Why Get a Second Opinion For an Elbow Injury?

[Lucas Seehafer PT]

Minnesota Twins pitcher Kenta Maeda was placed on the IL on Tuesday with what the team is calling right forearm tightness. MLB.com's Do-Hyoung Park later reported that Maeda will seek a second opinion regarding his diagnosis and that surgery is possible. 

Assuming the surgery in question is the dreaded Tommy John procedure, why would Maeda and the Twins even go about seeking a second opinion? It's an easy question, but the answer is wrapped in layers of complexity.

Let's begin with a brief anatomy and biomechanics lesson. 

The ulnar collateral ligament — more frequently referred to as the UCL — is a robust and triangular sheet of tissue that helps support the inner elbow against valgus stress. The elbow experiences the most valgus stress during a baseball game when the arm is driven forward at high rates of speed while throwing a ball.

Damage to the UCL occurs when the torque produced as the arm is thrust forward — the technical term is internal rotation — is more significant than what the structure can compensate. Injury can occur chronically as well as acutely and is generally described as a sprain. The degree of damage is graded on a scale of 1-3. Grade 1 sprains are usually minor injuries that heal within a week or two. Grade 2 sprains — also referred to as partial tears — cause instability in the joint as some 50% of the ligament fibers have been damaged; the most frequently reported symptoms are pain and swelling. The recovery timeline for grade 2 sprains generally extends into months. Grade 3 sprains — or ruptures — result in significant instability and require Tommy John surgery to address. 

Grade 2 sprains are where the best route of treatment is murkiest. As the UCL is technically an extension of the joint capsule — a larger sheet of tissue that envelops a joint and provides stability and nourishment — it has a relatively good blood supply, meaning it is technically capable of healing on its own without surgery. (Side note: This is why ACL injuries require surgery in most instances. Although the ACL is inside the knee, it is technically separate from the joint capsule, and, thus, has almost no blood supply.)

However, the UCL does not have the same blood supply throughout its structure. A recent study found evidence to suggest that the blood supply is best nearer where it connects to the upper arm bone — proximal — and decreases as the ligament extends to the forearm — distal. This finding may suggest that grade 2 sprains of the UCL that occur proximally are more likely to heal without surgery than those that are distal (or, read another way, Tommy John surgeries that treat proximal tears are more likely to be "successful" than their distal counterparts.) (Another side note: Interestingly, a study conducted in 2020 found data to suggest the opposite, though it should be noted that the study had a small sample size and was retrospective; both factors limit the findings' strength.)

Rest and anti-inflammatory medication are most often the first two steps in treating a grade 2 UCL sprains followed by physical therapy to improve range of motion and increase the strength of the surrounding muscles. While the UCL provides static stability for the inner elbow (i.e., its fibers don't contract and act as a brace), the forearm musculature provides dynamic stability (i.e., its fibers do contract and pull the inner elbow together). Having strong forearm muscles is vital for protecting the healing UCL.

Another treatment often reported after an athlete is diagnosed with a UCL sprain is platelet-rich plasma (PRP). 

The theory behind PRP is sound. The process involves drawing blood into a test tube, spinning it around rapidly in a centrifuge to separate the blood into plasma and red blood cells, sucking the plasma into a syringe, and injecting the plasma into the injured tissue. Plasma contains a variety of cells and other substances, one of which are platelets. Platelets help form the foundation on which new tissue grows and secret substances that help aid the healing process.

Again, theoretically.

The results surrounding PRP injections and return to play in baseball are … inconclusive, at best. Read one study, and you may come away believing that they work exceptionally well. Read another, and you may think they're just a bunch of hocus pocus. The fact of the matter is this: Despite being relatively well studied, there is little evidence, at this point, to suggest that PRP injections are the medical savior they were once considered to be.

So, back to the original question. Why should Maeda and the Twins even pursue a second opinion?

Well, the short answer is "Why not?" If the injury Maeda suffered is a UCL sprain, and if he ultimately undergoes surgery, he'll miss the entirety of the 2022 season anyway. Waiting another week or two to gather more information won't prevent him from playing next year.

The longer answer is that the most appropriate course of treatment may or may not be surgery, depending on various factors, including grade, location, and, frankly, a specific doctor's training and treatment philosophy. Again, if Maeda is dealing with UCL damage and if it is partial and proximal, it may have a chance to heal on its own. 

Also, and this bears repeating, what's the harm in trying conservative rehabilitation and waiting on surgery? Best case scenario: Maeda can pitch again in relatively short order and definitely be next season. Worst case scenario: Maeda has to undergo surgery, which, again, would keep him out of 2022 anyway. 

At this stage, there is minimal downside for the Twins and Maeda in gathering as much information as possible. The team isn't going to the playoffs, he's under contract next year, and he's one of the more critical pitching pieces in the Twins' system.

I'll pose the question again. Why should Maeda and the Twins seek a second opinion? Because it's the right thing to do.

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[wsnydes]

If this were me, I guess that I'd simply want a second opinion before rushing into a procedure and risking my career, millions of dollars, significant rehab and recovery time, and all of the stress that goes along with that.  Doesn't really need to get more complicated than that.

[TopGunn#22]

I totally agree with the second opinion.  Never "rush" into surgery of any kind unless necessary.  If he's possibly going to miss the entire season next year, then a couple days or even a couple weeks don't matter.  Be thorough, and proceed with caution.  

Assuming he's out all year next year, would this change the FO's plans for 2022 ?  This opens up an entirely new range of issues for endless discussion on TD.  One approach would be "heck, he was our #2 or #3, scrap any chance of contending in 2022, let's look at a LOT of young arms."  That might be their approach already.  The other would be to look at Maeda as a sunk cost for 2022, go out and sign/trade for a #1 (a Thor, Rodon, Gausman type) and then aim a little higher than a Dylan Bundy/Pineda type as a 2nd FA/Trade acquisition.  Lineup is by and large intact with some minor tweaking so let's see what 2022 brings.  Then, when Maeda comes back for 2023 you're that much deeper and you've seen what some of your young can or can't do.  

The problem is, unlike a team like the White Sox, that sees an off-season of opportunity and just flat out goes for it, the Twins have disappointed all the way back to the Santana, Mauer, Morneau years.  So to expect them to get serious about our favorite baseball team would be expecting a philosophical awakening.  

[dennistwinsfever2]

this was an excellent analysis of the situation - thanks!

[mikelink45]

I appreciate the insights and discussion.  Yes to a second opinion, but also yes to doing the surgery as soon as it is an agreed upon need. 

[Karbo]

I would always seek a 2nd opinion before considering surgery 

[LewFordLives]

My main takeaway was don't let your kids pitch.

[Dman]

No reason not to get a second opinion but it seems like about 90% of the time if there is a tear surgery is the only fix.  It just seems like once it acts up even after rest it just can't handle the same amount of stress it used to.  I would say odds are he ends up getting surgery but certainly no harm in a second opinion or trying all the least harmful options first if you think there is a chance they might help.  I just haven't seen rest work very often in these cases especially with older players.  I think there is a good chance he is out for 2022.

[Lucas Seehafer PT]

One thing I cut from the article for length purposes that I think is still important to mention is the report when Maeda first signed with the Dodgers about "irregularities" in his elbow. I chatted with out own Nick Nelson on Twitter about my thoughts:

 

 

[wabene]

I asked this exact question in the other Maeda elbow thread about why there is uncertainty with elbows but not ACL's. You have completely cleared this for me, thanks. So now when people complain that a team didn't have a player have surgery right away wasting time we know that it was a prudent course of action.

[4twinsJA]

What procedure did Rich Hill have? It seems to have worked and was not off as long as TJ surgery. 

[bean5302]

It's standard procedure to get a second opinion on UCL injuries regardless of the the recommendation. It's just as likely the first opinion was against surgery as it was to get the surgery. In any case, here's hoping the best for Maeda, regardless of the outcome.

[bean5302]

22 minutes ago, 4twinsJA said:

What procedure did Rich Hill have? It seems to have worked and was not off as long as TJ surgery. 

He had UCL reconstruction surgery rather than UCL replacement.

 

[Lucas Seehafer PT]

40 minutes ago, 4twinsJA said:

What procedure did Rich Hill have? It seems to have worked and was not off as long as TJ surgery. 

Hill had a quasi-experimental procedure in which a compound called "surgical tape" was dipped in collagen and sewn into his partially torn UCL. It can't be done on all UCL injuries, and in fact can only be done in particular cases. The results of not only his surgery but the ones completed before it are extremely encouraging, meaning we'll likely see more in the future.

[TwinsDr2021]

3 hours ago, TopGunn#22 said:

  The other would be to look at Maeda as a sunk cost for 2022, go out and sign/trade for a #1 (a Thor, Rodon, Gausman type) and then aim a little higher than a Dylan Bundy/Pineda type as a 2nd FA/Trade acquisition.

There should be no sunk cost next year for Maeda, The Dodgers gave the Twins 10 million dollars in the trade, which magically equals his base salary in (20,21,22), thus the Twins really only have to pay incentives for those 3 years, Based on Spotrac, he made 2,185,00 in incentives in 2020, and 1.5 million this year.

So if he misses next year, the Twins will be on the hook for a total of less than 4 million total for him between 20-22, which is pretty good for 32 starts, 172 innings, and a 3.9 ERA.

And assuming he comes back in 23, his base will be 3.125, and he is mostly likely not going to hit the big money incentives, so basically another cheap year.

[a-wan]

I'd love to hear a radiologists real opinion on their MR reads on pitchers elbows and shoulders. It would always show so much inflammation due to the stresses from pitching.

[Richie the Rally Goat]

5 hours ago, wsnydes said:

If this were me, I guess that I'd simply want a second opinion before rushing into a procedure and risking my career, millions of dollars, significant rehab and recovery time, and all of the stress that goes along with that.  Doesn't really need to get more complicated than that.

Agreed, and also would want the inverse, if I need the surgery, would want to get it as soon as possible. Would hate to spend 6 months resting and rehabbing a UCL that’s never going to heal, just to get TJ and lose half to 3/4 of 2023 as well.

[h2oface]

Thanks for the great informative article. Awesome read.

In answer to the OP question...... why wouldn't one always get a second and third opinion even? If it involves surgery, for anything at all, I would get 2 opinions, just as a matter of sane and smart personal policy.

The only guy I know of that the rest actually worked is Ervin Santana, but I think it is still partially torn all these years. Mostly, waiting just wastes time. The worst possible scenario for Maeda would be to wait several months, then try it, and have it blow or reinjure, and then one of the surgeries discussed. That would even take more time, and in his case, cost him a boat load of money with that goofy incentive laden contract.

[Lucas Seehafer PT]

18 minutes ago, h2oface said:

Thanks for the great informative article. Awesome read.

In answer to the OP question...... why wouldn't one always get a second and third opinion even. If it involves surgery, for anything at all, I would get 2 opinions, just as a matter of sane and smart personal policy.

The only guy I know of that the rest actually worked in Ervin Santana, but I think it is still partially torn all these years. Mostly, waiting just wastes time. The worst possible scenario for Maeda would be to wait several months, then try it, and have it blow or reinjure, and then one of the surgeries discussed. That would even take more time. 

100%. Though, I will say, rarely in such a situation would an athlete like Maeda try conservative options for several months. Of course there are exceptions, but, generally speaking, the docs/PTs/athlete/etc. will now within about 6-8 weeks if the rehab is working or not. They'll monitor MRIs, pain levels, velos, commands, force generation and numerous other variables and if things are just not progressing well, then they'll opt for surgery. Waiting a month or two won't delay the overall return to play too much, especially when it's this late in the season.

[h2oface]

7 hours ago, bean5302 said:

He had UCL reconstruction surgery rather than UCL replacement.

 

This article was great about the the Rich Hill procedure, as was the one by this author  Lucas Seehafer PT  and the link to that on is in the Heezy article, too. 

[nicksaviking]

Fantastic article. Thanks for this great information.

[Johnny Ringo]

I went to the doctor with a similar injury and he said that I needed surgery. I told him I wanted a second opinion.  He said "Ok, you're ugly too." 

[Heezy1323]

On 8/25/2021 at 10:38 AM, Lucas Seehafer PT said:

Hill had a quasi-experimental procedure in which a compound called "surgical tape" was dipped in collagen and sewn into his partially torn UCL. It can't be done on all UCL injuries, and in fact can only be done in particular cases. The results of not only his surgery but the ones completed before it are extremely encouraging, meaning we'll likely see more in the future.

This is mostly, but not completely accurate. Hill had a UCL repair in the sense that he did not have a new graft put in place, but simply had a direct repair of his existing ligament tissue. However, he had previously undergone UCL reconstruction in the early 2010s and as such had a repair of a previously reconstructed UCL, which is really a distinct situation from the vast majority of these operations in which the athlete's native ligament is reattached to the bone. 

 Agree with Lucas that we will probably see more of these 'primary repair' operations going forward. Hopefully they will be able to reduce the time needed for recovery for a subset of UCL-injured players. 

[Heezy1323]

On 8/25/2021 at 12:35 PM, a-wan said:

I'd love to hear a radiologists real opinion on their MR reads on pitchers elbows and shoulders. It would always show so much inflammation due to the stresses from pitching.

This is another HUGE variable in evaluation of these patients. The appearance of the UCL on MRI is often not particularly helpful.

 

Let's go through the scenarios:

1) The UCL looks completely normal (rare at the MLB level): rest and rehab, perhaps a PRP injection

2) The UCL is completely torn, obvious to everyone that the athlete needs surgery (maybe 20% of the time): proceed with surgery in most cases, though on occasion PRP or other means of treatment can be tried.

3) The UCL is somewhere in between. Small to moderate damage, but nothing terrible (this is the case the majority of the time): A huge range of possibilities. Some pitchers can throw for years on a partially torn ligament. Others can have an MRI that looks essentially normal and can't throw without pain despite extensive non-surgery treatments. This is what makes these decisions REALLY hard in a lot of cases. The exact same MRI findings can indicate opposite things in two different patients. Trying to figure out which patients will be successful with non-surgical treatment is tough. And remember, the return to play rate after TJ surgery is quite good (somewhere around 90%), but that still means 1 in 10 will not get back. This is why, in many cases, the athlete has to 'prove' they aren't going to be successful without surgery by trying the rest and rehab route initially before proceeding with surgery. Sometimes the calendar, an athlete's contract status or year in school, or other factors will push us to surgery faster.