Heezy1323

I took my 3 year old son to his first game today. He did pretty well until about the 8th inning (which was over 3:10 from first pitch) so we left after the Twins gave up the lead. Heard them take it back on the radio, then I got home just in time to see them blow the lead in the 9th, then Dozier's slam. Would've been great to see the slam in person, but 4.5 hrs for a ten inning game just ain't happening for a 3 year old. Glad they could pull this one out- would've been a shame to let it slip away as much as they battled.

There are many MLB team physicians that are very active in baseball/throwing related research, though essentially all pro team physicians (as far as I am aware, anyway) maintain a practice that probably limits their ability to spend the needed time on such concerns specifically for an MLB team. However, there are many situations (Rush in Chicago, Hospital for Special Surgery and Columbia in NY, Kerlan-Jobe clinic in LA, Andrews Institute in Pensacola for example) where physicians are part of a team of athletic trainers, biomechanists, research assistants, surgeons/physicians in training, strength and conditioning coaches and others that are studying things like you mention. In most of these situations, this is academic research that is published in the geeky journals I read. I would assume there are some things going on within teams that produces proprietary information, but I'm not privy to that info. More likely (I suspect) is that the teams use the data produced by those mentioned above and apply it to their draft/development strategy as their internal people prefer.

There are some studies that seem to show that a slider places more stress on the elbow, but I haven't seen any studies that directly relate slider % to need for TJ. I think of this in a similar way to the current concussion situation. We are realizing that it's not necessarily the 'big hits' that cause CTE down the road, its the collection of numerous 'subconcussive blows' that end up being the problem. Similarly, it's (usually) not just a single pitch that injures a UCL, rather a collection of thousands of incidents of 'micro damage' done over time that eventually adds up to the ligament being insufficiently strong to support a pitcher's elbow. There may be one pitch that causes the ligament to finally 'tear', but IMHO the ligament is very rarely normal one pitch, then completely torn the next.

A few things worth mentioning regarding this... 1) Graterol is almost certainly done growing, so growth plates are not an issue. 2) Age does not appear to be related to the likelihood of UCL reconstruction in most studies that I am aware of. The UCL is certainly fully formed by this time, and doesn't change considerably in it's constitution after probably 12-13 years of age. 3) Fastball velocity does not appear to be related to likelihood of undergoing TJ 4) About 15% of minor league and 25% of major league pitchers have undergone TJ (so 'nearly every single case' is probably a bit of an overstatement). Here is a portion of an article abstract from the Journal of Shoulder and Elbow Surgery in 2016 (Volume 25, Issue 4, April 2016, Pages 671-675 Keller et al.) Background The number of Major League Baseball (MLB) pitchers requiring ulnar collateral ligament (UCL) reconstructions is increasing. Recent literature has attempted to correlate specific stresses placed on the throwing arm to risk for UCL injury, with limited results. Methods Eighty-three MLB pitchers who underwent primary UCL reconstruction were evaluated. Pitching velocity and percent of pitch type thrown (fastball, curve ball, slider, and change-up) were evaluated 2 years before and after surgery. Data were compared with control pitchers matched for age, position, size, innings pitched, and experience. Results The evaluation of pitch velocity compared with matched controls found no differences in pre-UCL reconstruction pitch velocities for fastballs (91.5 vs. 91.2 miles per hour [mph], P = .69), curveballs (78.2 vs. 77.9 mph, P = .92), sliders (83.3 vs. 83.5 mph, P = .88), or change-ups (83.9 vs. 83.8 mph, P = .96). When the percentage of pitches thrown was evaluated, UCL reconstructed pitchers pitch significantly more fastballs than controls (46.7% vs. 39.4%, P = .035). This correlated to a 2% increase in risk for UCL injury for every 1% increase in fastballs thrown. Pitching more than 48% fastballs was a significant predictor of UCL injury, because pitchers over this threshold required reconstruction (P = .006). Conclusion MLB pitchers requiring UCL reconstruction do not pitch at higher velocities than matched controls, and pitch velocity does not appear to be a risk factor for UCL reconstruction. However, MLB pitchers who pitch a high percentage of fastballs may be at increased risk for UCL injury because pitching a higher percent of fastballs appears to be a risk factor for UCL reconstruction. I recognize it is wordy, but basically it showed no directly correlation between fastball velocity and TJ surgery. It did, however, show a relationship between percentage of fastballs and TJ. Other studies have shown similar results, with some studies conflicting. As always, the truth is likely somewhere in the middle.

Thank you for the very kind words. I am fortunate to be able to do something I love. Probably the thing I enjoy most in clinic is when a patient tells me at the end of an appointment, "Thanks for explaining that to me doc, I understand it a lot better now." I'm hopeful that I can occasionally bring some of that to TD.

Sure! I love talking elbows! I actually saw two local teenagers this week that need Tommy John surgery. Not my favorite discussion to have, but unfortunately something I see too frequently. Pitching is awfully hard on the shoulder and elbow. To me, it's a wonder that anyone can actually make it to MLB and have a long pro career given the stresses of throwing (though I probably have a bias because I tend to see the injured throwers). We do appear to be in a wave of growing recognition of the problems of overuse and sport specialization, but these injuries can clearly still occur even under ideal conditions.

Yes, that's correct. Nearly all tissues in your body are constantly in a state of equilibrium between 'build-up' and 'break-down'. Sometimes, for various reasons, the balance can get tilted in favor of 'break-down', which is when trouble can occur. Usually some rest and rehab will restore the balance, but of course there can be times where that doesn't do the trick, and something else is required (i.e. surgery, PRP, stem cell treatments, etc.)

I think his age only contributes to the extent that for the most part only young people are active enough to get this problem. By age 19, most males are done growing, though it's possible he isn't. If he isn't, that could be a factor. I think the most likely issue is relative overuse, given that he has likely played more baseball games this year than he ever has previously. He likely just needs some time to figure out what it is going to take to keep his body in the best condition possible while playing professional sports. The answer to that is different for everyone, and often takes some experience to find the best methods for an individual.

Thanks for the question. I wouldn't think so. Remember, this area is very small (around the size of a couple of peas), so we aren't talking about extensive involvement here. In this context, the term 'degenerative' refers more to the body's ability to rebuild this tissue in response to stress. When that balance is thrown out of whack by one or more factors, the tissue 'build-up' is unable to keep up with the tissue 'break-down' and the tissue starts to become 'degenerative'. Improving the balance of this equation can (and should) restore the tissue to a healthy condition. It may be something he needs to do maintenance exercises for going forward to prevent recurrence, but my hope would be that is the extent of it.

(Twins Daily Note: In a Jeff Johnson story in The Gazette from Cedar Rapids, Royce Lewis noted that he has been diagnosed with Patellar tendinitis and he has been playing with the injury for about a month. He did play in the Midwest League All Star game on Tuesday night, so it is considered a minor injury. Today, Heezy tells us all about patellar tendinitis.) The Twins community recently received some concerning news about highly-regarded prospect Royce Lewis. Lewis left the Cedar Rapids Kernels Saturday game with what is being reported as ‘patellar tendinitis’, which has been causing him trouble off-and-on for about a month. But what is ‘patellar tendinitis’ exactly? And what might it mean for Royce going forward? Let’s discuss:Question 1: Where is the ‘patella tendon’? The patella tendon is the tendon that goes from your kneecap (also called the patella) down to the upper part of your shin bone (tibia). It is the attachment of your quadriceps muscle group to your lower leg, and it is what allows people to extend the knee. Question 2: What is ‘patellar tendinitis’? Patella tendinitis is a term commonly used to refer to activity-related pain that occurs near the attachment of the patella tendon to the patella. The suffix ‘-itis’ is used to indicate inflammation. While the term is commonly used, in actuality a more appropriate term is ‘patella tendinopathy’, which refers to degenerative changes within the tendon in the absence of inflammation (which is more accurately the case in this diagnosis). This difference is important when considering treatment options. Question 3: Royce is clearly a high-level athlete. Why did he get this problem? Patellar tendinopathy is also commonly called ‘jumper’s knee’ since it occurs most frequently in athletes that do a lot of jumping. In some studies of professional volleyball and basketball players, the incidence of jumper’s knee has been shown to be more than 30%. It is much less common in non-jumping athletes, but still occurs in around 2-3% of soccer players. I was not able to find any information specifically discussing the incidence in baseball players. It is unclear exactly why this problem occurs. It is most likely a combination of factors including BMI, flat feet, muscle imbalance in the quad/hamstrings, low flexibility, and intrinsic properties of the patellar tendon. There are likely other factors as well, including overuse. The area involved is usually located directly at the bottom end of the patella/top part of the tendon. Symptoms usually come on gradually over time. Initially, the knee typically hurts only with activity. Over time, if the condition worsens, pain may begin to be present even at rest. Question 4: How is patella tendinopathy diagnosed? The diagnosis is usually fairly clear from the history and physical exam of the athlete. Xrays are usually normal, though in some cases calcifications of the tendon may be visible. An MRI is the standard test to identify the extent of the problem and also to rule out other problems inside the knee. The area of the tendon involved in the problem is typically fairly small- around the size of a couple tic-tacs. Question 5: How is patella tendinopathy treated? The most commonly prescribed treatment for patellar tendinopathy is rest from vigorous activity and specific physical therapy exercises (called eccentric exercises). These exercises are designed to strengthen the quad muscles, stretch the hamstrings and ultimately cause favorable adaptation of the knee. The time needed for symptoms to resolve can be highly variable, but often takes at least a few weeks. When therapy isn’t effective, other treatments can be tried including various injections and ultrasound. At this time, there is no significant evidence that PRP (platelet rich plasma) injections are helpful for this condition, though I suspect it is being considered. There is, to my knowledge, no significant data on stem cell injections for this problem. Question 6: Is surgery ever needed for patellar tendinopathy? Rarely, yes. In most studies, around 10% of patients will fail to respond to appropriate conservative treatment. In these cases, surgery may be needed. There are two main options: open surgery and arthroscopic surgery. In either case, the procedure is similar- the area of affected tendon is excised and a small (a few millimeters) part of the patella bone is removed to stimulate healing. Therapy is begun soon after surgery. The success rate for return to sports is around 80% for both surgeries, with return after the arthroscopic version being quicker on average. Usually, 4-6 months is needed for full return to sports after surgery. Question 7: Is Royce at increased risk of rupturing the patella tendon because of this problem? No. Having patella tendinopathy does not appear to place anyone at increased risk of having a patella tendon rupture when compared to those without the problem. Overall, I believe the most likely scenario to be that Lewis’ body is adjusting to playing professional baseball every day and he is having some minor issues as a result. I don’t expect this to be a substantial problem going forward, though the possibility that this requires surgery in the future does exist. Hopefully he will get through rehab quickly and be back on the field soon. Click here to view the article

Royce Lewis: Patellar Tendinopathy Heezy1323 The Twins community recently received some concerning news about highly-regarded prospect Royce Lewis. Lewis left the Cedar Rapids Kernels Saturday game with what is being reported as ‘patellar tendinitis’, which has been causing him trouble off-and-on for about a month. But what is ‘patellar tendinitis’ exactly? And what might it mean for Royce going forward? Let’s discuss: Question 1: Where is the ‘patella tendon’? The patella tendon is the tendon that goes from your kneecap (also called the patella) down to the upper part of your shin bone (tibia). It is the attachment of your quadriceps muscle group to your lower leg, and it is what allows people to extend the knee. Question 2: What is ‘patellar tendinitis’? Patella tendinitis is a term commonly used to refer to activity-related pain that occurs near the attachment of the patella tendon to the patella. The suffix ‘-itis’ is used to indicate inflammation. While the term is commonly used, in actuality a more appropriate term is ‘patella tendinopathy’, which refers to degenerative changes within the tendon in the absence of inflammation (which is more accurately the case in this diagnosis). This difference is important when considering treatment options. Question 3: Royce is clearly a high-level athlete. Why did he get this problem? Patellar tendinopathy is also commonly called ‘jumper’s knee’ since it occurs most frequently in athletes that do a lot of jumping. In some studies of professional volleyball and basketball players, the incidence of jumper’s knee has been shown to be more than 30%. It is much less common in non-jumping athletes, but still occurs in around 2-3% of soccer players. I was not able to find any information specifically discussing the incidence in baseball players. It is unclear exactly why this problem occurs. It is most likely a combination of factors including BMI, flat feet, muscle imbalance in the quad/hamstrings, low flexibility, and intrinsic properties of the patellar tendon. There are likely other factors as well, including overuse. The area involved is usually located directly at the bottom end of the patella/top part of the tendon. Symptoms usually come on gradually over time. Initially, the knee typically hurts only with activity. Over time, if the condition worsens, pain may begin to be present even at rest. Question 4: How is patella tendinopathy diagnosed? The diagnosis is usually fairly clear from the history and physical exam of the athlete. Xrays are usually normal, though in some cases calcifications of the tendon may be visible. An MRI is the standard test to identify the extent of the problem and also to rule out other problems inside the knee. The area of the tendon involved in the problem is typically fairly small- around the size of a couple tic-tacs. Question 5: How is patella tendinopathy treated? The most commonly prescribed treatment for patellar tendinopathy is rest from vigorous activity and specific physical therapy exercises (called eccentric exercises). These exercises are designed to strengthen the quad muscles, stretch the hamstrings and ultimately cause favorable adaptation of the knee. The time needed for symptoms to resolve can be highly variable, but often takes at least a few weeks. When therapy isn’t effective, other treatments can be tried including various injections and ultrasound. At this time, there is no significant evidence that PRP (platelet rich plasma) injections are helpful for this condition, though I suspect it is being considered. There is, to my knowledge, no significant data on stem cell injections for this problem. Question 6: Is surgery ever needed for patellar tendinopathy? Rarely, yes. In most studies, around 10% of patients will fail to respond to appropriate conservative treatment. In these cases, surgery may be needed. There are two main options: open surgery and arthroscopic surgery. In either case, the procedure is similar- the area of affected tendon is excised and a small (a few millimeters) part of the patella bone is removed to stimulate healing. Therapy is begun soon after surgery. The success rate for return to sports is around 80% for both surgeries, with return after the arthroscopic version being quicker on average. Usually, 4-6 months is needed for full return to sports after surgery. Question 7: Is Royce at increased risk of rupturing the patella tendon because of this problem? No. Having patella tendinopathy does not appear to place anyone at increased risk of having a patella tendon rupture when compared to those without the problem. Overall, I believe the most likely scenario to be that Lewis’ body is adjusting to playing professional baseball every day and he is having some minor issues as a result. I don’t expect this to be a substantial problem going forward, though the possibility that this requires surgery in the future does exist. Hopefully he will get through rehab quickly and be back on the field soon.

So this is a very complex question/issue- I could probably do a two hour talk about it. No one wants to be inundated with that much ortho info by me, so I'll do my best to summarize. As discussed in the article above, the meniscus is critical for normal function of many aspects of the knee. This includes stability, cushion and protection of the surface cartilage. Because of the importance of the meniscus, it is critical to try to preserve as much meniscus as possible, as often as possible in order to optimize the long-term function/health of the knee. For example, we know from studies that one of the biggest risk factors for ACL graft failure after reconstruction is having had part of your meniscus removed at the same time as reconstruction. We also know that the greater the amount of meniscus removed, the greater the risk that a person develops arthritis down the road. Recall, arthritis is thinning or damage to the gliding surface cartilage of the knee (which is different from the meniscus itself). Once damage to the surface cartilage occurs, we don't have a great way to repair or restore the cartilage to normal. (There are some procedures that we have as options, but they are rarely as good as normal cartilage.) Because of the lack of good options to treat arthritis, especially in young patients, we have become more aggressive over time at attempting to repair meniscus tears in order to prevent this problem. With regards to stability, think of the meniscus as a chock that you place behind the wheel of a trailer that is parked on a hill to prevent it from rolling away. The meniscus helps stabilize the knee in the same way. As a result, when you remove part of the meniscus during an ACL reconstruction, there is a smaller 'chock' and therefor the ACL sees higher stress and is at greater risk to fail/re-tear. In addition to our understanding of the function of the meniscus and its importance, we also have developed better tools to perform meniscus repairs more safely and easily. As a result of the above factors, the number of attempted meniscus repairs has increased dramatically over the past 10-15 years. Any time you increase the number of procedures, the number of failures also increases (by sheer volume). With respect to your specific examples noted in your post, I do have a couple of thoughts. One is, in young patients (particularly athletes) I am VERY aggressive with trying to repair any meniscus tear, because they are the patients that need their meniscus the most. If it fails, it is of course unfortunate, but removing meniscus that has a chance to heal is a bad idea, IMHO. A second thought is that there could be some technical factors in play. Studies have shown that technique is critical in repairing these tears, and it is possible that some component of the failure is attributable to this. A surgeon who does many meniscus repairs is likely to be more facile with the range of techniques necessary to treat these effectively than someone who only rarely does a meniscus repair. A third thought is that some meniscus tears are much more likely to heal than others, and perhaps you are seeing a selection bias of tears that were of low likelihood to heal even under the best of circumstances. We know from other studies that generally about 70% of what we call peripheral meniscus tear repairs will heal successfully. These are the type with the best healing potential. In larger tears, such as a bucket handle tears, the success rate is around 55-60%. So you can see by these numbers, there is still a significant failure rate even in ideal circumstances. I'm sure your observations are true- in fact they are probably what I would expect to see with respect to returning to activity more easily after a partial removal. The difficulty is that with partial removal, the 'rent doesn't come due' until years later. I have a number of patients referred to me who are in their 30's or 40's and had a meniscus removal in their teens or 20's and now have arthritis. This is an extremely challenging problem to solve. Hopefully this lengthy (and likely rambling) post helps clarify the thought process. Your question is a very good one. If we knew in advance which tears would heal and which wouldn't, of course these decisions would be easier. Unfortunately, as I often tell patients, my crystal ball is a little murky.

No worries, John. Thank you for the opportunity to contribute. I'm glad folks are finding the posts interesting.

This is definitely a bummer for Castro, but it may be best for the long-term health of his knee. For anyone who is interested, I wrote a blog post about meniscus injuries that some may find informative/helpful. http://twinsdaily.com/blog/1036/entry-11062-jason-castro-knee-surgery-qa/

Jason Castro Meniscus Surgery Q&A Heezy1323 Twins starting catcher Jason Castro went on the DL May 5th with pain in his right knee. Initially, it was reported that Castro underwent a cortisone injection and was hopeful to return to the lineup soon. Unfortunately, after traveling to Vail, CO to see noted orthopedic surgeon Dr. Robert LaPrade, Castro is now scheduled to undergo surgery May 15th to address a meniscus tear. (Update: Now being reported that he underwent more extensive surgery including a meniscus repair and is now out for the season). This will be the third surgery for Castro’s troublesome right knee, according to the Pioneer Press. He sustained an ACL tear along with a meniscus tear in spring training 2011 and underwent surgery, which caused him to miss the entire season. He also underwent arthroscopic surgery on the same knee in September 2013. Let’s discuss some knee anatomy and some meniscus ‘fun facts’ (Note: these facts may only be considered fun to me…) Question 1: What is the meniscus? What is its function? The meniscus is a C-shaped cartilage cushion that is positioned between the bones of the knee (the femur and tibia). It has several functions including acting as a shock absorber, a protector of the surface cartilage and a stabilizer of the knee. There are two menisci in each knee- a medial and lateral meniscus. The medial is positioned at the inside of the knee, the lateral to the outside. Both the medial and lateral meniscus increase the surface area of bone contact within the knee when walking/running, thereby spreading out the contact forces over a larger area. This function protects the surface gliding cartilage (called articular cartilage) from being damaged. Question 2: How is a meniscus torn/damaged? A meniscus can be torn in several ways, but most commonly it is damaged when the knee undergoes an abrupt change of direction and the stress is more than the meniscus can withstand. In the case of Castro, it sounds as though he had some damage to his meniscus in 2011 when he also tore his ACL. A meniscus tear accompanies an ACL tear about 50% of the time. Either the medial or lateral meniscus can be torn, and in some cases both sustain injury. Question 3: How are meniscus tears assessed? Most commonly an MRI is ordered to look at the meniscus more closely. The meniscus can’t be seen on xrays. There is a device that is similar to a large needle that has a camera inside it that can be inserted into the knee during an office visit to view the meniscus directly, but I don’t have much experience with this device. Question 4: What types of tears can occur? There are a number of different types of meniscus tears, and there are many tears which don’t fit neatly into a single category as well. Question 5: What are the treatment options for meniscus tears? There are a number of different options for treatment of meniscus tears. Not every meniscus tear will require surgery- in fact, many people may have a meniscus tear in their knee and not even be aware of it. Anti-inflammatory medication, injections (including cortisone, gel/lubricant, and PRP injections), and physical therapy are among the non-surgical options. When these are not successful (or surgery is deemed necessary early on), knee arthroscopy is performed. During knee arthroscopy, the knee is inflated with fluid and a camera is inserted inside the joint. The structures of the knee can be readily assessed, and tools are used to examine and probe the meniscus, surface cartilage and ligaments. The specifics of the meniscus tear are then evaluated. A decision is then made whether to repair the meniscus or remove the torn portion of meniscus (called a partial meniscectomy). This decision can be complex and is based on a number of factors including the size, location and orientation of the tear, patient-specific factors such as age, weight, health, prior surgery to the knee and others. Ideally, we would repair all meniscus tears, as removing meniscus can lead to the development of arthritis later on. However, some tears are simply unable to be repaired and must be partially removed. Tears closer to the outer edge of the meniscus have better blood supply are more likely to heal, and thus are better suited to repair. Question 6: What is the recovery time? This can vary significantly, but for partial removal, most athletes can return to sports between 6-10 weeks after surgery. For repair, the recovery is longer because of the additional time required for the repaired tissue to heal. Typically, a return to sports for a meniscus repair is around 3-5 months. Question 7: Are there any special circumstances with Castro’s knee? I would say yes. The fact that he has had two prior surgeries on the knee (including an ACL reconstruction) often makes the MRI more challenging to interpret and can complicate decision-making. It is unclear to me if the current meniscus damage is in the same area where he previously had surgery, which can create an already abnormal appearance on MRI. Thus, it is difficult to know whether what appears abnormal on a current MRI is ‘new’ or ‘old’. However, it sounds like he has continued to have intermittent problems over a lengthy amount of time now, and it seems reasonable to go ahead with arthroscopy. One concern is that a tear can enlarge in size over time if left alone (though this is difficult to predict). Dr. LaPrade is a world’s authority on knee problems and I’m sure he will do his best to get Castro back to action quickly and safely.

Fair point. But I would say, in my experience at least, this is almost never the case. We typically try to give our best evaluation of the likelihood of success with both surgical and non-surgical treatment (and now sometimes including consideration of PRP and/or stem cell treatment). It is typically up to the player to decide which route they would like to take. Certainly in some cases, suggestions may be made from team/agent/family etc, but I have not experienced a case where a surgeon or team 'convinced' anyone they didn't need surgery. Doesn't mean it doesn't ever happen, but my thought would be it is quite unlikely. There are cases where the reverse is true, I would say- that sometimes an athlete thinks they can overcome an injury without surgery and a surgeon's experience tells them it's going to be very difficult. In which case I have had to strongly recommend surgery to certain patients. But, even then, it is their choice. All we can do is provide the best information we can to let them make the best choice for themselves.

Thanks for the compliment! I don't have a lot of experience writing blog posts such as this, so I welcome feedback about how I can be better.