part. We know how long the ulna is 'supposed' to be, relative to the radius (the bone next to it). A fairly straightforward calculation can be made to identify the amount of bone that needs to be removed to 'normalize' the length. And there are jigs that can be used that account for the amount of bone, thickness of the saw blade (kerf), etc to obtain a precise removal. In my view, the more challenging things here are: 1) Deciding when to pull the rip cord and go ahead with the surgery 2) Predicting for Alex exactly how his body will respond and what effect this will have on his swing mechanics going forward 3) Identifying a timeline for recovery (as this can sometimes vary substantially from patient to patient) 4) Worrying about potential complications that can arise For the most part, as a surgeon I feel like the surgery is the thing I have 'control' over, where as so many of these other things are out of our control (either partially or entirely). I tend to stress about things I can't control (rightly or wrongly, I suppose one could argue).

I suspect this is precisely correct.

Not sure how much help I will be here, but I'm happy to put in my $0.02. I don't see many wrist issues in my practice, so this topic is out of my area of true expertise. Lucas did a great job covering this topic in the article. I tend to think of the TFCC much like the meniscus in the knee. It is designed to function as a cushion or shock absorber for loads across the wrist. Since most of us don't walk on our hands, the wrist 'meniscus' sees much less stress that the meniscus in the knee. This is why this type of injury/problem is uncommon in the general population. However, certain movements or activities (such as swinging a bat/golf club/tennis racket) do cause additional stress on this area. In a perfect world, the TFCC is up to the challenge of withstanding these stresses. However, some people have an ulna that is a shade longer than ideal (and we really are talking about a difference of just a few millimeters here). This can add enough stress to the area that the TFCC can begin to break down. As in the knee, when the meniscus is not fully performing its normal 'shock absorber' function, that stress is then transmitted instead to the surrounding structures. In this case, that is the cartilage of the small bones of the wrist (which is what it sounds like was addressed at his original surgery). Often, going in and 'cleaning things up' and repairing the TFCC injury is all that's needed. It is just unfortunate that in this case the more simple procedure didn't turn out to be very durable (meaning its positive effect didn't last very long). I also tend to agree with the option of trying a cortisone injection or two, to see if that can alleviate the problem as well. When things don't progress as we would like, and people still have pain in the wrist, the next option is to try to do something to change the mechanics of the area to lessen the stress. In this type of situation, that means shortening the ulna to offload the TFCC and cartilage in the area. The surgery is typically performed (at least as I understand it- I don't do this type of surgery) by cutting the bone, removing a small wafer of bone, and using a plate and screws to bring the bone edges back together. In this type of surgery, you are essentially 'creating' a fracture, and the body needs to do the work of healing the bone, just as it would a fracture that happens if someone was to fall and hurt their wrist traumatically. If it sounds like this is a significantly more aggressive surgery than the first type, you're right. Any time you perform a more complex surgery, it introduces additional risk of complications. If an athlete/surgeon had a crystal ball and could know in advance that the first surgery was not going to be totally successful, obviously neither would choose the first surgery. But that luxury doesn't exist, so we constantly have to balance risks and benefits when making these difficult decisions. I would be willing to bet that this possibility was discussed with Alex at the time of his first surgery, and he was perhaps even given the option to do the more aggressive surgery first (this is pure speculation on my part). I completely agree with Lucas that the success rate of this type of surgery on athletes is not well-studied. This makes it challenging to recommend it as a first-line procedure, particularly for professional athletes whose livelihood depends on milliseconds of reaction time and the generation of tremendous force. It's definitely unfortunate that Alex needs to have additional surgery, but as best I can understand the issues from the information available, the history leading up to this point and the plan going forward make a lot of sense to me. Fingers crossed that he can heal up and get back to mashing baseballs soon. Happy to try and answer questions if people have any. This was probably all clear as mud... Nice job, @Lucas Seehafer PT. Another tough topic to cover.

Great job Lucas. Difficult subject to describe using words alone. The analogy I use with patients when I recommend/perform this procedure in conjunction with an ACL reconstruction is that they should try to think of the knee like a steering wheel. The ACL is located in the center of the knee joint (steering wheel), while the ALL is located on the outer (lateral) edge of the steering wheel. Now imagine you are trying to hold the steering wheel of your car, and prevent it from turning. If you hold the steering wheel in the middle (ACL), it is hard to resist the wheel turning forcefully. However, if you hold the steering wheel on the outer portion (where we would typically put our hands), it is much easier to resist the rotation of the steering wheel. This represents the ALL. By performing the lateral extra-articular tenodesis (LET), you are recreating the ALL. This more easily resists the rotation forces that can put extra stress on the ACL. The data on the use of LET is intriguing, but it would be inaccurate (IMO) to say that it is conclusive at this point. I am mostly using the LET in re-do scenarios (such as Royce's) and select first-time surgeries where there is a more extensive injury or some other patient factors. Another interesting question I have not yet seen reported is- what type of graft did Royce have? I would assume he had a patellar tendon graft the first time around, and most commonly the graft is taken from the injured knee (though there are some surgeons who take it from the opposite knee the first time around). One of the (many) challenges of a revision situation is that most typically, the preferred choice for ACL graft was used the first time around. So the options are to go to the other knee and use the same type of graft, or to use a different type of graft from the injured knee (most typically quadriceps tendon or hamstring tendon). This can have an effect on recovery as well (if the 'other' knee requires rehab too, due to the graft harvest). Such a bummer for Royce, he was having such a promising debut. As if the kid needed any more adversity...

Good summary Lucas. I see bone bruises such as this fairly frequently, and they can be present for a number of different reasons. I tend to view them on the MRI images where fluid/edema shows up bright (T2 or PD FS), so I think of them as bright spots on MRI more than dark spots. Most likely, this is a result of the femur slamming into the tibia, causing a bruise just like you might get on your thigh if you accidentally bump into the edge of a table or something like that. Your description of the bone in that area is spot on- I tend to describe it to patients as kind of like a puffy cheeto. It is softer bone than in the shaft of longbones, and as a result is more susceptible to injuries like this. The timetable for recovery is dependent on a number of factors including the specific size and location of the bone bruise, the initial severity, whether it is present on both the femur AND tibia (called a kissing lesion) or on just one side, the alignment of the leg and probably several others. In my experience working with athletes, these always take longer than you think. If I had to guess, I would say 4 weeks would be the minimum for a full return (though I hope I'm wrong). Of course, bone bruises can (and often do) occur with ACL tears, so it's good to hear that the ACL graft appears to be fine. That would be a relative disaster in this case, obviously. This image shows an MRI of a knee with the darker gray areas being normal bone, and the brighter areas being the area of the bone bruise in this particular case.

With respect to the differing timelines, I covered a fair bit of that in this blog post a while back. Obviously, no one would willingly choose a procedure with a 12-18 month recovery when one with an expected 9-12 month recovery is also available. The distinction comes down to location of the tear within the UCL and the overall condition of the ligament. UCL Primary Repair (the shorter recovery procedure) is now being done on more and more elite level pitchers, but it isn't available to anyone and everyone. Only those injuries with certain features. It is being performed on very few cases of those with a prior UCL reconstruction (Rich Hill being the only one I know of- there could be more). Separately, there is some work now being done on adding what is called an 'internal brace' suture to UCL reconstructions. This is something that is done on all UCL Primary Repairs. The thought is that the internal brace helps protect the healing graft, and perhaps would allow for a more aggressive rehab and sooner return to play as a result. While this is an intriguing idea, it is not yet definitively known if/how much this will shorten the recovery timeline for UCL reconstruction. I can go into more detail if readers would like, but I figure I'd put in my $0.02.