PDX Twin

Baseball is a marathon, not a sprint . . . but I'm willing to bet you can spoil a marathon with a weak start. Mental fortitude cracking with the arrhythmic slapping of your feet against the pavement. Planning and precision giving way to panic. Comparing yourself to the other runners, who seem to be running flawlessly.
Baseball is a marathon . . . for the fans, too. It takes commitment to stay abreast of a whole season. The game this afternoon felt like a must-win situation to keep some sense of hope. These were winnable games against a beatable opponent. We won one, by a single run. For the fans to stay in this race, we're going to need to win a lot more. 
Of course, who am I to talk about marathons and baseball seasons? I've never run a marathon, and my baseball days ended in elementary school with me standing in right field, praying the ball would never come near me. I'd like to run a marathon by the time I turn 50, which gives me a little over 5 1/2 years to get this body into shape. 
People have been very supportive of my marathon pipe-dream. The way they describe it makes it seem simple. You start running. 26.2 miles later, you stop. Along the way, you keep your feet moving. Everyone says it's a mental battle. Right now, I'm battling to get in the gym and get into 5K shape. Little victories mean a lot. Just going to the gym on a day where I'd rather see how many peanut butter Oreos I could cram in my mouth is a victory.
This one run victory is like that. It keeps everybody grinding on, hoping the Twins find their footing, pick up the pace, and we all feel the breeze at our backs. 
It's hard to write series recaps about three lukewarm baseball games where one lukewarm baseball team faces another lukewarm baseball team. The biggest narrative seems to stem from Aaron Gleeman's revelation that this is the first time the Twins have ever batted under .200 for the first 12 games. Maybe a little chatter about some surprisingly good pitching. I bet I'm not the only one struggling to find something to write about, even at this early stage of the season. Hey, we can't all be Randball's Stu and hit it out of the park every time.
So let's pick up those feet and put 'em back down again, Twins! Get into the rhythm. Find your stride before it's late June/early July. Because before long it'll be time to listen to "Dirty Black Summer" by Danzig and pretend sparklers are still fun when you're over fifteen. I'd like to still be in the race then.

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.

Byron Buxton Shoulder Injury Q&A
heezy1323
 
 
Byron Buxton, as we all know, is an outstanding center fielder for our Twins. Unfortunately, he has dealt with a variety of injuries that have cost him significant time over the past few seasons. This weekend he sustained an injury to his left shoulder that was termed a ‘subluxation’ and is headed back to the IL. By the sound of things, he is likely to be away from the big club for at least a few weeks. This is a tough blow for the Twins as the Indians make a push to catch up to a team that has led the division essentially all season.
 
Medical terminology can be confusing, so I thought a post about shoulder subluxations might be of interest to TD readers. As usual- my disclaimer is that I am not a Twins team physician. I have not examined Byron nor seen any imaging of his injury. I am not speaking on behalf of the Twins. I am only hoping to familiarize TD readers with some of the concerns that may be ahead regarding injuries similar to Buxton’s.
Question 1: How does the shoulder normally work?
The shoulder is considered a ball-and-socket joint. The round ball (humeral head) sits in the socket (glenoid) similar to how a golf ball sits on a golf tee. Around the perimeter of the golf tee is a strong cartilage tissue called a labrum. The labrum surrounds the socket similar to the red gasket on a mason jar lid. Its function is to help act as a ‘bumper’ to hold the golf ball on the golf tee. It is also an attachment point for ligaments around the shoulder that also contribute to shoulder stability. The ligaments make up the ‘capsule’ of the shoulder joint. I often tell patients that the capsule is like a water balloon that surrounds the joint. The ligaments that make up the capsule form the connection between the ball and the socket.
 
Question 2: What is a shoulder subluxation?
 
The term ‘subluxation’ is typically used in situations where a joint partially (or nearly) dislocates. This is not specific to the shoulder and can happen in a number of other areas of the body as well (such as the kneecap, for example). This is distinct from a true ‘dislocation’ where the ball comes completely out of the socket and then goes back in.
 
If someone dislocates their shoulder and it stays dislocated, it is typically clear what has happened. Xrays will show the ball dislocated from the socket and the shoulder will be manipulated to ‘reduce’ the ball back to its normal position. However, in some cases cases the ball can completely dislocate and go back in on its own very quickly. In these cases, an xray would often look normal. In most cases when there is concern about an injury of this type, an MRI is ordered. This of course shows additional details of the bone and soft tissue that cannot be seen on an xray alone. Usually an MRI will allow for a pretty solid conclusion as to whether the injury that occurred was a ‘subluxation’ (less severe) or a true ‘dislocation’ (more severe).
 
There is, of course, a spectrum of damage that can occur with any injury and this is no exception. It’s possible that there was some minimal stretch to the ligaments around the shoulder and no other significant damage (best case). It’s also possible that there was more significant damage to the ligaments and potentially even a tear of the labrum (more worrisome). The MRI would typically give a good approximation of these issues. In most cases, the damage that occurs with a subluxation is less significant than that which occurs with a dislocation.
Question 3: Does it make a difference that the injury is to his left shoulder rather than his right?
 
In my opinion, absolutely. Because it is his non-throwing shoulder, the stresses placed on it are less. Even small issues with the ligaments can be problematic in the throwing shoulder- particularly someone who can approach 100mph on throws from the outfield.
 
That said, the left shoulder is Byron’s front shoulder when hitting. In most hitters it is the front shoulder that is more stressed. It is possible that Buxton’s recovery is more affected at the plate than in the field (though that’s impossible to predict with certainty, of course).
 
Question 4: Does this injury make it more likely that Byron will dislocate his shoulder in the future?
 
Possibly. As discussed above, there is a spectrum of damage that can occur with this injury. If the damage is near the minimal end, it probably doesn’t have a significant effect on his likelihood of injuring this shoulder in the future. If there is more significant structural damage, it may place him at higher risk.
 
Question 5: What is the purpose of the rehab?
 
In addition to the capsule and labrum discussed above in question 1, the muscles around the shoulder also contribute to stability. I often tell patients to imagine that there is canopy over the top of the golf ball pulling it down onto the golf tee and helping to hold it in place. This is similar to the way your rotator cuff functions. I suspect rehab for Buxton will include strengthening exercises for a number of muscles around the shoulder that contribute to stability.
 
Also, these muscles can be strained during the injury, so they can sometimes need additional time to recover along with the ligaments.
 
Question 6: Will Buxton need surgery?
 
This is essentially impossible to answer right now, likely even for the physicians and training staff involved in Byron’s care. As I sometimes tell my patients, “The crystal ball is a little murky.” Without knowing the extent of any structural issues in Byron’s shoulder, I would say that it is somewhat unlikely this will require surgery. I would expect that even if surgery is required, it would only occur after an attempt at non-surgical treatment has been unsuccessful.
 
Question 7: How long will it be before he is able to return to play?
 
This is also a difficult question to answer. The fact that the early word is that he will be out a few weeks is consistent with what I would expect from an injury like this. The rehab often takes time to regain full motion and strength. I would hope he can be back patrolling center field before the end of August, but it’s certainly possible this lingers into September. It seems unlikely that this would be a season-ending injury, but only time will tell.
 
 
Clearly this Twins team is better when Byron is on the field rather than on the IL. Let’s hope he heals quickly and can help the Twins down the stretch. GO TWINS!

In light of some posting styles we have been seeing lately on TD, I thought I'd do some venting of my own ... in a blog. The thread that broke this camel's back was this thread, 'It is time to end the insanity.' I've been meaning to address this for a while now, and have here and there in threads when posts become nothing more than venting general frustrations rather than addressing the topic at hand; and redundant threads get started on this same topic of frustration that seem more like rants than opening a new thread to discuss the latest news. Okay, okay ... the general topic of 'This is what's wrong with the Twins' is a topic of discussion ... but we've seen this in several threads already. Obviously there are new salient points that must be addressed, but it is this 'venting' and 'ranting' that becomes a detriment to my and others' enjoyment and participation in the forums.
 
I've always thought the purpose of the forums on TD is for discussion, critical discussion. Yes, with disagreements and passion, but, nonetheless, critical discussion, with maybe a little humor and/or snark mixed in from time to time, no matter what side you fall on with any given issue. Posters have always been encouraged to start threads to discuss a particular topic, or general topic, or a news item you saw, or a blog you read, or a question you have, or a move that was made/not made, management issues, player issues etc. And yes, those discussions will get emotional and passionate as we all have a vested interest in the outcome of the Twins, and have our own opinions on what should/should not be, and often disagree on the best way forward. And sometimes threads do get a bit meandering and off topic despite our best efforts to try and keep them within loose boundaries. But this recent posting style, such as the OP, in my opinion, really needs to be directed towards the Blogs area on this site. These threads, such as the one I made example of, serve no purpose other than to regurgitate a list of generalized complaints and are not focussed points of discussion and only invite generalized regurgitating of someone else's complaints. The title of this thread 'End the insanity' in and of itself just opens the floor to everyone's complaints and soon we have a morass of unpleasant vomiting to wade through. Yes, we're frustrated and I'm not trying to take that away from anyone, not in the least, because well, it IS frustrating, to no end, at least for me. And I guess we each have our own way of dealing, but the Blogs are there for you to let it all out. You want to vent? Start a blog and vent away. You want to have a legitimate, critical discussion, stick to the forums and structure a thread that leads to that; a post or a thread that has been thought out and isn't some generalized rant that has no real basis in reality other than it's some emotional response, not a genuine reading of facts, to what you think should have happened. Don't just vomit up all your frustration for the rest of us to wade through; that's just lazy. Those are the types of threads and posts that keep me from the forums, not the stances people may take on the Twins in general or specifically. If you don't like a topic, you are free to not read it. If you don't like a particular poster, put them on ignore or skip over their posts. So I find myself more and more throwing my hands up and 'walking away' because threads just become unreadable the more this style continues.
 
(Edit: I want to add that the thread I used as an example has generated a pretty fair and decent discussion. Many threads and posts of this 'listing of wrongs venting' have not. I'm in no way suggesting we can't be critical of the team and its management ... I mean, come on, look at the team ... I'm suggesting that don't just start a thread or make a post listing all that bothers you. Try to frame things so we can have legitimate discussions without being critical of fellow posters who might have a differing point of view, otherwise, try starting a blog. If you have to end a post or a thread start with '/end rant,' which this one did not, it probably would be better suited for a blog. They are very useful for 'getting it out' of your system. But given the OP of that thread, it was very easy for all of us to think to ourselves, 'Oy, this again?' and either walk away or get defensive or pile on. The following paragraph stands ... for all and everything. Stop the divisive language!)
 
Another issue I want to address: this generalized characterization of posters some of you think necessary to throw into their posts. This 'The Twins can do no wrong crowd' or the 'Twins can do no right crowd' is hugely disrespectful and dismissive, and from this moderator, will not be tolerated. If you want to divide and pick sides, fine, go play a game of dodge ball, your posts will be removed. Lumping posters into such 'all or nothing' categories because they choose to disagree with a point here and there needs to stop. I try to stay fairly objective, as objective as I can in my own like/dislike of certain topics, in my reading here, despite my own frustrations with the team, but there really are only two or three posters that fall into those mentioned categories on each end of this spectrum. The large majority of posters fall everywhere in between. Yes, some have definite leanings, but I have seen very, very few posters who have blindly taken these all or nothing stances on everything Twins. If all you want to do is read posts only in agreement with you, then you are in the wrong place. It is nothing but smug self-righteousness to declare yourself so right and others wrong and then to label others in such a dismissive way. It's the same with the negative/positive crowd. This is nothing but from your perspective, and your perspective is NOT the end all to defining anyone else. Say your piece. Have at it. And if others disagree, so be it. Have a debate, be open-minded to another's views and why they take them, give them the benefit of the doubt, ask for explanations, and disagree if you just disagree, but don't be dismissive about it by saying 'You're just part of that crowd.' If one poster likes a move and another doesn't, they are not in any of the above-mentioned crowds, they just differ in opinions. And if a poster wants to point out a silver lining or a black cloud, so what? It's their opinion and no one is right or wrong here. I'm not sure why that is so difficult to understand. Does it bruise egos when someone doesn't like your point, or picks it apart with their own interpretation of the facts, or their own use (right or wrong) of various metrics, stats, other numbers? Get over it. Don't double down and hunker down so hard you develop tunnel vision, and resort to the "Oh, you just hate so and so" or "Oh, you just love so and so" as an argument. It's unproductive, lazy and weak. And it gets old, and frankly, loses credibility for the poster who uses that as an argument. And maybe, just maybe, we don't need to fight to the end. When it gets to the point of labeling posters, I think it's time to agree to disagree and just let it go.
 
Okay ... I've run out of steam. Whew! That was so cathartic!!! You should give it a try.
 
See what I did there? Here's how I got started and so can you. There are all sorts of things to click on to help you find your way through the blogs. There's even a tutorial ... which I didn't click, because I didn't need to. So ... have at it.
 
1. On the red menu strip across the top, click on the word “Blogs”
2. Click on the black rectangle that says ‘Create a Blog’
3. Read the terms and rules, then check the box that says you have read and understood the terms, then click ‘Continue—>’
4. Fill in the blanks with the Blog name, Blog description, choose blog type, then click continue.
Example: Blog Name: ChiTown’s Fun Takes
Blog Description: All that frustrates me about the Twins
Blog Type: Local Blog
5. Choose your settings
6. Save
 
At that point you can choose ‘Options’ and then ‘Add new entry’ and go to town. Or leave, collect your thoughts, come back and choose ‘Blogs’ from the red menu strip across the top, click ‘Add Entry’ and go to town.