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  1. Biceps Tendinitis in Pitchers Q&A Heezy1323 A request was made by a poster for me to write a blog covering biceps tendinitis. This is actually a fairly complicated topic with quite a bit of controversy, but I’ll do my best to share some basic info that hopefully TD peeps will find interesting. There are some technical parts, so apologies for that, but I do think a basic understanding of the anatomy is helpful. Question 1: What is the biceps, exactly? The biceps is a muscle that we are likely all familiar with, lying in the front of the upper arm and used to perform curls and similar exercises. The word ‘biceps’ has a Latin origin meaning ‘two heads’. This describes the upper (or proximal) end of the biceps where there are two tendon attachments. The first is the long head of the biceps which attaches to the labrum at the top of the socket in the shoulder. It then curves over the top of the ball (humeral head) where it exits the shoulder joint and begins its course down the front of the upper arm bone (humerus). At the front of the shoulder joint, it travels through what is called the ‘bicipital groove’ which is an area of the bone of the humerus between two bumps (called tuberosities). This groove is often the site of issues in pitchers (more on this below). The second is the short head of the biceps, which originates from a bony projection off the shoulder blade in the front of your shoulder called the coracoid. It travels straight from here to meet up with the long head of the biceps in the upper 1/3 of the arm. There, the tendons join and form the biceps muscle. Below this (distally), the muscle turns back into a tendon just above the elbow and a single tendon then travels down to one of the bones of your forearm (called the radius) where it attaches at a bony prominence called the radial tuberosity. Question 2: How is this tendon involved in throwing? This is a great question, and a subject of much debate amongst experts. The short head of the biceps likely has a relatively insignificant role in throwing. The long head (which is the one that attaches inside the shoulder joint) is much more involved in the throwing motion. When throwing at MLB speeds, the shoulder rotates at 7000 degrees per second, which is the fastest known human motion. One can imagine the stress this places on the structures that surround the shoulder. Without delving into the weeds too much, it seems as though the biceps has a role in position sense of the shoulder during throwing, likely a role in stability of the shoulder joint and also helps slow down the arm after ball release. At the other end of the tendon (distal), the elbow changes rapidly from a bent position to a straight position as the ball is released during a throw. In order to keep the bones of the elbow from jamming into each other at a high speed, the biceps muscle fires to slow down this elbow straightening (what we call an eccentric contraction). This allows some of the force of throwing to be dissipated by the muscle (kind of like a shock absorber). If it seems like that is a lot of jobs for a small tendon/muscle- it’s because it is… Question 3: What happens when someone gets biceps tendinitis? Tendinitis is a fairly broad term and can mean a number of different things depending on the context. With respect to the biceps, a thrower can develop issues at either the upper (proximal) or lower (distal) end of the biceps. The suffix -itis means inflammation, so the general thought is that there is inflammation that develops in or around the tendon. The reasons ‘why’ are heavily debated, but generally there is probably some combination of overuse/fatigue and altered mechanics or muscle imbalances that contribute. It takes a tremendous amount of efficiency of motion and coordination of muscle movements to throw a baseball in excess of 90mph, and any small abnormality can easily be compounded by the sheer number of repetitions and intensity of a typical pitcher. Over time, this can add up to cause damage to the tendon and result in inflammation and pain. Arthroscopic image of normal biceps tendon (left) and inflamed biceps (right) Question 4: How does the player/medical staff separate this injury from other issues that can seem very similar? This can be VERY difficult. Often the player will have pain at the front of the shoulder (in cases of proximal biceps tendinitis) or just above the elbow (in distal cases). A thorough history and exam is performed in order to hone in on the likely problem area. An MRI is ordered in some cases. One of the challenges with this type of issue is that in many cases, an MRI of a pitcher already has some abnormalities on it which are likely adaptive and have been present for a long time (and are not the actual cause of pain). In addition, in many cases the inflammation around the bicep isn’t something that can be clearly seen on MRI. So interpreting imaging studies can be a significant challenge. Usually the exam is (in my experience) the most helpful thing in recognizing biceps tendinitis when it is present. The athlete is usually tender right in the area of the tendon, which is a helpful finding. Question 5: Once a pitcher is diagnosed with biceps tendinitis, how are they treated? Again, there are a lot of variables here. But presuming it is significant enough to affect the performance of the pitcher, they would typically be shut down for a period of time to prevent worsening of the condition. Anti-inflammatory medication may be used. In some cases, injections of cortisone are used to try and decrease the inflammation. With the recent increases in the use of technology, video may be consulted to see if there have been subtle mechanical changes which may have contributed to the issue. Muscle strength can also be tested in various areas around the shoulder to see if weakness is contributing. In essentially all cases, a rehab program will begin that is likely to include strength and flexibility components. When the pain has subsided, a return to throwing program is begun and once complete, the athlete can return to play. A group out of Mayo Clinic (led by Dr. Chris Camp) recently did a study of pro baseball players (minor and major league) and causes of injury over a several year period. Tendinitis of the proximal biceps was actually the #4 cause of injury with an average return to play time of about 22 days. Question 6: Is surgery ever needed? It is quite uncommon for surgery to be needed for this issue. In fact, in Dr. Camp’s study above surgery was only required in 3% of cases of proximal biceps tendinitis. So clearly most of these cases improve with non-surgical treatment. In addition, surgery for this particular issue has a fairly poor track record and is avoided if at all possible. Question 7: What can be done to prevent biceps tendinitis? Great question, reader. If I knew the answer, we could likely both be millionaires given how common this injury is and the dollar figures involved when a high-priced starter or reliever is on the shelf for this reason. Generally, I believe monitoring the workload of pitchers through the season, doing what you can to ensure they maintain a good off-season program and having a good line of communication with the players are all important. As video analysis and other analytic measures become more popular, my hope is that they can be incorporated into injury prevention as well. Thanks for humoring me on this complex topic. Please feel free to add a request for a future subject in the comments. GO TWINS!!
  2. 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!
  3. News came down yesterday that highly-touted Twins SS prospect Wander Javier will undergo season-ending surgery on his left (non-throwing) shoulder to repair a torn labrum. According to LEN, this was an injury that was suffered initially late last season, but initially the decision was made to attempt to treat Javier with rehabilitation. Unfortunately, he has continued to have pain in the shoulder, and he has taken the dreaded trip to Pensacola, FL to see Dr. James Andrews. It sounds like Dr. Andrews will perform surgery soon, and that Javier is expected to be out six to nine months. Shoulder injuries are common in baseball players, certainly. But they are much more common in the throwing shoulder, particularly in pitchers. Let’s discuss how this injury may be similar and different. Question 1: What is a labrum, anyway? 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. Question 2: How does a labrum get injured? There are several ways that someone could injure the labrum of the shoulder. In baseball players (and pitchers in particular), it is common for a labrum tear to occur at the top of the socket near the attachment of the biceps tendon. This is called a SLAP tear (Superior Labrum Anterior to Posterior) and is typically the cumulative result of repetitive use. However, it can also occur as a result of a dive/fall if the mechanism is just right. Another way the labrum can be injured is as a result of a shoulder dislocation. In the majority of cases, the ball dislocates out the front (anterior) of the socket, and the attachment of the labrum to the rim of the socket is damaged. A final way that I have seen labrum injuries in baseball players is in the front shoulder of hitters. Occasionally, as a result of an aggressive swing (or combination of swings) a player can damage the labrum in the back part (posterior) of the shoulder. This is also an injury that I sometimes see in golfers. In Javier’s case, the injury is to his left shoulder. As he is a right-handed hitter, this would be his front shoulder. I was not able to find any reports of him dislocating his shoulder last season (which would suggest an anterior labral tear). It is possible, then, that his labral tear is more in the back of the socket (though this is purely speculation on my part). Question 3: Why didn’t he just have surgery in the off-season to get this taken care of? This is always a difficult question to answer without knowing specifics of the situation. Hindsight is 20/20, but it is not always known at the time of an initial injury whether it is going to require surgery or whether rehab will be sufficient. Clearly, the Twins and Javier felt that rehab stood a reasonable chance of being successful, or I suspect surgery would have been undertaken previously. Question 4: What is done at surgery? There are subtle variations in technique for these type of injuries, but the majority are treated with arthroscopic surgery. This means a small fiber-optic camera is inserted into the shoulder, and the shoulder is filled with fluid. The labrum is then examined and the extent of the tear is assessed. Typically, the pre-op MRI will give the surgeon a good idea how extensive the tear is, but the precise size and location of the tear is not known until surgery. Once the tear has been assessed, the repair process begins. Small anchors (similar to plastic drywall screws) are inserted into the rim of the socket in the area of the labrum damage. These vary in size, but are typically somewhere around 3.0mm in diameter. These anchors have strong stitches attached. The stitches are passed around the labrum using special tools and the labrum is secured back to the rim of the socket. This process is repeated for as many anchors as are needed to completely repair the tear. After surgery, the small incisions are closed with suture and the patient heads to the recovery room. Surgery typically takes around 1-1.5 hours. Question 5: What happens after surgery? Why does it take so long to get back to full activity? Any time we repair a structure in orthopedics, the rate of healing is dependent on a number of factors. Some factors include the type of tissue injured, the severity of the injury, the age and health of the patient as well as numerous others. One helpful comparison in this case can be a fracture of a bone. Bone, as compared to cartilage (labrum) has a much greater blood supply. As such, most bone fractures are able to fully heal somewhere around 6-10 weeks (with some variability of course). Labrum (as with all cartilage) has a much poorer blood supply, and as a result takes a lot longer to heal. This is one of the main reasons for the lengthy rehab. In addition, the stresses placed on the shoulder are significant. The labrum has to withstand a tremendous amount of force when throwing a baseball or swinging a bat. The muscles around the shoulder tend to get weak quickly after surgery, and it takes time to rebuild the muscles. Proceeding too aggressively (before the muscles have recovered) places extra stress on the labrum, and can lead to failure of the repair to fully heal. Question 6: Will Javier’s shoulder ever be the same? This is perhaps the most difficult question to answer. Without knowing the extent and location of the damage, it is very difficult to comment on this subject. It is certainly better that this is his non-throwing shoulder, as that likely portends a better chance of full recovery. Few surgeons have done more of this type of surgery than Dr. Andrews, so he is in good hands.
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