Heezy1323

Check out this link- it may be helpful to those interested: http://www.asmi.org/bioeval.php?page=bio_eval

They have been doing this for many years. Actually, the newest technology doesn't require any sensors- it can basically generate a computerized 'stick-man' that overlays the pitcher and make measurements with that. Really cool. The difficult part is when you get down to specifics. Some studies make more than a dozen measurements on a single pitch (usually a fastball). But there are literally hundreds of variables. Different pitches. Set position and windup. Early game vs middle inning vs late game fatigue. How do you pick out the one or two things that 'cause' an injury? Extremely difficult. I guess I get a little frustrated when people imply that we aren't working on this as a sports medicine community. Believe me, we are. Extensively. But I promise you, it's REALLY hard to figure this stuff out.

I genuinely appreciate the compliment. I really enjoy this TD community and have learned a lot about baseball by reading others' posts. I enjoy chipping in where I can offer some insight. As far as bilateral leg weakness... let's just say that I'm not sure I would've been much help then, either.

I would say that the difference is that a breast aug is cosmetic. TJ is not. I'm not saying there aren't orthopedists out there who would do it (though I don't know any). I'm just saying it's not something I would be willing to do. When I consider signing someone up for surgery, the benefit needs to outweigh the risk, or I don't recommend surgery. There are an extremely small number of circumstances under which I would operate on a normal, uninjured joint.

The usual time frame is around 4 months. It is usually around 6 weeks of initial 'active rest', followed by a return to throwing program. Usually they can resume pitching around 3 months. It then usually takes about a month for them to progress to the 80% effort range, which is where most begin to experience trouble (if they are going to have trouble).

I can assure you, the decision is rarely cut and dry. I would say around 20% of the time it is clear surgery is needed. The rest of the time, the decision on when/if to operate is challenging.

On this, we agree. Though I'm not sure SS=29 is much better. Very challenging topic.

So your contention is that a position player is at higher risk to fail non surgical treatment than a pitcher? My suspicion would be the opposite- that since a position player places less stress on the elbow than a pitcher (proven in biomechanics studies), they are more likely to be successful with non surgical treatment. You can't just conjure the non-pitchers to study. You have to study what is available and extrapolate that data as best you can to other groups.

Also, here is a link to a power point presentation from Chris Ahmad (Yankees team doc) that discusses non surgical treatment in some additional detail. https://foreonline.org/wp-content/uploads/2016/11/9-2.pdf

There is some mixed data on PRP injections- some studies showing it helps, others showing no difference. A mentor of mine once told me when I asked him if he thought PRP works for this problem "No idea. But sometimes you have to do SOMETHING to them just to get them to listen to you and actually rehab the right way." I've always remembered that. Agree 100% on the rarity in HS OF's.

As a surgeon, I hope I never reach the point in my career that I am doing preventative TJ surgery. I will hang up my scrubs the day that happens.

I posted this link in the other thread as well, but it is helpful in answering this question. The short answer is (at least according to this study), most. http://journals.sagepub.com/doi/abs/10.1177/2325967114S00021 It isn't just the Twins that take this approach- that is the approach taken by the vast majority of teams/colleges.

The 'non operative treatment always fails' argument is common at TD, but the data is, at best, conflicting. Below is a link to a 2014 study showing that the return to play rates were actually better for non operative treatment than for surgical treatment (for incomplete tears). There are certainly other studies reporting lower success rates for non operative treatment, but I don't believe it's accurate to say rest/rehab 'does not work'. That is not the debate. The debate is how frequently, and for which specific injuries does rest/rehab work? http://journals.sagepub.com/doi/abs/10.1177/2325967114S00021

Clearly these are excellent questions that have complex answers, but I will throw in my 2 cents. -I think if TJ hadn't been invented, these players would likely be 'weeded out' for lack of a better term, or learn to cope and compete with diminished velocity/control -We are certainly committing significant research time and expense to trying to answer question 2, but it is presently unclear. I think the likely answer is some combination of all of your explanations. It is clear that as the average fastball speed has increased, there has been a corresponding increase in UCL injuries, and thus TJ surgery. This is likely due to the other things you mention- bigger, stronger players; year-round baseball, and increased awareness and surveillance. Personally, I think the radar gun, emphasis on strikeouts and focus on 'velo' is a major contributor. One can strengthen muscles/tendons, but for the most part ligaments (such as the UCL) have an inherent strength that doesn't increase along with the muscles.

Just to clarify, I was talking about non-operative rehab from a UCL strain/sprain. The majority of players who have this injury are (obviously) pitchers, so the situation doesn't come up frequently. I think it would certainly be an option to have a player DH for the season and have TJ at the end of the year, but that would still likely impact their throwing at the beginning of the following season to some degree. It seems unlikely to me that it would be done unless the player was an excellent hitter who didn't offer a lot in the field anyways, and also was at the major league level.

I don't have anything to add specific to Kirilloff, but my experience in treating UCL injuries has been that most pitchers don't have trouble in rehab until they reach around 80% of max effort. So as they are rehabbing from an injury/strain and working through the return to throwing protocol, they very frequently will go smoothly through the first portion of the program. The true test seems to be when they start to hit that 80% effort mark, particularly when they also increase the frequency of hard throwing. It's possible that (or something similar) is what has occurred here. I sure hope not...

Nice write up! Thanks for sharing

Do you have a link to your post/article? I'd love to read it. 'The Arm' is such a great book. Excellent reading for those interested. I co-authored some research with Dr. Andrews that shows that around 80% of tears occur at either the humeral or ulnar end of the ligament- making the majority of tears potentially amenable to treatment with this technique. As you mention, tissue quality is also a variable, and poor quality tissue can necessitate reconstruction. Looking forward to seeing results in the coming years.

I recently came across an article from the St. Louis Post-Dispatch about one of the Cardinals pitchers who underwent UCL repair, and thought it might be of interest to some people here. For those not familiar with the difference, a UCL repair is a procedure where the injured ligament itself is directly repaired back to bone, as opposed to UCL reconstruction (Tommy John procedure) where different tissue is used to make a 'new' ligament. I have known about this procedure for some time (and have heard Dr. Dugas talk about the first patient he did this for), but it is interesting to see its growth to the professional ranks. Hope people enjoy... http://www.stltoday.com/sports/baseball/professional/maness-a-trailblazer-new-surgery-for-elbow-repair-cut-recovery/article_165ee721-5a36-58f9-8d8e-fb515ba037da.html Edit: Apologies, I didn't see this link had been posted elsewhere.

Thank you ChiTown, I enjoy contributing where I can.

Infrequent poster, but frequent reader. I grew up on a farm in Verndale MN (near Wadena above, via PDX). Went to Concordia College and played a little baseball there (similar to Seth) but hurt my shoulder and it became clear that no one was going to be paying me to play baseball for a living . Ended up going to medical school and becoming an orthopedic surgeon. Have lived in several parts of the US through my training/career. Did a sports medicine fellowship with James Andrews, which affords me some insight into baseball injuries and the like. I was in practice at the University of South Carolina (go Cocks!) for three years when I had an opportunity to return to Minnesota and join a practice in the Twin Cities area this year. My wife is from Iowa, so it was a good opportunity for us, and we took it. I was a sports (and specifically baseball) nut from birth, so have been a Twins fan essentially my whole life. For just about anyone my age (mid 30's), Kirby is an easy choice for favorite Twin. I was pretty young in '87 and '91, but can clearly remember screaming my head off after game 7 in '87 (along with my parents, while watching on TV way past my bedtime) and after Kirby's game 6 in '91. I also loved Shane Mack and Knoblauch. Because I've lived outside of Minnesota for so long, I've never actually been to a game at Target Field (yet). I went to a few games at the Dome growing up, but I don't have any specific memories of the games (other than I know I've never seen the Twins win a game in person in Minnesota- though I did see a 16-10 Twins win in Milwaukee years ago). I've been reading Twins Daily since it started as a way to stay up to date on the Twins, since I didn't get to see many games living elsewhere. I especially enjoy the discussion of minor leaguers. I did get to watch Sano and Buxton in Chattanooga a couple years back- Sano hit a homer and bungled a play at third, Buxton hit a triple. Man, he's fast. Hard to appreciate on TV. I stop by TD daily, and probably read about 3/4 of the posts/articles. I really enjoy the differing points of view and (mostly) respectful (and often amusing) discussion. Thanks to Seth for starting this thread, I really have enjoyed 'getting to know' several frequent posters a little better. Thanks!

That's a nice link- overall a fairly good article. A couple things I would mention just for the sake of clarity. 1) While there technically do exist different types of ACL tears, it is for all practical purposes a binary classification. Meaning your ACL is either functional or non-functional. Most of the time it is clear from an MRI, history and exam which type of tear someone has. There is a small group of people who can function athletically at a very high level in the absence of an ACL (DeJuan Blair in the NBA doesn't have an ACL in either knee, for example). However, these athletes are by far the exception, and it is very difficult to determine who is going to fall into this group. 2) A small clarification about nomenclature: there is a difference between ACL 'repair' and ACL 'reconstruction', though the terms are often used interchangeably. 'Repair' indicates that the person's native ACL was stitched back into place and allowed to heal. This was tried historically and fell out of favor due to high failure rates. However, with the improvement in instrumentation and arthroscopic techniques, there is a recently renewed interest in ACL repairs. Certainly the long term data is lacking, but there are some promising initial results on this front. Something I am certainly keeping my eyes on as a surgeon, and I suspect it will become a larger part of the conversation in the next few years. ACL 'reconstruction' indicates the use of a separate piece of tissue (either from the patient or a cadaver) to create a 'new' ACL. This is certainly what is most commonly performed at this time. I could talk for an hour about how to choose the tissue source, but by and large it is fairly well-accepted that cadaver grafts have a significantly higher failure rate in patients under 20 years old particularly. In my practice, I almost never use cadaver grafts in anyone under 35 or 40 unless there are unique circumstances. 3. It is possible that when you said it was unknown how severe Ramos' injury was, that you were referring to the presence or absence of associated injuries. There are several commonly associated injuries that go along with ACL tears including meniscus tears, surface cartilage injuries, additional ligament injuries, fractures and others. There is certainly wide variation in the presence of these associated injuries along with an ACL tear, and they can affect surgery and recovery significantly. IMHO, catcher is probably the most difficult position to return to after ACL reconstruction due to the demands of the position, so that part of Ramos injury is concerning to me. Presuming he has undergone (or will soon undergo) surgery, a 6 month recovery would put him right around opening day (if everything goes perfectly). Definite financial as well as physical bummer for Ramos...

Well, being one of 'these guys', I feel an obligation to respond to this post (despite the fact that I think it is essentially true). Answering the question of which pitch places the most stress on the elbow has proven difficult from a scientific standpoint. The curve ball was never science based- it was based on assumption and expert opinion. Then, as technology began to improve, we began to be able to measure (with debatable accuracy) forces across the elbow. That's where some of the more recent thoughts come from (i.e. different studies have shown different numbers). There continues to be some disagreement in the medical community as to the specific cause of UCL injury. Clearly, it is multifactorial, but how much any one individual factor is responsible is difficult to say, scientifically. As to the physician's comment in the article re: a fastball being the most likely pitch to cause an injury, I think it is certainly possible, but very difficult to PROVE scientifically. Yes, I would say most pitchers that I have seen that report an acute 'pop' in the elbow with throwing were throwing a fastball. But what exactly does that mean? Was the UCL 100% normal before that pitch, and then tore completely? Seems unlikely. Also, at most levels, for most pitchers, the fastball is the most frequently thrown pitch (usually by a lot). So it certainly is a case (at least to me) of correlation not necessarily being causation. So ultimately, yes I would agree- there is much to be learned about the thrower's elbow. But I think it is somewhat unfair to characterize the professional community as being uninterested or incapable (though I can certainly understand the inclination). Finally- The Arm is a phenomenal book. I encourage anyone with an interest in the topic to read it.

REALLY unusual. I've treated a fairly large number of multi-ligament knee injuries, and I've never seen one as severe as is being reported without contact. The only exception is sometimes morbidly obese patients can get something like this doing something as simple as trying to stand up and slipping. But for a fairly normal sized athlete to sustain a noncontact injury like this in practice is quite strange. It wouldn't totally surprise me if there was a little more to the story than that, but total speculation on my part. If he had a knee dislocation, as is being reported, then by definition he has at least three ligaments injured (of the ACL, PCL, MCL and LCL). The good news so far is that there is, reportedly, no peroneal nerve or arterial injury, which can certainly occur and portends a worse outcome. Such a bummer for Teddy, and the Vikings.

I always enjoy good vocabulary usage. I'm not sure I've ever seen the term 'Brownian motion' used relative to baseball. Well done!