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.

I propose a thought exercise. I believe most would agree (regardless of position on robo umps) that calling balls and strikes in a game of 10-year-olds is easier than at the MLB level. What is the reason, exactly? Presumably, it is because the pitches are coming in much more slowly, and are breaking a much smaller distance. For the sake of argument, let's take this to an extreme. Let's pretend that the ability of pitchers to continue to improve their velocity knows no limit. Let's pretend that, say, 20 years from now it is routine to have pitchers throwing 110-115mph. Perhaps with even more break. What is the upper limit of human ability to make ball/strike calls with reasonable accuracy? Clearly if a baseball is coming in at 200mph, and breaking 30" or something, a human brain has no shot at telling if the ball goes through a defined box- particularly on borderline pitches. And logically, there is also a gradient along the way, such that with increasing velocity and break, the ability of even the best umpires to delineate balls from strikes goes down. Where, precisely, is the threshold at which this becomes 'unacceptable'? We already use computers in thousands of scenarios every day where the ability of the human senses is unable to reasonably discern one situation from another. I view this as no different. I don't believe it's because the umpires are necessarily 'bad' at their job. I just don't think it's reasonable to expect even those most skilled to be able to do this correctly 100% of the time. We've all seen games, series or even careers turn on ball/strike calls that were bad. We either have, or soon will have, the ability to be better. It's time. I can't imagine a scenario where a human is calling balls and strikes even 10 years from now. Merry Christmas TD. All the best to each of you.

Agreed on the good ice/bad ice analogy. Not sure I follow the second paragraph. The purpose of the internal brace is to avoid stretching of the graft (by resisting tension/reducing stress) during it's initial period of relative weakness after implantation, and perhaps some degree of protection of the graft going forward by acting as a sort of 'rebar.' This allows the graft to heal in at a more desirable (i.e. tighter) tension, rather than becoming loosened, as it might without the internal brace in place.

Ok- I'll give it a shot. Hopefully there's something valuable I can share. I did not see the STrib article (my bad, would've liked to read it), but I have been aware of the internal brace concept being utilized with UCL reconstructions for a short time. Feel free to review my prior blog post about UCL injuries. Nomenclature is important here. Recall that UCL repair means that the athlete's own ulnar collateral ligament (UCL) is repaired back to bone. This repair is often protected with an especially strong suture called an 'internal brace'. The internal brace has been around for a number of years. It has been (and is currently) used in a number of other places in the body to protect various ligament or tendon repairs. It began (if I recall correctly) being used to help protect the repair of ligaments at the outside part of the ankle when patients required surgery for chronic ankle instability. With it's success there, it has gradually been expanded to other parts of the body. By way of example, I have used it in basically every one of my ACL reconstructions for the past 2.5 years to protect the healing graft during recovery (somewhere around 150 ACL's). I have also used it to help protect PCL, MCL, patellar tendon and posterolateral corner surgeries in the knee, among others. When the UCL is repaired, the idea is that the tissue of the UCL is healthy/strong enough that it can successfully withstand the forces of pitching once it has become firmly healed back to the bone. The injury in these cases is to the area where the ligament meets the bone, not within the ligament itself. The purpose of the internal brace in this case is to 'protect' the repair. Specifically, when a patient moves the elbow after surgery (even if they aren't doing something demanding such as throwing), there is microscopic movement at the interface between the healing ligament and the bone. In theory, if there is excessive stress at this junction, the healing will be less robust and therefore the ligament less able to withstand substantial forces of throwing later on in the rehab process. By using an internal brace, the idea (as I understand it), is that the relatively small forces of day to day movements of the elbow are now shared between the healing ligament and the internal brace suture. Therefore, this stress is less likely to cause a negative effect on the healing progress of the ligament back to the bone. Hopefully (the idea goes) this results in more strong and robust amount of healing of the ligament when compared to a repair done without an internal brace. (Feel free to review my previous blog post about UCL repair vs. reconstruction here.) That leads us to this particular case with Kenta of a UCL reconstruction performed with an internal brace. This is similar, but not identical to the situation discussed above. Recall that the term 'reconstruction' is used when tissue (almost always a TENDON) from somewhere else (either the patient themselves or in some cases a donor/cadaver) is used to make a NEW ligament. There are numerous reasons why this option might be chosen rather than a repair, but most commonly it is because there is an accumulation of damage to the native ligament that makes it unlikely to be strong enough itself to stand up to the necessary stresses once healed. Indeed, most UCL repairs are performed on young athletes who don't have the same cumulative amount of damage as MLB pitchers. As a result of this, there is an additional variable in these cases of reconstruction. Namely, in addition to successful healing, the TENDON also requires time to 'turn into' a LIGAMENT. This is primarily why the recovery from UCL repair surgery is typically so much shorter than UCL reconstruction --> in a UCL repair the ligament is already a ligament. So it doesn't require time to undergo this transition from tendon tissue to ligament tissue (called ligamentization). (I know this is getting tedious- and I apologize. Hang with me here...) So the use of the internal brace with UCL reconstruction has a slightly different goal than with primary repair (again, as I understand it). Obviously, when you use a tendon to replace a ligament, you have to remove that tendon from the body completely for a short time in order to reimplant it. As a result, the tendon is completely removed from its normal blood supply. Once implanted, the body has to reestablish blood supply to this tendon in its new location in order to keep it alive. This takes some time to accomplish. There have been animal studies done that have shown that the strength of the newly implanted tendon in situations such as this actually goes down for the first few weeks after surgery, then starts to increase again. As a result, there is a period of time after surgery when this graft is vulnerable to 'stretching out' which could compromise the ultimate strength of the graft. The internal brace seeks to avoid this problem by protecting or 'bracing' the graft during this period of time so that it doesn't stretch out and is able to heal in more strongly and at the appropriate tension. How much difference in 'looseness' (what we would call laxity) is too much? Well, during my fellowship with Dr. Andrews we did a study that showed that when placed under stress, the injured elbow opened up on average only 0.3mm (that's a third of a millimeter!) more than their opposite, uninjured elbow. So it appears that it doesn't take much difference in laxity to cause a problem in a thrower's elbow. There is a mountain of data supporting the use of an internal brace with UCL repair. There is very little data available that I am able to find regarding the use of an internal brace with UCL reconstruction. I found one biomechanical paper that showed that the use of an internal brace with UCL reconstruction allowed the biomechanics of the elbow to more closely replicate a normal elbow than when UCL reconstruction was done without internal brace (this was a cadaver study). I was not able to find any clinical data reporting on the success rate of UCL reconstructions done with internal brace compared to those done without. My guess is that this data is coming, just not published yet. Logically, it makes a lot of sense to me that the use of an internal brace in conjunction with a UCL reconstruction would improve the success rate, but medicine doesn't always follow logic. I'll be interested to see the results in the future. Also, I don't know exactly which reconstruction technique Dr. Meister uses, which could potentially have some influence on results as well. One reservation I have about the idea that this internal brace shortens the return to play timeline is that despite the fact that this internal brace likely results in a 'tighter' ligament once healing is complete, the internal brace probably does not do anything to speed up the transition of the tendon tissue into ligament tissue that occurs over time. Perhaps we can be a bit more aggressive with the rehab when an internal brace is present, without as much concern for the new ligament 'stretching out'. But ultimately, the new ligament has to be (very) strong in order to withstand the extreme forces of pitching, especially at the MLB level. Time will tell if this new modification to UCL reconstruction technique will allow for a quicker return to play. I hope it does- 18 months is a darn long time. If you've managed to read this far- thank you. This is pretty dense stuff (sorry...)

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.