Heezy1323

I largely agree with you @Lucas Seehafer PT. Allow me to play devil's advocate to some degree. What do you think is the SPECIFIC question being asked of the consulting doctors (Dr. Anderson et al.)? I think it is most likely something along the lines of "Do you see anything on this imaging study (xray/MRI) that would indicate that there is the chance of Carlos developing an ankle problem that limits his function in the next 10-12 years?" I don't believe that is a question you can answer using the 'functional model' you are describing. The MD isn't being asked about how he is currently performing or how he has performed in the past. Everyone involved knows the CC of today is an incredible player. If the MD says, "Well, I see some arthritis on this MRI, but he is currently functioning fine," the response is going to be- "OK great. What does that mean for his future?" As such, the MD is essentially forced to make a prediction. Are predictions always correct? Absolutely not. But I don't think that the argument that "He is functioning just fine today" satisfies the question being asked. Also, the MRI here is not 'predicting future injury' to use a term you used. It is, more precisely, 'documenting the current state of the ankle'. This may seem like semantics, but I don't believe it is. The injury isn't being predicted- it is already there (presuming my assumption of some ankle arthritis is accurate). What is being predicted is how this ankle will hold up over time given the amount of arthritis currently present. Now, is there some room for subjectivity as to how an ankle with some arthritis will hold up over time? One hundred percent yes. This is likely (IMHO) where the MDs differed in their opinions. Or, perhaps the MDs said similar things, but team officials chose to utilize that information differently. I don't think we can say for sure. In any event, I thought your article was a very good synopsis. I agree entirely with the last 2/3 of it. Well done.

How do they know exactly what he said? All they know is that the Giants deal seemed to hinge on his feedback about the MRI. Not exactly what the feedback was. Allow me to phrase another way. Why NOT ask him? What is to lose by collecting all available information? You can always choose to disregard it. For $300 million, I am of the opinion that a 15 minute phone call is reasonable.

I think this is a great read of the situation. I agree entirely.

You don't believe the Mets spoke (at minimum) with any of their own physicians? I think this is tremendously unlikely.

Why is it that you find this weird? He is the preeminent foot/ankle physician for professional athletes in the world. The "Dr. James Andrews" of foot and ankle. Essentially every high level athlete seeks his opinion after an injury. I don't think it's weird at all. I would want to know what his concerns were. I may or may not choose to abide by his recommendations, but I sure as hell would want to know what he had to say. He didn't get to his level by accident.

IMO, this is VERY unlikely to be the case. These plates/screws just don’t suddenly come loose after 8 years. If something happened at the slide, the most likely disaster is fracture of the bone directly above the plate (which obviously didn’t happen here). I still like my theory of low-grade arthritis stemming from his original injury. Other possibilities exist, for sure.

I didn't intend my reply to come across as snarky. I certainly didn't take your response disrespectfully. Mine was simply an honest take (as I see it): This was, for all practical purposes, a one year deal. I'm guessing the team reviewed his medicals at hand, but did not require repeat imaging of *all* prior injured areas (again, due to this being effectively a 1 year deal). IMO, this is because anything that is not recently/currently bothering Carlos is unlikely to become important over the course of one year. To be clear, I'm not endorsing this approach as foolproof or the most ideal approach. I'm only giving my thoughts on what may have happened. I don't think I'm able to comment intelligently on what threshold exists for *standard* due diligence and *extreme* due diligence. I think most people would agree that a different level of scrutiny is necessary for a 10-year and what is effectively a 1-year deal.

IMO, this wasn’t a 3 year deal. It was a “3 year deal” in which essentially everyone involved knew it was a one year deal absent extraordinarily unusual circumstances. You’re welcome to disagree with my reasoning. I have no idea if I’m correct or not. It’s just the most plausible explanation to me given what we know.

Here's my $0.02: (I have no insider info) I think the most likely scenario is that Correa fell into the Twins lap quickly last year, and everyone recognized it was most likely a 1 year arrangement. So the level of due diligence required by the medical staff is lower. Imaging of all prior nicks/bruises isn't necessary in that case. This time around given the commitment of 10+ years, teams were being more diligent and likely getting new imaging of any body part that had ever been treated for an injury (surgically or not). My guess is that the imaging of his ankle shows some early arthritis related to the ankle fracture that was fixed 8 years ago. This is something that is essentially impossible to "fix" in the traditional sense. And it may be mild enough at this point in time that it isn't causing him any significant symptoms (hence no issue made of it last offseason). But imaging can still show some early signs of arthritis, even before a person has symptoms. My guess is that the Giants docs saw this, and said something to the effect of, "This ankle has some early arthritis. This is something that generally is going to get worse over time, at a rate that is impossible to know. As it worsens, it is likely to affect Correa's ability to perform quick movements and may require a position change. Worst case scenario, it could be progress more rapidly and be a significant hindrance to him playing at an effective level." There are certainly other possible explanations. This is the one that seems to fit the circumstances best as I think about it. Merry Christmas/Happy Holidays all.

I appreciate your further explanation. My response was perhaps a bit unfair, in that there were a few posts that questioned the aptitude of the medical staff, and I just chose yours to quote. My response was probably a more generally directed response to that notion, rather than a specific retort to your post. IMO your concerns are valid, and also highlight the incredibly complex nature of this type of decision-making. These are tough problems to solve. I would argue that they are even tough problems to 'measure' in any consistent or meaningful way, much less 'solve'. Thanks for your response.

That's an interesting question. My assumption has been that the force generated at the wrist is primarily from the swing itself, not necessarily the contact with the ball. But I would say I don't honestly know the difference in forces across the wrist on a swing and miss vs. a swing that makes contact. My best guess (and I would call it a guess) is that the gloves probably wouldn't make a difference unless they were quite thick/cushy, in which case they probably aren't realistically useful for an MLB hitter. Would be an interesting study...

I understand the frustration with injuries on the Twins. I understand the tendency to look for systems or people to blame. But the unfortunate truth is, it just doesn't work like that. The WWII analogy would be great, if baseball players were made from identical parts on an assembly line and reacted exactly the same way to the same adverse conditions. But the challenge of medicine, sports science/performance and similar fields is that there are hundreds, probably thousands of unknowns. And not just unknowns that exist because they haven't been studied- unknowns that cannot possibly be known under any circumstances. Is it possible that the medical and/or training staff of the Twins is underperforming? Sure, I suppose that's possible. I am not a Twins physician, but I know those who are. They are admirable docs, among the brightest in the field. Isn't it also possible that there is bad luck involved? Or that the scouting department is choosing to draft or trade for players who are prone to injury? Or not weighting the input from the medical team heavily enough? Or, is it possible… juuuuuuuuust possible, that this stuff is really frickin' hard. And despite having brilliant people working tremendously hard to solve these types of issues- some injuries are inevitable. I'm not trying to carry water for the Twins or anyone/anything else here. I have no vested interest in others' opinions of Twins or their team physicians. But I am familiar with the challenges of solving these types of problems- I do it on a daily basis. It's hard. An in my opinion, assuming it is due to incompetence undersells the difficulty of it by a substantial margin.

I'd be speaking out of turn if I said I am intimately familiar with the rehab of this surgery, but February puts us about 7 months from surgery. I think that's a very reasonable time frame for something like this. It's possible I'm wrong here, and there's more to it than I know, but I feel comfortable with that timeline.

I can assure you this is not the case.

I would humbly suggest that this part is actually the easy part. We know how long the ulna is 'supposed' to be, relative to the radius (the bone next to it). A fairly straightforward calculation can be made to identify the amount of bone that needs to be removed to 'normalize' the length. And there are jigs that can be used that account for the amount of bone, thickness of the saw blade (kerf), etc to obtain a precise removal. In my view, the more challenging things here are: 1) Deciding when to pull the rip cord and go ahead with the surgery 2) Predicting for Alex exactly how his body will respond and what effect this will have on his swing mechanics going forward 3) Identifying a timeline for recovery (as this can sometimes vary substantially from patient to patient) 4) Worrying about potential complications that can arise For the most part, as a surgeon I feel like the surgery is the thing I have 'control' over, where as so many of these other things are out of our control (either partially or entirely). I tend to stress about things I can't control (rightly or wrongly, I suppose one could argue).

I suspect this is precisely correct.

Not sure how much help I will be here, but I'm happy to put in my $0.02. I don't see many wrist issues in my practice, so this topic is out of my area of true expertise. Lucas did a great job covering this topic in the article. I tend to think of the TFCC much like the meniscus in the knee. It is designed to function as a cushion or shock absorber for loads across the wrist. Since most of us don't walk on our hands, the wrist 'meniscus' sees much less stress that the meniscus in the knee. This is why this type of injury/problem is uncommon in the general population. However, certain movements or activities (such as swinging a bat/golf club/tennis racket) do cause additional stress on this area. In a perfect world, the TFCC is up to the challenge of withstanding these stresses. However, some people have an ulna that is a shade longer than ideal (and we really are talking about a difference of just a few millimeters here). This can add enough stress to the area that the TFCC can begin to break down. As in the knee, when the meniscus is not fully performing its normal 'shock absorber' function, that stress is then transmitted instead to the surrounding structures. In this case, that is the cartilage of the small bones of the wrist (which is what it sounds like was addressed at his original surgery). Often, going in and 'cleaning things up' and repairing the TFCC injury is all that's needed. It is just unfortunate that in this case the more simple procedure didn't turn out to be very durable (meaning its positive effect didn't last very long). I also tend to agree with the option of trying a cortisone injection or two, to see if that can alleviate the problem as well. When things don't progress as we would like, and people still have pain in the wrist, the next option is to try to do something to change the mechanics of the area to lessen the stress. In this type of situation, that means shortening the ulna to offload the TFCC and cartilage in the area. The surgery is typically performed (at least as I understand it- I don't do this type of surgery) by cutting the bone, removing a small wafer of bone, and using a plate and screws to bring the bone edges back together. In this type of surgery, you are essentially 'creating' a fracture, and the body needs to do the work of healing the bone, just as it would a fracture that happens if someone was to fall and hurt their wrist traumatically. If it sounds like this is a significantly more aggressive surgery than the first type, you're right. Any time you perform a more complex surgery, it introduces additional risk of complications. If an athlete/surgeon had a crystal ball and could know in advance that the first surgery was not going to be totally successful, obviously neither would choose the first surgery. But that luxury doesn't exist, so we constantly have to balance risks and benefits when making these difficult decisions. I would be willing to bet that this possibility was discussed with Alex at the time of his first surgery, and he was perhaps even given the option to do the more aggressive surgery first (this is pure speculation on my part). I completely agree with Lucas that the success rate of this type of surgery on athletes is not well-studied. This makes it challenging to recommend it as a first-line procedure, particularly for professional athletes whose livelihood depends on milliseconds of reaction time and the generation of tremendous force. It's definitely unfortunate that Alex needs to have additional surgery, but as best I can understand the issues from the information available, the history leading up to this point and the plan going forward make a lot of sense to me. Fingers crossed that he can heal up and get back to mashing baseballs soon. Happy to try and answer questions if people have any. This was probably all clear as mud... Nice job, @Lucas Seehafer PT. Another tough topic to cover.

Great job Lucas. Difficult subject to describe using words alone. The analogy I use with patients when I recommend/perform this procedure in conjunction with an ACL reconstruction is that they should try to think of the knee like a steering wheel. The ACL is located in the center of the knee joint (steering wheel), while the ALL is located on the outer (lateral) edge of the steering wheel. Now imagine you are trying to hold the steering wheel of your car, and prevent it from turning. If you hold the steering wheel in the middle (ACL), it is hard to resist the wheel turning forcefully. However, if you hold the steering wheel on the outer portion (where we would typically put our hands), it is much easier to resist the rotation of the steering wheel. This represents the ALL. By performing the lateral extra-articular tenodesis (LET), you are recreating the ALL. This more easily resists the rotation forces that can put extra stress on the ACL. The data on the use of LET is intriguing, but it would be inaccurate (IMO) to say that it is conclusive at this point. I am mostly using the LET in re-do scenarios (such as Royce's) and select first-time surgeries where there is a more extensive injury or some other patient factors. Another interesting question I have not yet seen reported is- what type of graft did Royce have? I would assume he had a patellar tendon graft the first time around, and most commonly the graft is taken from the injured knee (though there are some surgeons who take it from the opposite knee the first time around). One of the (many) challenges of a revision situation is that most typically, the preferred choice for ACL graft was used the first time around. So the options are to go to the other knee and use the same type of graft, or to use a different type of graft from the injured knee (most typically quadriceps tendon or hamstring tendon). This can have an effect on recovery as well (if the 'other' knee requires rehab too, due to the graft harvest). Such a bummer for Royce, he was having such a promising debut. As if the kid needed any more adversity...

Good summary Lucas. I see bone bruises such as this fairly frequently, and they can be present for a number of different reasons. I tend to view them on the MRI images where fluid/edema shows up bright (T2 or PD FS), so I think of them as bright spots on MRI more than dark spots. Most likely, this is a result of the femur slamming into the tibia, causing a bruise just like you might get on your thigh if you accidentally bump into the edge of a table or something like that. Your description of the bone in that area is spot on- I tend to describe it to patients as kind of like a puffy cheeto. It is softer bone than in the shaft of longbones, and as a result is more susceptible to injuries like this. The timetable for recovery is dependent on a number of factors including the specific size and location of the bone bruise, the initial severity, whether it is present on both the femur AND tibia (called a kissing lesion) or on just one side, the alignment of the leg and probably several others. In my experience working with athletes, these always take longer than you think. If I had to guess, I would say 4 weeks would be the minimum for a full return (though I hope I'm wrong). Of course, bone bruises can (and often do) occur with ACL tears, so it's good to hear that the ACL graft appears to be fine. That would be a relative disaster in this case, obviously. This image shows an MRI of a knee with the darker gray areas being normal bone, and the brighter areas being the area of the bone bruise in this particular case.

With respect to the differing timelines, I covered a fair bit of that in this blog post a while back. Obviously, no one would willingly choose a procedure with a 12-18 month recovery when one with an expected 9-12 month recovery is also available. The distinction comes down to location of the tear within the UCL and the overall condition of the ligament. UCL Primary Repair (the shorter recovery procedure) is now being done on more and more elite level pitchers, but it isn't available to anyone and everyone. Only those injuries with certain features. It is being performed on very few cases of those with a prior UCL reconstruction (Rich Hill being the only one I know of- there could be more). Separately, there is some work now being done on adding what is called an 'internal brace' suture to UCL reconstructions. This is something that is done on all UCL Primary Repairs. The thought is that the internal brace helps protect the healing graft, and perhaps would allow for a more aggressive rehab and sooner return to play as a result. While this is an intriguing idea, it is not yet definitively known if/how much this will shorten the recovery timeline for UCL reconstruction. I can go into more detail if readers would like, but I figure I'd put in my $0.02.

I'm an orthopedic surgeon, but not a hand/wrist specialist. The difficult part here for me is- I can't really find any specifics on what surgery Kirilloff had performed. I can only find 'ligament repair' in his wrist. Unfortunately, there are numerous ligaments in the wrist and they may each have different implications. Secondarily, with regards to the cartilage- there are at least 10 bones that I would consider being part of 'the wrist', so there could be cartilage wear between any of those bones (or multiple). If a proposed procedure to remedy this is cutting the ulna and shortening it (what we would call an ulnar shortening osteotomy), the arthritic changes (cartilage wear) probably involve wither the distal radioulnar joint (DRUJ) or the lunate (one of the pebble shaped bones of the wrist). The distal radioulnar joint is the area where the two forearm bones meet just above the wrist. The radius rotates around the ulna as one turns their hand from palm up to palm down position. If there is arthritis between these bones, as is being reported, I'm not aware of any good fixes. Because I don't do much hand/wrist stuff, there may some cutting edge things I'm not aware of. But this, to me, is a pretty significant bummer. I wish I could say different, but I'm not super-optimistic for a resolution of this problem. It's possible more information would change my opinion.

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.

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.

Agree with Nine of twelve, this pitch looks to have hit him just at or above the wrist, almost certainly on the ulnar side. At the level of the wrist, the ulna is the smaller bone on the small finger side of the forearm. It's obviously hard to say exactly where this pitch hit him- whether it is a fracture of the ulna right at the wrist and into the wrist joint (what we would call intra-articular) or more on the shaft of the ulna (away from the joint a bit, within the bone itself or extra-articular). Neither is ideal, obviously, but you would prefer that the fracture be away from the joint so that there is less risk of damage to the cartilage of the wrist joint. Cartilage has less blood supply and therefore less healing potential when compared to bone. We do occasionally hear about injuries to part of the wrist cartilage in baseball players. This is called the Triangular Fibro-Cartilage Complex (TFCC for short). I believe Carl Crawford and Matt Holliday had this issue some years ago. I am hopeful this is a fracture above the wrist joint, and involves only the bone of the ulna. This would typically be fixed with a plate and several screws to hold the bone in the appropriate position while the body heals the fracture. Healing of these type of fractures often takes around 6-8 weeks. On occasion, ulna fractures can have trouble healing and may heal slowly, or in rare cases not heal at all. In those cases, sometimes additional surgery or other treatments may be needed to get the bone to heal. There are also tendons that glide close to the ulna in this area, and the sheath they glide in could potentially be damaged as well in this case. This can occasionally cause issues for baseball players as well (i.e. Mark Tiexeira). Overall, definitely a bummer for Rooker, who was having a nice start to his career. Without knowing details, it's difficult to comment on the time frame for recovery or the likelihood of this affecting him in the future. Let's hope it's a straightforward fracture and surgery goes smoothly. I know the Twins have an excellent group of physicians to take great care of him. Let me know if folks have questions or would like me to clarify anything. GO TWINS!!!

"Of course there are undoubtably additional factors that put pitchers at risk for arm injuries. Twins Daily’s very own medical expert, Lucas Seehafer, did a great job of illustrating the roll proper mechanics can play in pitcher injury prevention and the increase of specialization at a young age has also been cited as a potential cause of injury. College and minor league pitchers have a much higher rate of Tommy John surgery than their MLB counterparts, which fits our narrative as they’re likely to be throwing a higher mix of fastballs and have less developed mechanics." As a clarification of perspective, there are a greater number of TJ surgeries performed on college and minor league players when compared to MLB; however, there are MANY more players at the college and minor league level than MLB. As such the raw number is higher in college and MiLB, but the rate is much higher in MLB. There is definitely information to take away from this fact (such as early specialization, throwing harder at younger age, year-round play, etc.) but I don't think you can make the correlation to more fastballs meaning higher rate of TJ in these non-MLB players. The Twins and other MLB teams are starting to do some work on managing workload on an individual basis and understanding what stresses each athlete is placing on their elbow (rather than using a universal 'recipe' for every player). This is being done using Motus sleeves and other cutting edge technology (mo-cap, etc.). We are still probably in, like, mile 3 of a 26 mile marathon to understanding all of this, but we are now in a better position from a technology standpoint to make meaningful advancements. I hope we can find a way for me to do fewer TJ surgeries- especially on young players. As much as I love to operate, I'd be totally on board with a dramatic decrease in UCL reconstruction being necessary in the first place.