There are many things in Nick's article that are incorrect, and some that I agree with. This isn't meant to attack but to show a different viewpoint that he might not see.
"Our community is broken. Our country is broken." We live in the greatest country on earth. Our community/country is not broken. You are stating your opinion as fact. A tragic death lead to a protest which lead to planned riots and anarchists coming to Mpls and many large cities throughout the nation. There are problems with bad police. There are problems with bad media that spreads divide. There are problems with bad plumbers, electricians, bankers, etc... that believe the divide and buy into the hate and anger. Go to most communities and you'll see blacks, whites, brown, you name the color, all get along.People that live in the same community or neighborhood will defend those they associate with regardless of color because of their shared interests or shared sense of community. "To shy away from this conversation is to contribute to the widespread apathy and complacency that has brought us to this tragic state." "Unaware of what the mask meant." Why does he need to get involved in the conversation? There isn't one person I've seen in social media whether they be on the left or right that has condoned the former cops horrible actions. He's been condemned in every corner. Believe it or not he doesn't have to post his every thought on social issues. He already got harassed by wearing a blue lives matter face mask. (To those people that shamed him, shame on you. Those officers protect your freedoms and risk their lives every day. A cop in Waseca is learning to walk again because he was shot by meth dealer/addict). There's nothing wrong with supporting the police because 99% of them are good and want to uphold the law. What does the mask mean? It means that police lives matter, too. By saying that police lives don't matter you create the divide that was mentioned earlier.
"Racism has no place in our world and I do not in any way support the actions that we all witnessed that led to George Floyd’s passing.” Max denounced racism. He denounced the murder. He doesn't need to part of a demonstration to make a change. He can do that by backing his friends in his own private way. Because you don't see him out on the streets carrying a sign or screaming at the police doesn't make his statements any less important. "Not into politics [peace sign]." This is the attitude that has gotten our society to this point: comfortable white people choosing to excuse themselves from the conversation, because it doesn't affect them personally." Do you actually believe we have a more civil society with the combination of social media and politics? He doesn't need to be into politics...at least no publicly. He can have Walter Mondale buttons or Barry Goldwater signs in his garage for all we know. This murder is not political and murder never should be. "comfortable white" people? Seriously??? If a person isn't interested in politics it doesn't make them a comfortable white person. Would you say the same about someone that's black and not involved in political discourse? You are making a group think statement that everyone must think and act as you.
"Kepler's comments come as a slap in the face to a grieving and enraged community where he's supposed to be a leader." I've spent a lot of time on social media lately and I haven't seen one person clamoring to hear Max Keplers take on the protests/riots. As a matter of fact I haven't seen anyone wondering what any of the MN Twins, Vikings, or any other professional organization is saying. It's not a slap in the face to the community at all. The community doesn't need Max Kepler to say anything. Who appointed him as a leader and what is he a leader of? Most people that I know don't look to baseball players as leaders. They look to him to make plays on the field. I personally don't care what Chris Cuomo says. I had to get that in only because your news source quote pegs you as left of center. If you had quoted people on both sides of the aisle it adds credibility. That's more of a journalism critique than anything else. "precisely what perpetuates a lack of change that is destroying us." Kepler on the sidelines isn't the problem. What's the underlying problem? Is it the people in the city or the people running it. If it's the people in the city then the problem was there long before Max got here. If it's the people running the city you have to look at who has been running the city for decades. The problem isn't new so you're going to have to go back. If people won't vote for a change then the problem will continue.
"Kepler and the Twins aren't playing baseball due to a global health crisis that has sadly been framed as "political" by some". It is sad that a health crisis is political. 80% of the deaths in MN have been in Long term care facilities. A new study out of Max's home country shows that a majority of the people would have eventually died this year regardless. When all the info doesn't come out and people are left in the dark it's going to become political. "our site's audience is predominately white, and relatively affluent. We are the voices needed most in this fight." Soft bigotry at it's finest. Our voices our no more important than the poorest minority in the poorest area of Minneapolis/St Paul. I can't speak to their plight, any injustice (real or perceived), or relate to what it's like to get pulled over because of color. I can only advocate for justice for every human being that walks the earth.
"a meaningless platitude, copping out with a "not into politics" comment is not an option...."We need to confront these issues seriously," It's meaningless to you if you view it that way. To me it means he wants peace and you see, not into politics is an option. I believe what bothers you is he's not into your politics and you want him to be. Politics is a touchy issue. The blue lives matter mask proved it. He plays for 100% of Minnesotans, not just the ones who want him to be politically active. Everyone - at least caring, logical people, want injustice to end. What really needs to happen right now is justice for George Floyd.
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.
Bear with me now - I am about to go off the baseball rails here. I read all the speculation, all the projections of player salaries and all the moaning from our team and fans and the rest of the teams and their fans so I am going to say something no one wants to hear. We do not need an Ace, we do not need a superstar! There it has been said. The follow up to that is - and I want us to win the series!
Okay, now for my reasons. Lets start with the easiest - the Ace. The Ace in the 1800s pitched much more than any current pitcher. Old Hoss Radbourne won more games - 59 than any pitcher starts in a season. He was the triple crown of pitching leader - 1.38 earned run average, 59 wins and 441 strikeouts. I know we are all about strikeouts now - look at that total. And he pitched 12 years! Okay that was an Ace that made a real difference.
Then we got to the 30 win era where this was the standard that really set out the ACE - Denny McClain in 1968 was the last to win 30. There were 21 thirty game win seasons with most in the early 1900s. And they still had arms on their bodies the next year. These thirteen pitchers were also Aces of course Denny took to Aces in the gambling dens and ruined his career.
Then came the twenty game winners - with Warren Spahn winning 20 - 13 different years during his career - despite losing years to serving in the war. His last 20 game year came in my high school graduation year - 1963. He and the other 20 game regulars were Aces. On this list of twenty game winners is Nolan Ryan - yes he also lost a lot, but he was the real leader into the strikeout era and he also was a complete game pitcher.
Then we went to five man rotations and now to openers (the shame) and the argument that wins don't matter. The above pitchers also completed games - Cy Young completed 749 games - yes he won and lost games. And he earned his wins just like the other Aces above.
Now, the Ace not only pitches one of five games, but only 6 - 7 innings in most outings. I see Kershaw get $35m a year and think - why? He cannot even move them forward in the off season and his speed is diminishing.
Sign two number twos and three number threes and we will be better off than signing a one, running out of money and ending up with most games being toss ups or worse. Of course you can also make that a different combinations of 2s,3s,and 4s, but don't break the bank on the ACE.
Then there is the Bryce Harper/Manny Machado madness. Who in the world is worth the kind of money they are talking about. Living in MN I have heard for years about how the Mauer contract impacted the team ability to sign other players (I know it was an excuse, a joke, not real), but 300 - 400m is not a joke. Look at Mike Trout - the greatest player of our current era. By himself he cannot lead them to a championship season. Nor has Machado or Harper shown that they can either.
Each player is up to bat 3 - 5 times a game - that is all and if no one is on base they cannot drive them in. If they swing for the fences and have a crap average like Harper or Sano or Morrison did last year you get 30 HRs - which if they are spread out give you 30 games of production and 132 of small or no production. In the field only the catcher and first baseman are involved in the majority of fielding plays, so even in the field there is limited production most of the time.
Since WAR is such a popular figure think about the numbers the best players puts up. No one is worth 80 or 90 WAR, the great ones are 10 and there are few is any each season. This individual game is still a team game and if the team does not pitch, field, hit, the team does not win and wins are what we want. Look at the Angels other player - HOF to be - Pujols. Tell me his worth to the team, tell me how that contract impacts the team.
No - sign a lot of good players, good fielders, good on base average, good production people, steal some bases, be fast and be involved. It is the team with production 1 - 9, rotation 1 - 5, even slightly above average at all positions that wins. Not the team with the biggest star.