Under the Knife: Opening Week Injuries Around MLB
Time for a little perspective, people. While injuries have certainly been the story of the spring, they're not really up. We're noticing them more, perhaps, and there's an unusual pattern of second Tommy John surgeries, but there's no increase or epidemic. I've never had a problem filling up UTK since it started 13 years ago, though it always hurts to see big names like Clayton Kershaw, Yu Darvish and Bryce Harper in there.
We saw last year early in the NFL season that there was an apparent increase in ACL injuries. The raw count was up by the end of the year, but not so much that there was anything out of the norm. There were some big names, a cluster that got notice, but really things were just at the top of what seems to be a normal range. The same is likely true here.
Maybe things are starting to change a bit. I had a nice talk with Frank Coonelly, the president of the Pittsburgh Pirates yesterday, while he was here in town kicking off the season for the Pirates affiliate, the Indy Indians. When I talked injuries with him, I get the sense that he's already got Dan Fox working on some things. The last thing the rest of the NL wants is the Pirates getting smarter about injuries.
That advantage is still out there for a team that can figure things out, joining teams like the Tampa Bay Rays and Seattle Mariners. The tipping point for injury management is still a long way off, which gives us plenty to discuss today, so let's get to it.
The news is not good on Clayton Kershaw. Dylan Hernandez of The Los Angeles Times reports that Kershaw is headed for a "submaximal throwing program." That's a fancy term for playing catch and reducing his rehab. The strained teres major has now been confirmed by the team, but as I said last week, there may be more going on here than a simple strain.
While Kershaw isn't being shut down, he's just short of it. If this goes anything more than the two or three weeks discussed, it will confirm that there's something else complicating the strain or that the strain is much more significant than indicated. Watch for any indication of additional inflammation, especially bursitis. That should be responding to rest and medication by this point.
There's a continued and meaningless argument about whether this is a "back" injury or "shoulder" injury. Call it either, and it doesn't change the actual problem. Losing Kershaw for the first month of the season is bad enough, but if there's a bigger underlying issue, the Dodgers have much bigger issues.
While they can sidestep his absence for the first few weeks and do hope to have Josh Beckett back in the rotation soon, everyone is going to be a big step down. Worse, the $215 million investment in Kershaw's future is going to put a lot of focus on the medical staff in a situation that they likely had little control over.
Last week, Murray Chass wrote about a "secret surgery" that Tommy John had after the surgery that came to bear his name. Problem is, the surgery wasn't secret at all. Dr. Frank Jobe went back in to fix a complication, an entrapment of the ulnar nerve, that set back his rehab but had no later bearing on his recovery. To this day, surgeons debate whether to move the ulnar nerve during the surgery despite only about one in five having issues.
The ulnar nerve issues usually happen during rehab, but for Brian Wilson, it may have waited a while. Wilson hit the DL after one bad outing with what the Dodgers are calling a nerve irritation. Normally, that can feel like hitting the "funny bone" over and over, or there can be weakness or changes in the hand, as John had.
The downside here could be a surgery to move (transpose) the nerve into a position where it won't be entrapped and irritated, but that would cost Wilson significant time. The rehab isn't as significant, but the nerve controls that hand so it's not something that can be done flippantly.
There's also the chance that Wilson, just about 18 months removed from his second Tommy John surgery, has damaged the elbow. That would be very unusual, but we've seen quick revisions necessary in other pitchers recently, like Brandon Beachy, who needed one after a similar time out. The Dodgers say that images indicated no ligament damage.
We'll know more about Wilson soon, but early indications aren't good for The Beard's elbow. Watch to see if he's able to do anything after a period of rest. He'll likely start to throw after rest and medication, but they'll look to make a quick decision if there's any recurrence.
First, a bit of an anatomy lesson. I can remember my A&P class at the University of South Alabama. I had signed up for the night class because I'm not a morning person, but I hadn't read the fine print. Instead of being the relatively easy but rote course that most sports med majors take, I had put myself in the medical school's version—the one with a cadaver lab.
That came as a shock, but I can remember the teacher to this day every time I go through things, hearing the slight British accent and the occasionally odd terminology. To this day, when I look at my arm to think through the anatomy, I hear that voice as I flip my arm palm up to mimic anatomical position. While the ulnar nerve and ligament are on the outside of the arm as you stand, they're called "medial" because of how the cadaver lays on the slab.
In sports medicine, knowledge and habits are passed down. Saying something like 'abduction' as 'ay-bee-duction' tell you which school of thought they come from, or at least where their teachers learned. The same is true in baseball. David Altchek, the Mets team doctor, uses the term MCL for the elbow ligament that is key to pitching and replaced in Tommy John surgery. Most use the term UCL. It's the same ligament.
That's the one that Bobby Parnell has damaged, as detailed by The New York Times. He's shown reduced velocity all spring as he comes back from neck surgery, but maybe the changed mechanics or increased effort led to more stress on the ligament. Images showed damage, but not enough that they decided to do surgery immediately. Surgeons know that somewhere between 25 and 33 percent of tears in the thickness of the ligament are too much, but when the strain is right on the border, they'll almost always elect to try to rehab it for a few weeks and see. There's always the chance they can avoid surgery.
Parnell had a PRP injection, which we should just assume in pretty much all cases these days. He'll try to throw again in a couple weeks and a decision should come quickly. The Mets have been saying there's no safe harbor from these kinds of injuries, but there's a lot more that they and baseball in general could do. Maybe one more lost season for a key pitcher will push Sandy Alderson to act.
Yu Darvish made it through a throwing session on Tuesday, and from all we could see, it went well, just as his bullpen session on Sunday did. Evan Grant has more details on the bullpen and the chance that the Rangers could go with a de facto seven-man rotation for the first weeks of the season.
Darvish could be back in the rotation as soon as Sunday, but expect for the Rangers to be very conservative as they get him back on the mound. He's lost very little in the way of stamina due to the neck stiffness, but the medical staff wants him as close to 100 percent as possible before they set him loose.
I wouldn't expect any major changes for Darvish. The Rangers are acting with caution with their ace, as much because of the pitchers around him as with Darvish himself. Missing him for one or two starts is much better than missing him for months the way they will with Derek Holland or Matt Harrison.
Speaking of Harrison, he'll make a rehab start on Thursday at Frisco (AA). I'll have one of my best observers at the game, so expect a full report. The Rangers will have some of their top guys, perhaps Greg Maddux, at the game to watch, and there's some anticipation of having Harrison back in April.
"Bryce Harper just took a roundhouse kick to the head," said the text message. One of my many friends and observers shot me the message which sounded, well, dramatic. It wasn't exactly how it happened, however.
Harper slid into second base and caught the shin of Eric Young Jr. on a typical double play. It did look similar to the play in which Justin Morneau was concussed, but Harper was checked quickly and passed concussion tests. He remained in the game, as detailed here by The Washington Post, but he did report a headache. That's a bit worrisome, but the ATs and doctors have cleared him.
One thing that you'll notice in the Post's picture is that Harper's helmet came off in the incident. I asked an MLB Athletic Trainer about helmet fitting, which is an important part of concussion prevention in football. He told me that while teams have done a bit more with making sure the helmet is tight since switching to the new R100 helmets, it's still mostly a matter of comfort for the players. That means it's on the players to take the issue seriously.
Harper should be fine, though the team will monitor him for progression of symptoms as mandated by MLB's concussion protocol. Harper wasn't really playing recklessly on the slide—it was a pretty standard play—but it's precisely the kind of thing he should be avoiding. Breaking up the double play there had almost no value, while Harper's health is huge for the Nats.
Wilson Ramos has spent half his career, maybe more, on the DL. I always wonder who made the most appearances in UTK over the years—at one point it was Moises Alou—but Ramos would be a contender. His latest injury is a tough one, but a comeback is pretty standard from hamate surgery.
Reports were all over the place after Ramos was removed from the Opening Day game. Now it turns out that Ramos was having wrist problems back in spring training, as detailed by MLB.com's Bill Ladson. Ramos will meet with a specialist, but it looks like he's headed for surgery to remove part of the hamate bone.
The hamate, one of the several small bones in the wrist, causes weakness and pain if it is fractured. It's an easy fix to pull all or part of it, but the wrist's complexity makes the recovery a bit troubling. There's going to be a loss of power for a period of time, but that usually comes back.
Pablo Sandoval is probably the best example here, having had surgery on both wrists and returning to full power in about six weeks each time. Ramos will have a bit more of an issue given the battering he'll take behind the plate. Jose Lobaton will get more of the catching load while the Nats hope to be able to paper over the backup catcher slot while they wait to get Ramos back in late May.
Jose Reyes may be "injury prone," but really, it's just one part. Even then, it's really more amazing that Reyes has been able to have the career he's had with the early career hamstring issues that came very close to derailing it altogether.
Reyes heads to the DL with a mild hamstring strain after re-injuring himself on Opening Day. Reyes had a late spring hamstring strain and played through it, even showing up on the hard turf of Montreal for the exhibition there. (Actually, I don't know that the infamously bad turf at Montreal is still that bad, but it claimed many a victim, so I'll assume recidivism.)
Reyes is expected to miss only the minimum as he rests the Grade I+ strain, but the fact that he was able to push out there for Opening Day only to get hurt is a black eye for the medical staff. The Jays are under a lot of pressure, bottom to top, and if Reyes doesn't pay off, the big deal that was intended to turn the franchise around is going to be Exhibit A against Alex Anthopolous. Keeping him healthy needs to be a priority, if that wasn't clear already.
Three innings in a friendly between two Single-A affiliates doesn't sound like much of a step for one of the top pitchers in the league, but Cole Hamels will take it. He's had no real problems since his "dead arm" slowed his ramp-up to the 2014 season. The Phillies are still calling his issue tendonitis, but he's really had no issues with inflammation since early in camp.
Hamels will need at least a couple more outings as he continues to build stamina, but Hamels is making progress. He hasn't missed any side work since starting back onto his throwing program, which is a very positive sign. The Phillies haven't determined yet where Hamels will start his rehab, but they'll likely keep him in Clearwater for at least some time due to weather and comfort.
Look for Hamels to get his pitch count up before they bring him to a higher level. Hamels may not be up to the bacon-wearing Lehigh Valley (AAA) or Reading (AA), and even then, only for one start to show that he's ready. Watch for Hamels to get his pitch count up over 50 in his next couple starts, with the goal of 80-90 in that final rehab. If he stays on track, he could make it back before April is done.
It's kind of amazing how well Aroldis Chapman is doing after being hit in the head by a comebacker. Of course, "well" includes having a plate fixated to the bone above his eye and a halo of staples holding his face on. I guess "well" is relative, as it could have been much worse.
Chapman was able to take part in Opening Day festivities and is expected to start physical activity soon. He'll have lost a bit of stamina, but it shouldn't take much once he gets back to throwing. An April return is looking a bit ambitious, but late April shouldn't be completely ruled out just yet. Early May is a near certainty.
Chapman doesn't appear shaken by it, though everyone will be waiting to see if he flinches any when he does return. The Reds will take those steps very deliberately, but as of now, there have been no problems beyond the normal medical issues.
Look for Chapman to throw by next week and start a rehab assignment shortly thereafter. He'll get his closer slot back immediately upon return and will give the banged-up Reds pen a real boost.
For those wondering about Cabrera's huge contract, it is insured. There's some pretty big premium on it, perhaps as much as $1.5 million per year, as well as a long elimination period. (An elimination period is the disability equivalent of a deductible.)
Cabrera would have to miss a full season before the policy pays out. Even then, the Tigers would only get back around half of the contract's value while he's out, though it's clear he's irreplaceable.
The Indians sound very positive about Michael Bourn. The speedster is coming back from a tough hamstring surgery. He could play as soon as Thursday at Columbus (AAA) and be back with Cleveland by the weekend. While steals are likely to be down, look for any quick first steps as evidence that he's healthy. That could come out of the box, in the field, anywhere.
Derek Jeter's backup is hurt, which leaves the Yankees in a very tenuous position. Jeter has had no trouble with his ankle this spring, though he's not pushing things much. Ryan is still unable to swing due to a pinched nerve in his back.
The Yankees sound worried that Ryan won't be back soon and may be forced to go find something more than Yangervis Solarte to take some time at shortstop. There are some whispers that Stephen Drew is on their radar, but the Yankees are hoping not to make the deal until after the June draft so as not to give up a pick.
The Dodgers still think they could have Matt Kemp back as soon as Friday. The team has been conservative with their outfielder as he comes back from multiple issues. The ankle has done well late in spring, so Kemp could be ready to play in the outfield soon, though he hasn't done significant work in games yet.
There's also a question about whether he can go back to back, so having him active will shorten Don Mattingly's roster a bit. It's unclear how the Dodgers will shift the roster to activate him, though Mike Baxter is the most likely to get a ticket to Albuquerque.
Tim Lincecum escaped a comebacker to the knee with nothing more than a bruise, but that could be enough if it changes his complex mechanics. The Giants want to see him on the side one more time before clearing him to throw in a game. That was scheduled to happen Tuesday, but there's been no official word on how it went yet. If he passed, he'll go on Thursday.
Latos will make a rehab start at Pensacola (AA) on Thursday. Latos has had no major issues since coming back from minor knee surgery early in camp. He's building his stamina, so look to see how many pitches he goes. The Reds will want to get him around 80 before bringing him up, so anything under that means he'll make one more start in the minors.
Another Jays pen injury? We shouldn't be surprised at this point, especially when it comes to Casey Janssen. The oblique strain for the closer may be more serious than initially let on. There's conflicting reports on when Janssen will throw, but for now, Sergio Santos will take the saves. Expect Janssen to be back in April, but when he does restart his throwing program will tell us more about how long he'll miss.
The Braves give their Mississippi (AA) affiliate a gift, letting them have Mike Minor rehab on their Opening Day. He's expected to go pretty deep and could have only this one rehab start before returning to Atlanta's thin rotation if all goes well. Look for Minor to look as close to game ready as possible in terms of both stamina and stuff.
Quentin is coming back from surgery on his right knee, but now it's the left one that's sore. That's a bad sign, and the "bruise" may be a sign of internal damage. Quentin's productive when healthy, but that can be few and far between. The Padres haven't been able to keep him as productive as the White Sox did, but that's no surprise, right?
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