Heezy1323

This is getting fairly 'into the orthopedic weeds', but this internal brace construct (which is the general term for the biotape) is designed to be load-sharing, not load-bearing. Essentially, it is designed to provide time zero strength to the construct to allow for healing without plastic deformation/elongation of the repaired tissue. This does allow for a faster return to sport (in an ideal scenario), but it is yet to be determined if this provides greater strength to failure when compared to a UCL graft once ligamentization of the graft is complete. Lab/cadaver studies can simulate the time zero condition. They are unable to account for healing of the graft over time which certainly has an effect on the construct strength. Being that there have been so few of these done on major league players, I don't think there is enough available data to say that the biotape would result in such an improved likelihood. It may, but I don't think there is enough data to support it at this time. Another point to consider is that in this case, I believe it's likely that Hill was presented the option of repair of his UCL graft with this internal brace versus revision reconstruction, with the difference being that repair MAY allow a quicker return to play. Given his age and stage of career, my best guess is that he opted for the repair to give him a shot to pitch again, as undergoing reconstruction with 1.5 year timeline would likely put him out of baseball. As a result, I don't think even the limited results of UCL repair (which is typically done in young players on an otherwise normal ligament with a focal injury) can be extrapolated to Hill. You're certainly welcome to disagree- I would absolutely not advertise my opinions as fact. I also hope I'm being pessimistic and Hill knocks everyone's socks off this year. But from my end of the microscope, I'm skeptical.

One important difference here is that Hill had a repair not of his own UCL, but of a previously reconstructed UCL. This makes him different from Manness, into another category altogether. I am not aware that this has been done successfully at the major league level. Also, you can't compare Hill to a typical UCL reconstruction for purposes of return to play percentage. He is, at best case, comparable to a revision UCL reconstruction, which has a MUCH lower rate of return to MLB-level play. Most studies I have seen put that number around 40-50%. I hope I am wrong on this front, and Hill doesn't need to return to throwing 97 mph to be effective (i.e. less stress on elbow), but I would put his odds for returning to meaningful contribution to the Twins this year around 50%. Great review- thanks for a well-done article.

Obviously I don't have any specific knowledge of Buxton's case, so I really can't say with any certainty. But, I can give my interpretation of the freely available info. Buxton's issue has been called subluxation, which typically means less significant structural damage as compared to a dislocation. As a result, there is typically not a need for as extensive surgery (when surgery is needed). Because there is usually less damage to the ligaments/labrum, fewer anchors and less tightening of the tissue around the shoulder would be expected. This (hopefully) means easier recovery of range of motion after surgery, which hopefully will lead to fewer problems with overall function and (hopefully) a slightly quicker recovery than more extensive surgery. It can often take several months for recovery (I think I saw somewhere a 5-6 month timetable, which I would consider about right). Once 'recovered', there can still be some additional time needed to be 'back to normal'. I often specify to my patients that I would define 'recovered' differently from 'back to normal'. Sometimes those two are the same, and sometimes it takes more time to feel 'normal'. On occasion, the joint never feels back to 'normal', but many athletes can adapt to their 'new normal' and perform at a very high level. So to answer your question, I would expect the surgery to have a more significant effect on Buxton's hitting than his fielding. The magnitude of that difference is basically impossible to predict with any reliability. Despite Buxton's many injury issues, I don't recall ever reading anything regarding him being less than diligent about his recovery, and I would expect this to be no different. My guess is that he will be a full go either at the beginning of spring training or soon thereafter- though obviously many things could happen between now and then that could have an effect on that. For Byron's and the Twins' sake, I hope everything goes smoothly and he is back to his speedy, joy-to-watch self. Dr. ElAttrache is certainly a well-respected surgeon within the orthopedic world, so he is in good hands.

A bummer for Buxton and the Twins. I'm sure they were hoping to avoid surgery, but in some cases it becomes clear that it just isn't going to be possible. For those interested, I did an old blog post regarding Wander Javier's shoulder surgery, which I suspect is quite similar to what Buxton is going through. Feel free to post with additional questions and I’ll do what I can. http://twinsdaily.com/blog/1036/entry-11043-wander-javier-injury-qa/

Tennis serving has some similarities to throwing so the issues are sometimes similar. The shoulder can be tricky for sure- a lot of times there is a list of two or more possible diagnoses. Glad I can help a little! If it's anything like my shoulder, it always feels a little better when the Twins win haha

Did some additional research. In Camp's study quoted in my blog, they found over 1200 cases of proximal biceps tendinitis. 2% of those cases were 'repeat' cases during the study period (2011-2016), so it seems as though the vast majority are 'new' cases (which was my suspicion). Hope that helps.

Nicely done article Nick. I've enjoyed the discussion as well. For this who are interested, I wrote a blog post about biceps tendinitis here: http://twinsdaily.com/blog/1036/entry-11602-biceps-tendinitis-qa/ My guess would be that it was bothering him a little bit, but that he didn't think it was having a signifiant effect on his performance while in SF, and therefore didn't say anything (you can have a valid argument regarding whether this is appropriate or not, but that is a different discussion). He was likely hoping it would settle down over some time (which these issues often do), but had some issues his first couple outings here and was asked about it- at which point this came to light. It seems unlikely to me they would have put him back out there for his second appearance if they had know of a problem after the first (IMHO).

I suppose it's possible to have pain at both ends of the muscle, but I would think that it's uncommon. Similar to how it is difficult to break a chain in multiple locations at once, usually the most susceptible area becomes symptomatic first. There are a number of other anatomic issues that can appear similar to these conditions that can be difficult to sort through. This is a tough area to say much of anything with certainty.

Good question. That's always a possibility, but I'm not able to find any data on 'return trips to the IL for same diagnosis within a season'. Would be an interesting study for sure. My best guess is that it is typically a 'one-off' issue that when addressed appropriately recurrence can be avoided. Though as usual, nothing is 100%.

http://twinsdaily.com/blog/1036/entry-11602-biceps-tendinitis-qa/ See what you think. It's not exhaustive, but hopefully it's informative. Hope you enjoy!

Biceps Tendinitis in Pitchers Q&A Heezy1323 A request was made by a poster for me to write a blog covering biceps tendinitis. This is actually a fairly complicated topic with quite a bit of controversy, but I’ll do my best to share some basic info that hopefully TD peeps will find interesting. There are some technical parts, so apologies for that, but I do think a basic understanding of the anatomy is helpful. Question 1: What is the biceps, exactly? The biceps is a muscle that we are likely all familiar with, lying in the front of the upper arm and used to perform curls and similar exercises. The word ‘biceps’ has a Latin origin meaning ‘two heads’. This describes the upper (or proximal) end of the biceps where there are two tendon attachments. The first is the long head of the biceps which attaches to the labrum at the top of the socket in the shoulder. It then curves over the top of the ball (humeral head) where it exits the shoulder joint and begins its course down the front of the upper arm bone (humerus). At the front of the shoulder joint, it travels through what is called the ‘bicipital groove’ which is an area of the bone of the humerus between two bumps (called tuberosities). This groove is often the site of issues in pitchers (more on this below). The second is the short head of the biceps, which originates from a bony projection off the shoulder blade in the front of your shoulder called the coracoid. It travels straight from here to meet up with the long head of the biceps in the upper 1/3 of the arm. There, the tendons join and form the biceps muscle. Below this (distally), the muscle turns back into a tendon just above the elbow and a single tendon then travels down to one of the bones of your forearm (called the radius) where it attaches at a bony prominence called the radial tuberosity. Question 2: How is this tendon involved in throwing? This is a great question, and a subject of much debate amongst experts. The short head of the biceps likely has a relatively insignificant role in throwing. The long head (which is the one that attaches inside the shoulder joint) is much more involved in the throwing motion. When throwing at MLB speeds, the shoulder rotates at 7000 degrees per second, which is the fastest known human motion. One can imagine the stress this places on the structures that surround the shoulder. Without delving into the weeds too much, it seems as though the biceps has a role in position sense of the shoulder during throwing, likely a role in stability of the shoulder joint and also helps slow down the arm after ball release. At the other end of the tendon (distal), the elbow changes rapidly from a bent position to a straight position as the ball is released during a throw. In order to keep the bones of the elbow from jamming into each other at a high speed, the biceps muscle fires to slow down this elbow straightening (what we call an eccentric contraction). This allows some of the force of throwing to be dissipated by the muscle (kind of like a shock absorber). If it seems like that is a lot of jobs for a small tendon/muscle- it’s because it is… Question 3: What happens when someone gets biceps tendinitis? Tendinitis is a fairly broad term and can mean a number of different things depending on the context. With respect to the biceps, a thrower can develop issues at either the upper (proximal) or lower (distal) end of the biceps. The suffix -itis means inflammation, so the general thought is that there is inflammation that develops in or around the tendon. The reasons ‘why’ are heavily debated, but generally there is probably some combination of overuse/fatigue and altered mechanics or muscle imbalances that contribute. It takes a tremendous amount of efficiency of motion and coordination of muscle movements to throw a baseball in excess of 90mph, and any small abnormality can easily be compounded by the sheer number of repetitions and intensity of a typical pitcher. Over time, this can add up to cause damage to the tendon and result in inflammation and pain. Arthroscopic image of normal biceps tendon (left) and inflamed biceps (right) Question 4: How does the player/medical staff separate this injury from other issues that can seem very similar? This can be VERY difficult. Often the player will have pain at the front of the shoulder (in cases of proximal biceps tendinitis) or just above the elbow (in distal cases). A thorough history and exam is performed in order to hone in on the likely problem area. An MRI is ordered in some cases. One of the challenges with this type of issue is that in many cases, an MRI of a pitcher already has some abnormalities on it which are likely adaptive and have been present for a long time (and are not the actual cause of pain). In addition, in many cases the inflammation around the bicep isn’t something that can be clearly seen on MRI. So interpreting imaging studies can be a significant challenge. Usually the exam is (in my experience) the most helpful thing in recognizing biceps tendinitis when it is present. The athlete is usually tender right in the area of the tendon, which is a helpful finding. Question 5: Once a pitcher is diagnosed with biceps tendinitis, how are they treated? Again, there are a lot of variables here. But presuming it is significant enough to affect the performance of the pitcher, they would typically be shut down for a period of time to prevent worsening of the condition. Anti-inflammatory medication may be used. In some cases, injections of cortisone are used to try and decrease the inflammation. With the recent increases in the use of technology, video may be consulted to see if there have been subtle mechanical changes which may have contributed to the issue. Muscle strength can also be tested in various areas around the shoulder to see if weakness is contributing. In essentially all cases, a rehab program will begin that is likely to include strength and flexibility components. When the pain has subsided, a return to throwing program is begun and once complete, the athlete can return to play. A group out of Mayo Clinic (led by Dr. Chris Camp) recently did a study of pro baseball players (minor and major league) and causes of injury over a several year period. Tendinitis of the proximal biceps was actually the #4 cause of injury with an average return to play time of about 22 days. Question 6: Is surgery ever needed? It is quite uncommon for surgery to be needed for this issue. In fact, in Dr. Camp’s study above surgery was only required in 3% of cases of proximal biceps tendinitis. So clearly most of these cases improve with non-surgical treatment. In addition, surgery for this particular issue has a fairly poor track record and is avoided if at all possible. Question 7: What can be done to prevent biceps tendinitis? Great question, reader. If I knew the answer, we could likely both be millionaires given how common this injury is and the dollar figures involved when a high-priced starter or reliever is on the shelf for this reason. Generally, I believe monitoring the workload of pitchers through the season, doing what you can to ensure they maintain a good off-season program and having a good line of communication with the players are all important. As video analysis and other analytic measures become more popular, my hope is that they can be incorporated into injury prevention as well. Thanks for humoring me on this complex topic. Please feel free to add a request for a future subject in the comments. GO TWINS!!

Let me see what I can do... This is actually a fairly controversial area with probably more questions than answers, but I'll do a little lit review and try to put something together.

Such a bummer to see Byron head back to the IL. He just can't seem to catch a break. Hopefully he can return soon. For those interested, I did a quick blog post about Byron and shoulder subluxations here: http://twinsdaily.com/blog/1036/entry-11598-buxton-shoulder-qa-what-is-a-shoulder-subluxation/

Byron Buxton Shoulder Injury Q&A heezy1323 Byron Buxton, as we all know, is an outstanding center fielder for our Twins. Unfortunately, he has dealt with a variety of injuries that have cost him significant time over the past few seasons. This weekend he sustained an injury to his left shoulder that was termed a ‘subluxation’ and is headed back to the IL. By the sound of things, he is likely to be away from the big club for at least a few weeks. This is a tough blow for the Twins as the Indians make a push to catch up to a team that has led the division essentially all season. Medical terminology can be confusing, so I thought a post about shoulder subluxations might be of interest to TD readers. As usual- my disclaimer is that I am not a Twins team physician. I have not examined Byron nor seen any imaging of his injury. I am not speaking on behalf of the Twins. I am only hoping to familiarize TD readers with some of the concerns that may be ahead regarding injuries similar to Buxton’s. Question 1: How does the shoulder normally work? The shoulder is considered a ball-and-socket joint. The round ball (humeral head) sits in the socket (glenoid) similar to how a golf ball sits on a golf tee. Around the perimeter of the golf tee is a strong cartilage tissue called a labrum. The labrum surrounds the socket similar to the red gasket on a mason jar lid. Its function is to help act as a ‘bumper’ to hold the golf ball on the golf tee. It is also an attachment point for ligaments around the shoulder that also contribute to shoulder stability. The ligaments make up the ‘capsule’ of the shoulder joint. I often tell patients that the capsule is like a water balloon that surrounds the joint. The ligaments that make up the capsule form the connection between the ball and the socket. Question 2: What is a shoulder subluxation? The term ‘subluxation’ is typically used in situations where a joint partially (or nearly) dislocates. This is not specific to the shoulder and can happen in a number of other areas of the body as well (such as the kneecap, for example). This is distinct from a true ‘dislocation’ where the ball comes completely out of the socket and then goes back in. If someone dislocates their shoulder and it stays dislocated, it is typically clear what has happened. Xrays will show the ball dislocated from the socket and the shoulder will be manipulated to ‘reduce’ the ball back to its normal position. However, in some cases cases the ball can completely dislocate and go back in on its own very quickly. In these cases, an xray would often look normal. In most cases when there is concern about an injury of this type, an MRI is ordered. This of course shows additional details of the bone and soft tissue that cannot be seen on an xray alone. Usually an MRI will allow for a pretty solid conclusion as to whether the injury that occurred was a ‘subluxation’ (less severe) or a true ‘dislocation’ (more severe). There is, of course, a spectrum of damage that can occur with any injury and this is no exception. It’s possible that there was some minimal stretch to the ligaments around the shoulder and no other significant damage (best case). It’s also possible that there was more significant damage to the ligaments and potentially even a tear of the labrum (more worrisome). The MRI would typically give a good approximation of these issues. In most cases, the damage that occurs with a subluxation is less significant than that which occurs with a dislocation. Question 3: Does it make a difference that the injury is to his left shoulder rather than his right? In my opinion, absolutely. Because it is his non-throwing shoulder, the stresses placed on it are less. Even small issues with the ligaments can be problematic in the throwing shoulder- particularly someone who can approach 100mph on throws from the outfield. That said, the left shoulder is Byron’s front shoulder when hitting. In most hitters it is the front shoulder that is more stressed. It is possible that Buxton’s recovery is more affected at the plate than in the field (though that’s impossible to predict with certainty, of course). Question 4: Does this injury make it more likely that Byron will dislocate his shoulder in the future? Possibly. As discussed above, there is a spectrum of damage that can occur with this injury. If the damage is near the minimal end, it probably doesn’t have a significant effect on his likelihood of injuring this shoulder in the future. If there is more significant structural damage, it may place him at higher risk. Question 5: What is the purpose of the rehab? In addition to the capsule and labrum discussed above in question 1, the muscles around the shoulder also contribute to stability. I often tell patients to imagine that there is canopy over the top of the golf ball pulling it down onto the golf tee and helping to hold it in place. This is similar to the way your rotator cuff functions. I suspect rehab for Buxton will include strengthening exercises for a number of muscles around the shoulder that contribute to stability. Also, these muscles can be strained during the injury, so they can sometimes need additional time to recover along with the ligaments. Question 6: Will Buxton need surgery? This is essentially impossible to answer right now, likely even for the physicians and training staff involved in Byron’s care. As I sometimes tell my patients, “The crystal ball is a little murky.” Without knowing the extent of any structural issues in Byron’s shoulder, I would say that it is somewhat unlikely this will require surgery. I would expect that even if surgery is required, it would only occur after an attempt at non-surgical treatment has been unsuccessful. Question 7: How long will it be before he is able to return to play? This is also a difficult question to answer. The fact that the early word is that he will be out a few weeks is consistent with what I would expect from an injury like this. The rehab often takes time to regain full motion and strength. I would hope he can be back patrolling center field before the end of August, but it’s certainly possible this lingers into September. It seems unlikely that this would be a season-ending injury, but only time will tell. Clearly this Twins team is better when Byron is on the field rather than on the IL. Let’s hope he heals quickly and can help the Twins down the stretch. GO TWINS!

Thanks for the reply- very interesting to hear your take. I'm not even sure we know exactly what TOS is. I know we often divide it into neurogenic and vascular types, but it likely is even more complex than that, IMHO. I believe some component of UCL injury is that we are probably reaching the edges of human performance. Muscles can be made stronger, but ligaments have an intrinsic strength that probably can't be appreciably improved. Nerves and blood vessels likely similar... Did you see the injury Nick Burdi had, that was called basically a brachial plexus strain? He was in excruciating pain... not sure how to explain that one exactly.

TOS is a very complicated condition, indeed. I’d love to hear your thoughts about it.

For some reason Bonnes says all checks need to be made out to him...?

Oh yes. Very familiar with Dr. Clancy.

It’s difficult to know for certain, but yes I suspect that rehab will be focused in this area. Refining mechanics and improving overall core strength with the goal of avoiding placing extra stress on any particular anatomic structures.

Thanks for comment. Yes, I am an orthopedic surgeon with a subspecialty in sports medicine. I did my sports medicine fellowship (1 year of additional training after completing residency) with Dr. James Andrews, which was a great opportunity to learn first hand about treating throwing athletes.

I would guess that yes, he's gotten an MRI. A torn labrum is often part of the spectrum of this problem termed 'internal impingement', so they are not mutually exclusive and are, in fact, often found together.

Heralded Twins prospect Brusdar Graterol was recently shut down and placed on the IL for ‘shoulder impingement’. This is concerning given the promising start to the 2019 season Graterol had and what it could mean for his future. So what is ‘shoulder impingement’? And when might it need surgery? Let’s see what we can figure out:Disclaimer: I am not a team physician for the Twins. I have not treated or examined any Twins players. The information I am using is only that which is publicly available. My goal with these posts is to provide some education to TD readers around general injuries that are peculiar to baseball players. Question 1: What is shoulder impingement? Shoulder impingement is a sort of catch-all term that can be used to mean a number of different things depending on the specifics of the situation. It Is a term that is often used in application to patients who have pain in their shoulders, often without any specific structural damage or a particular injury. Most frequently, people have pain in their shoulder area that gets worse when working above chest level. It is often treated with physical therapy, activity modification, oral medication and occasional cortisone injections. It is uncommon for these patients to require surgery, but it is sometimes needed after the preceding treatments have failed to provide adequate relief. Some also refer to this condition as shoulder bursitis. It involves irritation of the rotator cuff and the bursa, which lies between the rotator cuff tendons and a part of the bone of the shoulder blade (called the acromion). You may have friends or family members who have been told they have ‘impingement’- this is a fairly commonly used diagnosis. More specifically, this condition is referred to as ‘external impingement’. Shoulder impingement in pitchers, however, often means something entirely different than what is described above. Whereas external impingement occurs between the rotator cuff and the acromion (outside of the ball and socket joint of the shoulder), pitchers more commonly have problems with what is called ‘internal impingement’. This occurs specifically in overhead athletes because of the tremendous motion that is necessary to hurl a baseball 90+ mph accurately. During the course of throwing, the arm is cocked back, placing it in an awkward position. In this position, part of the rotator cuff can get pinched between the bone of the ball and the bone of the socket (also often including pinching of the labrum). This may not seem like a big deal, but over time this repetitive motion can begin to take its toll. Experts agree that some changes/damage to the structures of the shoulder are likely normal and adaptive in pitchers rather than problematic. In some cases, however, these structural changes progress down the spectrum and become an issue- causing pain, lack of velocity and/or control and fatigue of the shoulder. There is not perfect agreement among experts about why exactly these athletes begin to have pain in some cases. Regardless, it is likely a very complex combination of factors ranging from subtle changes in mechanics to core strength to gradual loosening of shoulder ligaments over time (and many others). Each individual case is likely different, and treatment needs to be tailored to the specifics of the athlete. Question 2: How/when did this injury occur? Typically, this is not an injury that results from a single trauma (though theoretically it can happen that way). It is much more typical for this to be the result of an accumulation of ‘microtraumas’ over a long period of time. Question 3: Does this injury always need surgery? No. As mentioned above, painful shoulder impingement in throwers is likely related to a complex set of factors. Because of this, treating any ONE thing with a surgery is somewhat unlikely to be effective. As a result, treatment is almost always begun by trying to calm down inflamed tissues. This typically involves rest from throwing. It may also involve oral medications and in some instances, cortisone injections. There is some discussion around PRP and so-called ‘stem cell’ injections (what orthopedists refer to as Bone Marrow Aspirate Concentrate or BMAC) for these types of problems, though this is not yet something I would consider standard of care. During this time, the athlete is also likely to undergo physical therapy to work on improving some of the other factors mentioned above- core strength, range of motion, rotator cuff strength, etc. As the pain and inflammation improve, the athlete is likely re-examined by trainers and physicians. This can take anywhere from a week or two to several weeks depending on the case. When things have improved sufficiently, the athlete is likely to begin an interval throwing program, which involves progressively more aggressive throwing sessions. Once they have completed this, they would likely return to the mound and begin throwing from there. Once appropriate progress has been made (and of course presuming no setbacks are encountered), they are likely cleared to return to play. The success of non-surgical treatment for these types of problems is all over the map in the literature. There are ranges from percents in the teens to 70%+. Again, it likely depends on a large number of factors which makes prognosticating nearly impossible. Question 4: How do we tell which cases of impingement need surgery and which do not? This can be among the most difficult decisions to make when dealing with pitchers. One of the problematic elements is that surgery to treat this problem is comparatively not very successful. As noted above, in general there are likely a number of different structural abnormalities in the shoulder that are in play with this injury. Some of them are adaptive and are considered ‘normally abnormal’ for pitchers. Others are problematic. Separating these two is something about which even experts readily disagree. It is difficult (and perhaps foolish in this setting) to quote surgery success rates, but in general they are not the best. There is a reason behind the old saying that for pitchers “If it’s the elbow, call the surgeon. If it’s the shoulder, call the preacher.” Question 5: What is done during surgery? This is widely variable depending on the specific structures that are injured, and (quite honestly) the particular views of the operating surgeon. I was recently watching a lecture on just this subject that featured a panel of a number of the preeminent North American surgeons that treat these problems. The differences of opinion and differences in strategy between surgeons were substantial. Yet another reason to make significant efforts to make non-surgical treatment successful. Question 6: How concerning is this for Graterol? This is hard to know from the information available. As stated earlier, the term ‘impingement’ can mean a wide variety of things- some more concerning than others. One of the positives in this case would seem to be that Graterol was pitching very effectively quite recently. Thus, this doesn’t seem to be something that has been festering for months. Hopefully that means they’ve ‘caught it early’ and can get things back on track sooner than later. I would imagine he will be out for a few weeks at least, but I would be surprised if he required any surgery in the near future. Overall, many pitchers have occasional blips on the radar with things like this that are improved with rest and rehab and don’t recur in the future. Predicting the future is difficult for anything- and this type of issue especially- but hopefully Graterol can get back on the mound throwing gas soon. Go Twins! Click here to view the article