Heezy1323

I haven't done 100, but I've done a fair number on appropriate candidates. I see many more teenagers than I do professional athletes in my practice, so it is definitely a good tool to have in the toolbox for this age group. Most don't have the cumulative damage to their ligament that someone who is older might. Good luck to your son! Sounds like he is progressing very well. Being diligent about the rehab is also critical, and it sounds like he has done his part. Nice job!

The studies looking at injury early in the season for pitchers are often skewed IMO because they don't always account accurately for those injuries that have been simmering through the offseason. So if someone (like Sale, Severino etc.) ends up having TJ in March or April, the injury can get recorded as occurring in 'March' or 'April', when in reality it has (in most cases) occurred earlier, was being monitored in hopes that it would improve without surgery, but ultimately doesn't. So it's hard to know how to use that info when calculating injury rates. I do think the injury rate is probably higher earlier in the season, but probably not as dramatically different as some studies seem to show. For position players, I think it is likely more accurate. A very minor point about PRP- the platelets release chemical signalers called cytokines that are somewhat different from hormones. Hormones can make people think things like 'steroids' (which are naturally produced- or sometimes injected- hormones), when what PRP provides is an alphabet soup of things like TGF-beta, IGF, PDGF, VEGF and others that regulate cell activities like inflammation and healing. I just think it is important to make a distinction that injecting PRP is different from a steroid injection (whether anabolic or corticosteroid- which is a whole other discussion).

http://twinsdaily.com/blog/1036/entry-11884-rich-hill-elbow-surgery-discussion/ It got a little longer than I anticipated, but hopefully you'll find it helpful. Thanks for the question!

Rich Hill Elbow Surgery Discussion Heezy 1323 Happy Supposed-To-Be Opening Day everyone. Since the baseball season is (unfortunately) on hold due to the coronavirus pandemic, about the only recent baseball-related news to report has been that both Chris Sale and Noah Syndergaard (in addition to Luis Severino earlier this spring) are in need of Tommy John surgery. I covered some information about Sale’s injury and some discussion regarding techniques used in UCL reconstruction in previous blog posts. In the comment section of the latter post, TD user wabene asked an astute question about Rich Hill’s surgery and how it is similar or different from typical UCL reconstruction. Hill’s surgery is indeed different from a typical Tommy John surgery, and I thought a post about it might be interesting to some readers. As usual, my disclaimer: I am not an MLB team physician. I have not seen or examined Hill or reviewed his imaging studies. I am not speaking on behalf of the Twins or MLB. I am only planning to cover general information about this type of surgery and my take on what it might mean. Twins Daily contributor Lucas Seehafer posted an excellent article about Hill’s surgery back in January that was a good look into the surgery basics and some background about UCL primary repair. There was some additional discussion in the comments as well. Since Lucas did such a nice job covering the surgery, I won’t go into excessive detail in this post, but I’ll give my version of the basics, and then cover how Hill’s surgery is similar and different. Basics of UCL Primary Repair As covered in my post about Sale, the UCL is a strong ligament at the inside of the elbow that resists the stretching forces that occur when trying to throw a baseball. Obviously, hurling a baseball 90+ mph can take a toll on this ligament and it can, in some cases, result in a tear. These tears can occur at the top (humeral) end, bottom (ulnar) end or in the middle (called midsubstance). The figure above is from a study we did when I was in fellowship indicating the location of the ligament injury in 302 patients who had undergone surgery with Dr. Andrews. The most common areas of injury are at either end of the ligament, with the humeral end being slightly more common (at least in this series) than the ulnar end. These patients all underwent UCL reconstruction, which is the standard operation to treat these injuries when non-surgery treatments have failed to result in adequate improvement. More recently (I would say within the past 5-7 years), there has been emerging interest in performing a different operation for a subset of these patients called UCL Primary Repair. This operation differs from UCL Reconstruction in that when the repair is chosen, the injured ligament is reattached back to the bone at the site of the injury using special anchors. There is typically also a strong stitch called an ‘internal brace’ that is passed across the joint along the path of the repaired UCL as well. I often refer to this internal brace as a ‘seat belt’ stitch. The idea behind the internal brace is that early in the healing process, before it has re-developed strong attachments to the bone, the ligament is susceptible to reinjury which could cause failure to heal (or compromised strength of healing). The internal brace (theoretically) helps protect the healing ligament and allows for development of a stronger attachment back to the bone. Once healing has occurred, the internal brace is thought to act like ‘rebar’, adding some strength to the ligament (though the exact magnitude of this contribution is unclear). This figure illustrates the repair technique with the blue ‘internal brace’ also in place. This is different from UCL reconstruction, where tissue from elsewhere in the body (typically either a forearm tendon called palmaris or a hamstring tendon called gracilis) is passed through bone tunnels and used to create a ‘new’ ligament. One of the reasons for the interest in primary repair of the UCL has to do with the length of time needed for recovery from UCL reconstruction. As many of us know from having watched numerous pitchers undergo (and subsequently return from) Tommy John surgery, there is usually around 12-18 months needed for full return to pitching at the major league level. There are a number of reasons for this long time frame, but a major contributor is that this is the amount of time needed for the graft to fully heal. Recall, we are taking a tendon (which normally attaches muscle to bone) and putting it in the place of a ligament (which normally attaches one bone to another bone). Though tendons and ligaments are similar, there are differences in their microscopic structure. Over time, as the graft starts to heal and have new stresses placed on it (namely throwing), it begins to change its microscopic structure and actually becomes a ligament. In fact, there have been animal studies done that have shown that a biopsy of a sheep ACL graft (which was originally a tendon) over time evolves into what is nearly indistinguishable from a ligament. We call this process ‘ligamentization’, and it is probably the most important part of what allows the new ligament to withstand the stresses of throwing. This process, however, takes time. And because of this, the recovery from UCL reconstruction is lengthy. With primary repair of the UCL, this process of conversion of the tendon to ligament is not necessary since we are repairing the patient’s own ligament back to its normal position. Some healing is still required; namely the healing of the detached ligament back to the bone where it tore away. But this process does not typically require the same amount of time as the ligamentization process. So why, then, wouldn’t everyone who needed surgery for this injury just have a primary repair? In practice, there are a few issues that require consideration when choosing what surgery is most suitable for a particular athlete. The first brings us back to the first graph from this post regarding location of injury to the UCL. It turns out that asking an injured ligament to heal back to bone is a much different thing than asking a torn ligament to heal back to itself. Specifically, trying to heal a tear in the midsubstance of the UCL (which requires the two torn edges of the ligament to heal back together) results in a much less strong situation than a ligament healing to bone. That makes those injuries that involve the midsubstance of the UCL (about 12% in our study) not suitable for primary repair. It can only be realistically considered in those athletes who have an injury at one end of the ligament or the other. In addition, there is significant consideration given to the overall condition of the ligament. One can imagine that repairing a nearly pristine ligament that has a single area of injury (one end pulled away from the bone) is a different situation than trying to successfully repair a ligament that has a poorer overall condition. Imagine looking at a piece of rope that is suspending a swing from a tree branch- if the rope is basically brand new, but for some reason breaks at its attachment to the swing, it seems logical that reattaching the rope to the swing securely is likely to result in a well-functioning swing with less cause for concern about repeat failure. Conversely, if you examine the rope in the same situation and notice that it is thin and frayed in a number of places, but just happened to fail at its attachment to the swing, you would be much less likely to try and repair the existing rope. More likely, you would go to the store and buy a new rope to reattach the swing (analogous to reconstruction). Similarly, when we are considering surgical options, we examine the overall health of the ligament on the MRI scan, and also during the surgery to determine whether repair is suitable or whether a reconstruction is needed. If there is a significant amount of damage to the UCL on MRI, primary repair may not be presented to the athlete as an option. Also, consideration is given to the particulars of an athlete’s situation. For example, let’s say I see a high school junior pitcher who has injured his elbow during the spring season. Let’s also say that he wants to return to pitching for his senior year but has no interest in playing baseball competitively beyond high school. In this case, the athlete is trying to return relatively quickly (the next spring) and is not planning to place long term throwing stress on the UCL beyond the next season. If this athlete fails to improve without surgery (such that all agree a surgery is needed), and his MRI is favorable- he is a good candidate for UCL primary repair. This would hopefully allow him to return in a shorter time frame (6-9 months) for his senior season, which would not be possible if a reconstruction was performed. Indeed, this is the exact type of patient that first underwent this type of surgery by Dr. Jeff Dugas at American Sports Medicine Institute in Birmingham, AL. Dr. Dugas is a protégé of Dr. James Andrews and has been instrumental in pioneering the research behind UCL primary repair. As you can probably imagine, the longer players (and pitchers in particular) play baseball, the more likely it is that there is an accumulation of damage to the UCL over time. This is the factor that most commonly eliminates the option of primary repair of the UCL in many of these players. So how does any of this relate to Twins pitcher Rich Hill? Let’s discuss. Hill underwent UCL reconstruction of his left elbow in 2011. He was able to successfully return from his surgery but has certainly faced his share of injury concerns since then (as described nicely in Lucas Seehafer’s article). This past season he began to have elbow pain once again and was placed on the 60-day IL as a result. He then underwent surgery on the elbow in October 2019 by Dr. Dugas (noted above). The procedure performed was a repair procedure, but in this case instead of repairing Hill’s own UCL, the repair was performed to reattach the previously placed UCL graft. I don’t have any first-hand knowledge of Hill’s surgery, but my best guess is that the technique was very similar to what was described above for a typical primary repair with internal brace. To my knowledge, this has not been attempted before in a major league pitcher. There is data showing a relatively good return to play rate with primary repair that is very similar to UCL reconstruction. However, most UCL repair patients are much younger than Hill and the vast majority that have been studied to this point are not major league pitchers. There are a couple of ways you can interpret this data when it comes to Hill. One perspective is that he had a repair of a ‘ligament’ (his UCL graft) that was only 8 years old (since his TJ was done in 2011), and as such it likely doesn’t have as much cumulative damage as his UCL might otherwise have if he had not had any prior surgery. An opposing perspective would be that this is his second UCL operation, and even though his most recent surgery was not a reconstruction, the data that would be most applicable to him would be data regarding athletes who have undergone revision UCL reconstruction (meaning they have had a repeat TJ procedure after the UCL failed a second time). This data is less optimistic. Most studies would put the rate of return to play after normal UCL reconstruction around 85% (depending on exactly how you define successful return to play). In most studies, the rate of return to play after revision UCL reconstruction is much lower, around 60-70%. There are two MLB pitchers that I am aware of that have undergone primary repair of the UCL (Seth Maness and Jesse Hahn). Maness has yet to return to MLB and Hahn didn’t fare very well in 6 appearances in 2019. Finally, my last input on this topic as it pertains to Hill is to imagine the specific position he is/was in. He is likely nearing the end of his career (he turned 40 in March 2020). He had a significant elbow injury that was not getting better without surgery. Presumably his choices were four: 1) Continue trying to rehab without surgery and see how it goes, understanding that the possibility exists that rehab may not be successful. (Perhaps a PRP injection could be tried) 2) Retire. 3) Undergo revision UCL reconstruction with its associated 12-18 month recovery timeline, likely putting him out for all of 2020 with a possible return in 2021 at age 41. 4) Undergo this relatively new primary repair procedure with the possibility of allowing him to return to play for part of the 2020 season, but with a much less known track record. In fact, a basically completely unknown track record for his specific situation. If that doesn’t seem like a list filled with great options, it’s because it isn’t. If I’m being honest, I think Hill probably made the best choice (presuming that he still has a desire to play), even with the unknowns regarding his recovery. He obviously couldn’t have seen this virus pandemic coming, but that would seem to make the choice even better since he is not missing any games (because none are being played). For Hill’s and the Twins sake, I hope his recovery goes smoothly and he is able to return and pitch at the high level he is used to. He sure seems like a warrior and is certainly the kind of person that is easy to root for. But based on what we know about his situation, there is an element of uncertainty. If I were Hill’s surgeon, I likely would have told him that he had around a 50-60% chance to return and pitch meaningful innings after this type of surgery. Let’s hope the coin falls his way, and also that we can figure out how to best handle this virus and get everyone back to their normal way of life as soon and safely as possible. Thanks for reading. Be safe everyone. Feel free to leave any questions in the comment section.

It was! Quite different, in fact. Let me see what I can put together.

http://www.quickmeme.com/img/87/87f8bff37864a91ee3d279c3167dcb6037f74096eb3961d1cbbc9c855f72580f.jpg

UCL Reconstruction Surgery Heezy1323 I recently posted a blog about Chris Sale and the news that he was set to undergo UCL reconstruction. That post covered some questions surrounding the diagnosis and decision-making that occurs when players/teams are faced with this dilemma. That post got a little lengthy, and I chose not to delve into the surgery itself, as I felt that may be better presented as a separate entry. My intention with this post is to discuss some of the different techniques that are used to perform UCL reconstruction. This does get fairly technical, and I apologize in advance if it is more than people would like to know. First, we should revisit the anatomy. The ulnar collateral ligament (UCL) is a small but strong ligament on the medial (or inner) part of the elbow. It is around the size of a small paper clip. Ligaments (by definition) connect one bone to an adjacent bone. The UCL spans from the medial epicondyle of the humerus (the bump you can likely feel on the inside of your elbow) to the sublime tubercle of the ulna (one of the two forearm bones). (As an aside, sublime tubercle is one of my favorite terms in all of anatomy). As with nearly any reconstructive surgery in orthopedics, our aim is to recreate the native/normal anatomy as closely as possible. In order to do this, most techniques utilize small tunnels that are drilled into the bone at the ligament attachment sites. The tissue that is used to reconstruct the ligament is then woven through these tunnels and tightened to create a secure new ‘ligament’ that heals and strengthens over time. The primary differences between different techniques are the ‘approach’ (or how tissues are moved aside to see the damaged areas), the specifics of how the tunnels are made and used, the type of tissue (or graft) that is used to make the new ligament, and the way that the graft is secured in place. There are a number of variations that exist, but I’ll cover a few of the most commonly used methods. First, some history may be in order. The first UCL reconstruction was, famously, performed on Tommy John. Tommy John was an outstanding pitcher for the LA Dodgers in the early 1970’s, and had compiled a 13-3 record in 1974 when he had a sudden injury to his elbow and was unable to throw. Imaging was performed, and the diagnosis of a UCL tear was made by pioneering orthopedic surgeon, Dr. Frank Jobe (of the famous Kerlan Jobe clinic in LA). Dr. Jobe had an idea to perform a reconstruction of the UCL, and practiced on several cadavers until he felt he had worked out a promising technique. He told Tommy that he thought he had a 1 in 100 chance of a successful return to MLB pitching. John decided to go ahead. The surgery was ultimately successful, and John returned to pitching in 1976. Though Tommy made it back, he did have a temporary palsy of his ulnar nerve after surgery, which is the ‘funny bone’ nerve that is near the UCL. This caused him significant weakness in his hand at first, but fortunately the strength returned over time and Tommy was able to return to pitching. Interestingly, he won more MLB games after surgery than he did before surgery, and pitched until 1989. There is a story that Jose Canseco hit a homer off John late in his career. Apparently Canseco’s father was Tommy’s dentist, and Tommy said something to the effect of “When your dentist’s kid starts hitting home runs off you, it’s time to retire.” The technique used for this first surgery was termed the Jobe Technique (for obvious reasons). It involved removing the attachment of the muscles to the inner part of the elbow and pulling the muscles toward the wrist to get a good look at the UCL itself. Tunnels were drilled in the bone at the normal attachment sites of the ligament, and a small tendon from the forearm (called the palmaris) was used to weave through the tunnels making a ‘figure-8’ in order to make a new ligament. (The palmaris is a non-necessary tendon that is located in the forearm of about 2/3 of the population. For those patients who don’t have a palmaris, we usually use a hamstring tendon called the gracilis for this procedure.) The old ligament was left in place and sewed into the graft. The nerve was also moved from its normal location (behind the bump) to in front of the bump to take some of the tension off. This is called a ‘transposition’ of the ulnar nerve. This technique was used for a while, but it did have some drawbacks, such as a high percentage of patients having ulnar nerve problems after surgery and some weakness resulting from detaching and reattaching the muscles of the forearm. Because of this, other surgeons sought new ways to perform this surgery. One commonly used technique was termed the ASMI-modification of the Jobe Technique. ASMI stand for American Sports Medicine Institute (in Birmingham, AL) and this modification was initially described by Dr. James Andrews and colleagues. This involved similar bone tunnels, but the main difference was in the way that the muscles were treated. Rather than detaching the muscle and reattaching at the end of the surgery, in the ASMI technique the muscle was lifted up (and not detached) and the work was done underneath the muscle. The ulnar nerve is transposed when this technique is used (like the Jobe technique). The passing and fixation of the graft is essentially identical to the Jobe Technique as well. Another commonly used technique is called the ‘docking method’. There are a couple of main differences between the docking method and ASMI method. First, the docking method utilizes a ‘muscle-splitting’ approach rather than a ‘muscle-lifting’ approach like the AMSI technique (see figure). This means that the muscle is divided between its fibers and a ‘window’ is created in the muscle in order to see the torn UCL and make the tunnels. There is also a difference in the way the tunnels are made. In the ASMI technique, the tunnels are the same size all the way through, and the graft tissue is passed all the way through the tunnels. In the docking technique, the tunnel on the ulna side is the same. But on the humeral side, the tunnels are sort-of half tunnels with smaller tunnels continuing on through the back side of the bone. This is because the graft is fixed in a different way- there are strong stitches that are attached to the ends of the graft that pull each end into the large tunnels. The stitches then pass through the small portion of the tunnels and are tied behind the bone, which secures the graft in place. This technique does not require transposition of the ulnar nerve, which is an advantage because less handling of the nerve generally means less risk of trouble with the nerve after surgery. There are a handful of other techniques that are slight variations on these themes, primarily using different devices such as anchors, interference screws or metal buttons to achieve graft fixation. There have been a number of cadaver biomechanical studies done that have compared methods, and they have been found to be largely equivalent. There seems to be a smaller incidence of ulnar nerve symptoms after surgery when the nerve is not handled/transposed (which makes some sense). The return to play rates are very similar regardless of which technique is used, with perhaps a slight favor to docking technique depending on the study. I trained with Dr. Andrews, and performed nearly 100 UCL reconstruction cases during my fellowship using the ASMI technique. In my own practice, I tend to use the docking technique most commonly. I do this because I would prefer not to transpose the nerve if I don’t have to in order to decrease the likelihood of nerve problems after surgery. We also saw some problems with fracture of the bone near the humeral tunnels when using the ASMI technique, and using the docking technique allows us to make smaller tunnels. This makes fracture in this area less likely. That said, Dr. Andrews has had (and continues to have) tremendous success using this technique. As we have learned more about this type of surgery, it has become clear that it is important that the bone tunnels be made very accurately, as improperly placed tunnels seem to be a risk factor for inability to return to full participation. There has also been some investigation as to whether addition of PRP or other biologics to the reconstruction area at the time of surgery makes a difference in healing speed or strength. At this time, I am not aware that any research has shown a difference. If anyone has managed to make it this far without falling asleep, I hope you found this discussion interesting. Feel free to leave a comment below if you have additional questions. Thanks for reading. Safe wishes to you and your families.

Thanks for the kind words- good to know my stuff isn't putting everyone asleep I'd be happy to do a surgery focused article. Lots happening at my hospital/practice in the past 24 hrs, so I'll see what I can do... stay tuned.

Chris Sale Tommy John Q&A Heezy 1323 It has been reported that Chris Sale of the Boston Red Sox will undergo UCL reconstruction surgery, also known as Tommy John surgery. Sale has not pitched in a live game since August 13, 2019. He then went on the Injured List on August 17 and did not return for the remainder of the 2019 campaign. He was reportedly seen at that time by several of the best-known US surgeons who care for pitchers and a decision was made to hold off on surgery, and instead try a platelet rich plasma (PRP) injection. He finished the 2019 season with a 6-11 record and ERA north of 4.00, significantly below the standard he had established throughout his excellent career. This is on top of the fact that Sale has yet to even begin his 5-year, $145 million contract extension. Sale will now miss whatever portion of the MLB season is played this year, as well as potentially some part of the 2021 season. A number of questions can often surround a decision such as this, so let’s cover a few things that readers may find helpful. (Disclaimer: As per the usual, I am not an MLB team physician. I have not examined Sale or seen his imaging studies. I am not speaking on behalf of the Red Sox or any other team. This article is for educational purposes only for those who might want to know more about this injury/surgery or about how these types of decisions get made.) Question 1: What is this injury? How does it occur? The ulnar collateral ligament (or UCL) is a strong band of tissue that connects the inner (medial) part of the elbow joint. (Figure 1) Though it is relatively small (about the size of a small paper clip), it is strong. The native UCL is able to withstand around 35 Nm (or about 25 foot pounds) of force. However, by available calculations the force placed on the elbow when throwing a 90mph fastball exceeds this, at around 64 Nm. How, then, does the UCL not tear with each pitch? Fortunately, there are other additional structures around the elbow that are able to ‘share’ this load and allow the UCL to continue to function normally (in most cases). The flexor/pronator muscles in the forearm are the most significant contributor. The geometry of the bones of the elbow also help. In many cases, the UCL is not injured all at once (acutely), but rather by a gradual accumulation of smaller injuries which lead to deterioration and eventual failure of this ligament. When the ligament is injured, it obviously does not function at 100% of its normal capacity- in which case the other structures around the elbow are required to ‘pick up the slack’ in order to continue throwing at the same speed. This is why when a pitcher reports a ‘flexor strain’, there is concern that the UCL is not functioning properly – the muscles of the forearm are being forced to work overtime to compensate for a damaged UCL. There are also cases where the ligament does fail suddenly. These are often accompanied by a ‘pop’ and immediate significant pain. Question 2: What do players report as the problem when their UCL is injured? Most commonly, players report pain with throwing at the inner part of the elbow as the most pronounced symptom. However, other symptoms can also be present including loss of throwing control/accuracy, inability to fully move the elbow, swelling, numbness or tingling of the hand and more. Symptoms can be significant almost immediately, or they can begin very subtly and slowly increase over time. Once they have reached higher levels of baseball, most players are aware of this type of injury (thanks to efforts toward education for coaches, athletic trainers and others) and are able to recognize symptoms and report them to the appropriate personnel. Question 3: Once the player is concerned about an injury to the UCL, what happens next? Most commonly the player will be examined by an athletic trainer or team physician to assess the injury and direct further treatment. Often, xrays will be performed of the elbow to assess the bones of the elbow joint for any abnormalities. There can sometimes be bone spurs, small fractures, bone fragments or other findings on these xrays. However, much of the time the xrays are normal and an MRI may be performed to further assess the situation. An MRI allows us to see the soft tissues around the elbow in addition to the bones. Specifically, we are able to look more closely at the actual UCL itself, the surrounding muscles as well as get a closer look at the nearby bone. (Figure 2) The MRI helps the treatment team get a sense of the integrity of the ligament, which allows for the next step in the process: deciding how to treat the injury. Question 4: How are UCL injuries treated? This is where the challenges often really begin. Much of the time, the UCL will appear abnormal on MRI. There are a handful of grading systems that are used to classify these injuries (one of which, incidentally, I helped create), though there isn’t one that is universally used or agreed upon. Generally speaking, they try to separate injuries into those that are partial tears or complete tears and also try to identify the specific location of the damage. The damage can occur at the upper end of the ligament (called the humeral end), the middle (called midsubstance) or at the lower end of the ligament (called the ulnar end). In those cases where there is a complete tear of the ligament (meaning that the ligament is no longer in continuity and attached at both ends), there is near universal agreement that surgery is typically necessary to allow that athlete to return to competitive throwing activities. The problem, however, is that most MRI’s show a partial injury to the UCL. These injuries can be extremely difficult to predict how they are going to respond to a chosen treatment. In addition, athlete A can have an MRI that looks much more abnormal than athlete B, yet the symptoms of athlete B are substantially worse. This is the basic cause of the uncertainty as it pertains to treatment for this injury. There has been tremendous research performed attempting to quickly identify ways to reliably separate those throwers that are going to need surgery from those that will not. Indeed, with pitchers such as Sale, there can be tens or even a hundred million dollars plus at stake. However, to date there is not a perfected method that can be used for every athlete to make this surgery vs. no surgery decision. Question 5: What non-surgical options are available? There are primarily two non-surgery options available to these athletes, and I’ll attempt to briefly cover them here. A) Physical therapy- the commonly used ‘rest and rehab’ method. This is probably the most important component of any treatment plan, and a good therapist who has specialized training in the care of overhead athletes is critical. Often, the athlete is prescribed rest from throwing in order to allow the UCL an opportunity to ‘settle down’ any inflammation and perhaps perform some healing of the injured tissue. In addition, as we discussed above, the muscles of the forearm contribute to stability of the elbow joint. Strengthening these muscles (along with a number of other muscles throughout the body) contributes to ‘protecting’ the UCL from further injury. As the recovery progresses, a return to throwing program is initiated, usually starting with a small number of throws from a short distance and gradually progressing to longer throws with greater effort and eventually throwing from the mound (for pitchers). This hopefully results in a more well-balanced and mechanically sound athlete who is more evenly distributing the forces of throwing across the various anatomic structures involved. B ) Platelet rich plasm (PRP)- This is a product that is obtained from the athlete’s own blood which is drawn and then spun in a centrifuge to separate the blood into its components. The portion of the blood which contains the platelets is then taken and injected at the site of injury to the UCL. This injection includes a number of chemical signals (called cytokines) that regulate healing and inflammation (along with many other things). The injections are thought to help with healing of these partial UCL injuries. The available data on this is mixed, with some studies showing improved results with PRP and others showing no difference. In the linked study, the rate of ‘successful’ non-surgical treatment was 54% (including both PRP and non-PRP athletes). Question 6: How is the decision to proceed with surgery made? This is probably the most challenging part of the evaluation process of UCL injuries. There are a tremendous number of factors which play a role in this decision. These include the specific characteristics of the athlete (such as age, position, role, contract status, stage of career, desire to continue playing and several others); exam and imaging findings (understanding that these are frequently ambiguous); as well as response to previous non-surgery treatment (to name a few). Often more than one expert opinion is sought, particularly when it is a big name/big contract player. Usually, surgeons will speak with a number of people when considering options including the athlete and family, team doctors and staff, team officials, and other experts (who may or may not have seen the patient themselves). In my experience in these situations, the vast majority of the time there is a consensus amongst those involved how best to proceed. Occasionally there will be differing opinions, in which case the athlete often has to make a choice on how to proceed. Question 7: Why didn’t Sale just go ahead with surgery last fall? I suspect that this is a question that many Red Sox fans are wondering about right now. As discussed above, these decisions are typically difficult and have many contributing factors. While it may seem as though ‘rest and rehab’ never works and everyone should just go ahead and have Tommy John surgery at the first sign of trouble, that is not really borne out in the data. There is some variance depending on the definition of ‘successful return to play’ used in any particular study, but for the most part the rate of success of Tommy John surgery in pitchers is around 80-85%. That means about 1 in 5 never make it back to pitch. This may not seem like bad odds, but I submit that your opinion might change if it was your elbow (and livelihood/contract) at risk. As they say, hindsight is always 20/20. In the case of Sale, I suspect that the season being shortened by the unusual circumstances of coronavirus this year likely also played a role. Once it became clear that a full season would not be played, the decision may have been easier. I think I’ll stop there for now (if anyone has continued to read this far…). If people are interested in technical aspects of how the surgery is performed, please let me know in the comments an I’d be happy to do another post about it. I have spare time currently, as you might imagine. Stay safe everyone, and please listen to the medical professionals who are trying to help us combat this virus. It is a serious threat to our way of life, and we need to treat it as such in order to minimize the damage. Thanks for reading.

I can understand the argument here, and evaluating medical info is definitely fraught with uncertainty in baseball players (as in any human being). Smoltz's shoulder MRI looked like a bomb went off in there- while he was pitching at the top of his game. But if teams are considering investing millions (and in some cases hundreds of millions) of dollars, my view is they should be allowed every opportunity to evaluate their investment to ascertain level of risk. Just like statistics/analytics should be used to project the player's likely level of performance (which is only a best guess, really), medical information needs to be able to be used for risk stratification, IMHO.

Chris Camp from Mayo Clinic (along with a number of others) put together an outstanding review of baseball injuries (MLB and MiLB) from 2011-2016 here: https://journals.sagepub.com/doi/10.1177/0363546518765158 (full text only available with subscription- sorry) Gastrocnemius strain was the 19th most common injury, resulting in a mean of 11.6 days missed (median 4 days). There were 419 recorded injuries during this time. None required surgery. Only 1.4% (6) were repeat injuries. From this data, I think it’s reasonable to suggest that the likelihood of repeat injury is low. FWIW, hamstring injury was the most common injury during this time frame (3,337 injuries) with a re-injury rate of 2.6%. No one can predict the future, obviously. But I believe this injury is likely to be among those with the lowest recurrence likelihood. I was not aware of the ‘rupture’ report as noted above by another post- though a gastroc strain and a gastroc rupture are similar entities (with rupture obviously being a more severe variation). I don’t know of any data specifically regarding reinjury risk for gastroc ‘rupture’. Let’s hope none of it becomes important, and JD anchors the middle of the lineup for like 150 games. Here's a link to the page for gastroc strains that I put in my gallery: http://twinsdaily.com/gallery/image/2694-gastroc-strains/