Heezy1323

Thanks for the kind words- good to know my stuff isn't putting everyone asleep I'd be happy to do a surgery focused article. Lots happening at my hospital/practice in the past 24 hrs, so I'll see what I can do... stay tuned.

Chris Sale Tommy John Q&A Heezy 1323 It has been reported that Chris Sale of the Boston Red Sox will undergo UCL reconstruction surgery, also known as Tommy John surgery. Sale has not pitched in a live game since August 13, 2019. He then went on the Injured List on August 17 and did not return for the remainder of the 2019 campaign. He was reportedly seen at that time by several of the best-known US surgeons who care for pitchers and a decision was made to hold off on surgery, and instead try a platelet rich plasma (PRP) injection. He finished the 2019 season with a 6-11 record and ERA north of 4.00, significantly below the standard he had established throughout his excellent career. This is on top of the fact that Sale has yet to even begin his 5-year, $145 million contract extension. Sale will now miss whatever portion of the MLB season is played this year, as well as potentially some part of the 2021 season. A number of questions can often surround a decision such as this, so let’s cover a few things that readers may find helpful. (Disclaimer: As per the usual, I am not an MLB team physician. I have not examined Sale or seen his imaging studies. I am not speaking on behalf of the Red Sox or any other team. This article is for educational purposes only for those who might want to know more about this injury/surgery or about how these types of decisions get made.) Question 1: What is this injury? How does it occur? The ulnar collateral ligament (or UCL) is a strong band of tissue that connects the inner (medial) part of the elbow joint. (Figure 1) Though it is relatively small (about the size of a small paper clip), it is strong. The native UCL is able to withstand around 35 Nm (or about 25 foot pounds) of force. However, by available calculations the force placed on the elbow when throwing a 90mph fastball exceeds this, at around 64 Nm. How, then, does the UCL not tear with each pitch? Fortunately, there are other additional structures around the elbow that are able to ‘share’ this load and allow the UCL to continue to function normally (in most cases). The flexor/pronator muscles in the forearm are the most significant contributor. The geometry of the bones of the elbow also help. In many cases, the UCL is not injured all at once (acutely), but rather by a gradual accumulation of smaller injuries which lead to deterioration and eventual failure of this ligament. When the ligament is injured, it obviously does not function at 100% of its normal capacity- in which case the other structures around the elbow are required to ‘pick up the slack’ in order to continue throwing at the same speed. This is why when a pitcher reports a ‘flexor strain’, there is concern that the UCL is not functioning properly – the muscles of the forearm are being forced to work overtime to compensate for a damaged UCL. There are also cases where the ligament does fail suddenly. These are often accompanied by a ‘pop’ and immediate significant pain. Question 2: What do players report as the problem when their UCL is injured? Most commonly, players report pain with throwing at the inner part of the elbow as the most pronounced symptom. However, other symptoms can also be present including loss of throwing control/accuracy, inability to fully move the elbow, swelling, numbness or tingling of the hand and more. Symptoms can be significant almost immediately, or they can begin very subtly and slowly increase over time. Once they have reached higher levels of baseball, most players are aware of this type of injury (thanks to efforts toward education for coaches, athletic trainers and others) and are able to recognize symptoms and report them to the appropriate personnel. Question 3: Once the player is concerned about an injury to the UCL, what happens next? Most commonly the player will be examined by an athletic trainer or team physician to assess the injury and direct further treatment. Often, xrays will be performed of the elbow to assess the bones of the elbow joint for any abnormalities. There can sometimes be bone spurs, small fractures, bone fragments or other findings on these xrays. However, much of the time the xrays are normal and an MRI may be performed to further assess the situation. An MRI allows us to see the soft tissues around the elbow in addition to the bones. Specifically, we are able to look more closely at the actual UCL itself, the surrounding muscles as well as get a closer look at the nearby bone. (Figure 2) The MRI helps the treatment team get a sense of the integrity of the ligament, which allows for the next step in the process: deciding how to treat the injury. Question 4: How are UCL injuries treated? This is where the challenges often really begin. Much of the time, the UCL will appear abnormal on MRI. There are a handful of grading systems that are used to classify these injuries (one of which, incidentally, I helped create), though there isn’t one that is universally used or agreed upon. Generally speaking, they try to separate injuries into those that are partial tears or complete tears and also try to identify the specific location of the damage. The damage can occur at the upper end of the ligament (called the humeral end), the middle (called midsubstance) or at the lower end of the ligament (called the ulnar end). In those cases where there is a complete tear of the ligament (meaning that the ligament is no longer in continuity and attached at both ends), there is near universal agreement that surgery is typically necessary to allow that athlete to return to competitive throwing activities. The problem, however, is that most MRI’s show a partial injury to the UCL. These injuries can be extremely difficult to predict how they are going to respond to a chosen treatment. In addition, athlete A can have an MRI that looks much more abnormal than athlete B, yet the symptoms of athlete B are substantially worse. This is the basic cause of the uncertainty as it pertains to treatment for this injury. There has been tremendous research performed attempting to quickly identify ways to reliably separate those throwers that are going to need surgery from those that will not. Indeed, with pitchers such as Sale, there can be tens or even a hundred million dollars plus at stake. However, to date there is not a perfected method that can be used for every athlete to make this surgery vs. no surgery decision. Question 5: What non-surgical options are available? There are primarily two non-surgery options available to these athletes, and I’ll attempt to briefly cover them here. A) Physical therapy- the commonly used ‘rest and rehab’ method. This is probably the most important component of any treatment plan, and a good therapist who has specialized training in the care of overhead athletes is critical. Often, the athlete is prescribed rest from throwing in order to allow the UCL an opportunity to ‘settle down’ any inflammation and perhaps perform some healing of the injured tissue. In addition, as we discussed above, the muscles of the forearm contribute to stability of the elbow joint. Strengthening these muscles (along with a number of other muscles throughout the body) contributes to ‘protecting’ the UCL from further injury. As the recovery progresses, a return to throwing program is initiated, usually starting with a small number of throws from a short distance and gradually progressing to longer throws with greater effort and eventually throwing from the mound (for pitchers). This hopefully results in a more well-balanced and mechanically sound athlete who is more evenly distributing the forces of throwing across the various anatomic structures involved. B ) Platelet rich plasm (PRP)- This is a product that is obtained from the athlete’s own blood which is drawn and then spun in a centrifuge to separate the blood into its components. The portion of the blood which contains the platelets is then taken and injected at the site of injury to the UCL. This injection includes a number of chemical signals (called cytokines) that regulate healing and inflammation (along with many other things). The injections are thought to help with healing of these partial UCL injuries. The available data on this is mixed, with some studies showing improved results with PRP and others showing no difference. In the linked study, the rate of ‘successful’ non-surgical treatment was 54% (including both PRP and non-PRP athletes). Question 6: How is the decision to proceed with surgery made? This is probably the most challenging part of the evaluation process of UCL injuries. There are a tremendous number of factors which play a role in this decision. These include the specific characteristics of the athlete (such as age, position, role, contract status, stage of career, desire to continue playing and several others); exam and imaging findings (understanding that these are frequently ambiguous); as well as response to previous non-surgery treatment (to name a few). Often more than one expert opinion is sought, particularly when it is a big name/big contract player. Usually, surgeons will speak with a number of people when considering options including the athlete and family, team doctors and staff, team officials, and other experts (who may or may not have seen the patient themselves). In my experience in these situations, the vast majority of the time there is a consensus amongst those involved how best to proceed. Occasionally there will be differing opinions, in which case the athlete often has to make a choice on how to proceed. Question 7: Why didn’t Sale just go ahead with surgery last fall? I suspect that this is a question that many Red Sox fans are wondering about right now. As discussed above, these decisions are typically difficult and have many contributing factors. While it may seem as though ‘rest and rehab’ never works and everyone should just go ahead and have Tommy John surgery at the first sign of trouble, that is not really borne out in the data. There is some variance depending on the definition of ‘successful return to play’ used in any particular study, but for the most part the rate of success of Tommy John surgery in pitchers is around 80-85%. That means about 1 in 5 never make it back to pitch. This may not seem like bad odds, but I submit that your opinion might change if it was your elbow (and livelihood/contract) at risk. As they say, hindsight is always 20/20. In the case of Sale, I suspect that the season being shortened by the unusual circumstances of coronavirus this year likely also played a role. Once it became clear that a full season would not be played, the decision may have been easier. I think I’ll stop there for now (if anyone has continued to read this far…). If people are interested in technical aspects of how the surgery is performed, please let me know in the comments an I’d be happy to do another post about it. I have spare time currently, as you might imagine. Stay safe everyone, and please listen to the medical professionals who are trying to help us combat this virus. It is a serious threat to our way of life, and we need to treat it as such in order to minimize the damage. Thanks for reading.

I can understand the argument here, and evaluating medical info is definitely fraught with uncertainty in baseball players (as in any human being). Smoltz's shoulder MRI looked like a bomb went off in there- while he was pitching at the top of his game. But if teams are considering investing millions (and in some cases hundreds of millions) of dollars, my view is they should be allowed every opportunity to evaluate their investment to ascertain level of risk. Just like statistics/analytics should be used to project the player's likely level of performance (which is only a best guess, really), medical information needs to be able to be used for risk stratification, IMHO.

Chris Camp from Mayo Clinic (along with a number of others) put together an outstanding review of baseball injuries (MLB and MiLB) from 2011-2016 here: https://journals.sagepub.com/doi/10.1177/0363546518765158 (full text only available with subscription- sorry) Gastrocnemius strain was the 19th most common injury, resulting in a mean of 11.6 days missed (median 4 days). There were 419 recorded injuries during this time. None required surgery. Only 1.4% (6) were repeat injuries. From this data, I think it’s reasonable to suggest that the likelihood of repeat injury is low. FWIW, hamstring injury was the most common injury during this time frame (3,337 injuries) with a re-injury rate of 2.6%. No one can predict the future, obviously. But I believe this injury is likely to be among those with the lowest recurrence likelihood. I was not aware of the ‘rupture’ report as noted above by another post- though a gastroc strain and a gastroc rupture are similar entities (with rupture obviously being a more severe variation). I don’t know of any data specifically regarding reinjury risk for gastroc ‘rupture’. Let’s hope none of it becomes important, and JD anchors the middle of the lineup for like 150 games. Here's a link to the page for gastroc strains that I put in my gallery: http://twinsdaily.com/gallery/image/2694-gastroc-strains/

This is getting fairly 'into the orthopedic weeds', but this internal brace construct (which is the general term for the biotape) is designed to be load-sharing, not load-bearing. Essentially, it is designed to provide time zero strength to the construct to allow for healing without plastic deformation/elongation of the repaired tissue. This does allow for a faster return to sport (in an ideal scenario), but it is yet to be determined if this provides greater strength to failure when compared to a UCL graft once ligamentization of the graft is complete. Lab/cadaver studies can simulate the time zero condition. They are unable to account for healing of the graft over time which certainly has an effect on the construct strength. Being that there have been so few of these done on major league players, I don't think there is enough available data to say that the biotape would result in such an improved likelihood. It may, but I don't think there is enough data to support it at this time. Another point to consider is that in this case, I believe it's likely that Hill was presented the option of repair of his UCL graft with this internal brace versus revision reconstruction, with the difference being that repair MAY allow a quicker return to play. Given his age and stage of career, my best guess is that he opted for the repair to give him a shot to pitch again, as undergoing reconstruction with 1.5 year timeline would likely put him out of baseball. As a result, I don't think even the limited results of UCL repair (which is typically done in young players on an otherwise normal ligament with a focal injury) can be extrapolated to Hill. You're certainly welcome to disagree- I would absolutely not advertise my opinions as fact. I also hope I'm being pessimistic and Hill knocks everyone's socks off this year. But from my end of the microscope, I'm skeptical.

One important difference here is that Hill had a repair not of his own UCL, but of a previously reconstructed UCL. This makes him different from Manness, into another category altogether. I am not aware that this has been done successfully at the major league level. Also, you can't compare Hill to a typical UCL reconstruction for purposes of return to play percentage. He is, at best case, comparable to a revision UCL reconstruction, which has a MUCH lower rate of return to MLB-level play. Most studies I have seen put that number around 40-50%. I hope I am wrong on this front, and Hill doesn't need to return to throwing 97 mph to be effective (i.e. less stress on elbow), but I would put his odds for returning to meaningful contribution to the Twins this year around 50%. Great review- thanks for a well-done article.

Totally agree- he did seem to be grabbing hamstring area at first. But seeing the replay, his ankle definitely inverted. There certainly could be more than one thing going on, but that would be unusual. An inversion injury would be a very odd way to rupture the Achilles.

Speculation is just that, but to me Arraez injury looked like an ankle sprain-type mechanism rather than Achilles (as postulated by another poster). The fact that he seemed to be unable to bear any weight on it is concerning, but may or may not ultimately be predictive of the severity of the problem. I suspect he will get X-rays soon (if he hasn't already) and we may hear something yet today regarding fracture vs. no fracture. Obviously no fracture would be better, but even a bad ankle sprain can sometimes take a few weeks to heal to the degree necessary to allow playing at this level. It's possible an MRI may be utilized as well, but they aren't always used if the diagnosis is an ankle sprain. Whatever the case, let's hope for the best for such an impressive young player who has been so important to the Twins the latter part of the season.

Obviously I don't have any specific knowledge of Buxton's case, so I really can't say with any certainty. But, I can give my interpretation of the freely available info. Buxton's issue has been called subluxation, which typically means less significant structural damage as compared to a dislocation. As a result, there is typically not a need for as extensive surgery (when surgery is needed). Because there is usually less damage to the ligaments/labrum, fewer anchors and less tightening of the tissue around the shoulder would be expected. This (hopefully) means easier recovery of range of motion after surgery, which hopefully will lead to fewer problems with overall function and (hopefully) a slightly quicker recovery than more extensive surgery. It can often take several months for recovery (I think I saw somewhere a 5-6 month timetable, which I would consider about right). Once 'recovered', there can still be some additional time needed to be 'back to normal'. I often specify to my patients that I would define 'recovered' differently from 'back to normal'. Sometimes those two are the same, and sometimes it takes more time to feel 'normal'. On occasion, the joint never feels back to 'normal', but many athletes can adapt to their 'new normal' and perform at a very high level. So to answer your question, I would expect the surgery to have a more significant effect on Buxton's hitting than his fielding. The magnitude of that difference is basically impossible to predict with any reliability. Despite Buxton's many injury issues, I don't recall ever reading anything regarding him being less than diligent about his recovery, and I would expect this to be no different. My guess is that he will be a full go either at the beginning of spring training or soon thereafter- though obviously many things could happen between now and then that could have an effect on that. For Byron's and the Twins' sake, I hope everything goes smoothly and he is back to his speedy, joy-to-watch self. Dr. ElAttrache is certainly a well-respected surgeon within the orthopedic world, so he is in good hands.

A bummer for Buxton and the Twins. I'm sure they were hoping to avoid surgery, but in some cases it becomes clear that it just isn't going to be possible. For those interested, I did an old blog post regarding Wander Javier's shoulder surgery, which I suspect is quite similar to what Buxton is going through. Feel free to post with additional questions and I’ll do what I can. http://twinsdaily.com/blog/1036/entry-11043-wander-javier-injury-qa/

Tennis serving has some similarities to throwing so the issues are sometimes similar. The shoulder can be tricky for sure- a lot of times there is a list of two or more possible diagnoses. Glad I can help a little! If it's anything like my shoulder, it always feels a little better when the Twins win haha

Did some additional research. In Camp's study quoted in my blog, they found over 1200 cases of proximal biceps tendinitis. 2% of those cases were 'repeat' cases during the study period (2011-2016), so it seems as though the vast majority are 'new' cases (which was my suspicion). Hope that helps.

Nicely done article Nick. I've enjoyed the discussion as well. For this who are interested, I wrote a blog post about biceps tendinitis here: http://twinsdaily.com/blog/1036/entry-11602-biceps-tendinitis-qa/ My guess would be that it was bothering him a little bit, but that he didn't think it was having a signifiant effect on his performance while in SF, and therefore didn't say anything (you can have a valid argument regarding whether this is appropriate or not, but that is a different discussion). He was likely hoping it would settle down over some time (which these issues often do), but had some issues his first couple outings here and was asked about it- at which point this came to light. It seems unlikely to me they would have put him back out there for his second appearance if they had know of a problem after the first (IMHO).

I suppose it's possible to have pain at both ends of the muscle, but I would think that it's uncommon. Similar to how it is difficult to break a chain in multiple locations at once, usually the most susceptible area becomes symptomatic first. There are a number of other anatomic issues that can appear similar to these conditions that can be difficult to sort through. This is a tough area to say much of anything with certainty.

Good question. That's always a possibility, but I'm not able to find any data on 'return trips to the IL for same diagnosis within a season'. Would be an interesting study for sure. My best guess is that it is typically a 'one-off' issue that when addressed appropriately recurrence can be avoided. Though as usual, nothing is 100%.

http://twinsdaily.com/blog/1036/entry-11602-biceps-tendinitis-qa/ See what you think. It's not exhaustive, but hopefully it's informative. Hope you enjoy!

Biceps Tendinitis in Pitchers Q&A Heezy1323 A request was made by a poster for me to write a blog covering biceps tendinitis. This is actually a fairly complicated topic with quite a bit of controversy, but I’ll do my best to share some basic info that hopefully TD peeps will find interesting. There are some technical parts, so apologies for that, but I do think a basic understanding of the anatomy is helpful. Question 1: What is the biceps, exactly? The biceps is a muscle that we are likely all familiar with, lying in the front of the upper arm and used to perform curls and similar exercises. The word ‘biceps’ has a Latin origin meaning ‘two heads’. This describes the upper (or proximal) end of the biceps where there are two tendon attachments. The first is the long head of the biceps which attaches to the labrum at the top of the socket in the shoulder. It then curves over the top of the ball (humeral head) where it exits the shoulder joint and begins its course down the front of the upper arm bone (humerus). At the front of the shoulder joint, it travels through what is called the ‘bicipital groove’ which is an area of the bone of the humerus between two bumps (called tuberosities). This groove is often the site of issues in pitchers (more on this below). The second is the short head of the biceps, which originates from a bony projection off the shoulder blade in the front of your shoulder called the coracoid. It travels straight from here to meet up with the long head of the biceps in the upper 1/3 of the arm. There, the tendons join and form the biceps muscle. Below this (distally), the muscle turns back into a tendon just above the elbow and a single tendon then travels down to one of the bones of your forearm (called the radius) where it attaches at a bony prominence called the radial tuberosity. Question 2: How is this tendon involved in throwing? This is a great question, and a subject of much debate amongst experts. The short head of the biceps likely has a relatively insignificant role in throwing. The long head (which is the one that attaches inside the shoulder joint) is much more involved in the throwing motion. When throwing at MLB speeds, the shoulder rotates at 7000 degrees per second, which is the fastest known human motion. One can imagine the stress this places on the structures that surround the shoulder. Without delving into the weeds too much, it seems as though the biceps has a role in position sense of the shoulder during throwing, likely a role in stability of the shoulder joint and also helps slow down the arm after ball release. At the other end of the tendon (distal), the elbow changes rapidly from a bent position to a straight position as the ball is released during a throw. In order to keep the bones of the elbow from jamming into each other at a high speed, the biceps muscle fires to slow down this elbow straightening (what we call an eccentric contraction). This allows some of the force of throwing to be dissipated by the muscle (kind of like a shock absorber). If it seems like that is a lot of jobs for a small tendon/muscle- it’s because it is… Question 3: What happens when someone gets biceps tendinitis? Tendinitis is a fairly broad term and can mean a number of different things depending on the context. With respect to the biceps, a thrower can develop issues at either the upper (proximal) or lower (distal) end of the biceps. The suffix -itis means inflammation, so the general thought is that there is inflammation that develops in or around the tendon. The reasons ‘why’ are heavily debated, but generally there is probably some combination of overuse/fatigue and altered mechanics or muscle imbalances that contribute. It takes a tremendous amount of efficiency of motion and coordination of muscle movements to throw a baseball in excess of 90mph, and any small abnormality can easily be compounded by the sheer number of repetitions and intensity of a typical pitcher. Over time, this can add up to cause damage to the tendon and result in inflammation and pain. Arthroscopic image of normal biceps tendon (left) and inflamed biceps (right) Question 4: How does the player/medical staff separate this injury from other issues that can seem very similar? This can be VERY difficult. Often the player will have pain at the front of the shoulder (in cases of proximal biceps tendinitis) or just above the elbow (in distal cases). A thorough history and exam is performed in order to hone in on the likely problem area. An MRI is ordered in some cases. One of the challenges with this type of issue is that in many cases, an MRI of a pitcher already has some abnormalities on it which are likely adaptive and have been present for a long time (and are not the actual cause of pain). In addition, in many cases the inflammation around the bicep isn’t something that can be clearly seen on MRI. So interpreting imaging studies can be a significant challenge. Usually the exam is (in my experience) the most helpful thing in recognizing biceps tendinitis when it is present. The athlete is usually tender right in the area of the tendon, which is a helpful finding. Question 5: Once a pitcher is diagnosed with biceps tendinitis, how are they treated? Again, there are a lot of variables here. But presuming it is significant enough to affect the performance of the pitcher, they would typically be shut down for a period of time to prevent worsening of the condition. Anti-inflammatory medication may be used. In some cases, injections of cortisone are used to try and decrease the inflammation. With the recent increases in the use of technology, video may be consulted to see if there have been subtle mechanical changes which may have contributed to the issue. Muscle strength can also be tested in various areas around the shoulder to see if weakness is contributing. In essentially all cases, a rehab program will begin that is likely to include strength and flexibility components. When the pain has subsided, a return to throwing program is begun and once complete, the athlete can return to play. A group out of Mayo Clinic (led by Dr. Chris Camp) recently did a study of pro baseball players (minor and major league) and causes of injury over a several year period. Tendinitis of the proximal biceps was actually the #4 cause of injury with an average return to play time of about 22 days. Question 6: Is surgery ever needed? It is quite uncommon for surgery to be needed for this issue. In fact, in Dr. Camp’s study above surgery was only required in 3% of cases of proximal biceps tendinitis. So clearly most of these cases improve with non-surgical treatment. In addition, surgery for this particular issue has a fairly poor track record and is avoided if at all possible. Question 7: What can be done to prevent biceps tendinitis? Great question, reader. If I knew the answer, we could likely both be millionaires given how common this injury is and the dollar figures involved when a high-priced starter or reliever is on the shelf for this reason. Generally, I believe monitoring the workload of pitchers through the season, doing what you can to ensure they maintain a good off-season program and having a good line of communication with the players are all important. As video analysis and other analytic measures become more popular, my hope is that they can be incorporated into injury prevention as well. Thanks for humoring me on this complex topic. Please feel free to add a request for a future subject in the comments. GO TWINS!!

Let me see what I can do... This is actually a fairly controversial area with probably more questions than answers, but I'll do a little lit review and try to put something together.