Heezy1323

Stem cell (BMAC) treatments are not yet FDA approved for bone and joint issues (I think they are technically only approved for blood or bone marrow cancers). That said, they can be used if the provider and patient discuss risks and benefits and decide to proceed. They are not covered by the vast majority of insurances, so most payment is out-of-pocket. They typically run a few thousand bucks or more for one injection. There are starting to be some regulations around this because of some less scrupulous people who were advertising and making false claims about what BMAC can do. We are still in the early phases of trying to figure out when, where and how they can best be used. The science is promising, but we have a ways to go to translate that to treating patients regularly and affordably.

Brusdar Graterol Shoulder Impingement Q&A Heezy1323 Heralded Twins prospect Brusdar Graterol was recently shut down and placed on the IL for ‘shoulder impingement’. This is concerning given how promising a start to the 2019 season Graterol has 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 amongst 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!

http://twinsdaily.com/blog/1036/entry-11499-graterol-shoulder-impingement-qa/ Hope you enjoy.

http://twinsdaily.com/blog/1036/entry-11499-graterol-shoulder-impingement-qa/ Hope you find it informative. Feel free to let me know if there are things that aren't clear- I can do my best to explain further.

Here ya go... hopefully it doesn't put you to sleep http://twinsdaily.com/blog/1036/entry-11499-graterol-shoulder-impingement-qa/

#1 it is... gimme a bit

I apologize that I haven't been very active on TD thus far this season. One good reason is that the number of injuries (and severity of those that have occurred) has been fairly low. Unfortunately, with this news there are a few things people may have questions about. As such, I'd like to do an informal poll. I'm happy to do a blog post about a topic, but not sure I have the time this week to tackle multiple posts. (Can certainly do additional posts in the future... but we are closing on a new home this week and in preparations for our move) The options would be: 1. What does 'shoulder impingement' in a baseball player mean? 2. What is a 'stress reaction' in the elbow of a pitcher? 3. Tommy John surgery in position players... 4. Other (open to alternate suggestions) If people generally don't have a preference, I can choose one also. Hope everyone has had a great Memorial Day Weekend!

This is a complicated area, but generally yes, a substantial trial of non-surgical treatment is tried prior to proceeding with shoulder surgery. This is, in part, due to the fact that conservative treatment often works. It's also due, in part, to the fact that the return to play rates after shoulder surgery in pitchers are... suboptimal.

FWIW, the area of skin overlying the Achilles tendon is VERY thin (and has poorer blood supply compared to surrounding tissue) and these types of wounds (whether created surgically or by trauma) are always susceptible to healing problems. As with many things in medicine, hindsight is 20/20, but at the time of the injury it couldn't be known how things would play out. Yes, looking back, could things have been handled differently? Sure! But it's a totally different thing in hindsight than at the time the decisions needed to be made. Since the report is that a number of different physicians were consulted and a consensus was made, then I can only assume these were sound decisions that, unfortunately, didn't turn out as one would hope. Medicine is tough like that.

Take this for exactly what it's worth, but I have a friend who plays baseball in the Latino league in the metro. He told me that Escobar came to a few of the games this summer prior to being traded. Apparently they asked him about returning after being traded (once it was apparent he was likely to be traded away from the Twins), and he stated pretty flatly that he wasn't interested in returning. I don't know what his reasoning was, but according to my friend, it was fairly clear we shouldn't expect him back. Who knows, could be totally inaccurate, but that's what I am expecting.

I think the more likely scenario is that they realized early on that the hip was an issue. Some people are able to play through this problem and compete at a high level. If he were to have surgery, whether in April or August, his season is over. So I can understand the trial to attempt to play through the pain. Now, whether the decision could or should have been made earlier is difficult to know without knowing the specifics. But I have been involved in enough of these situations (though not necessarily professional athletes), that I know the decision is rarely clear-cut. Logan is a competitor. I suspect he really wanted to compete and try to help the team win.

I apologize you didn't find the post helpful. The intent is not really to do a deep dive into LoMo specifically. I'm not privy to the details of his case (and even if I was, not at liberty to share due to privacy reasons). My hope for this post (and other similar ones I have done) is to provide some basic background information on a particular condition/injury that a Twin is dealing with. Medical jargon can be confusing, and there are many misconceptions that exist. As to your comment, I'm certain he knew he had pain. The more complicated question would be, "Is the hip the cause of the pain." It often is. However, just as often, it is something else, even with findings on MRI, X-rays, etc. Medicine is funny that way.

Twins DH/1B Logan Morrison was recently shut down for the remainder of the season and, by reports, is expected to undergo surgery for a hip condition that has been bothering him for much of the year. The problem is being reported as ‘hip impingement’, which is a fairly common diagnosis. Some may recall that the NBA’s Isaiah Thomas dealt with this problem over the past couple seasons and underwent surgery more recently. So what is ‘hip impingement’? And when does it need surgery? And what happens during surgery? Let’s dive in and see what we can find out: Question 1: What is hip impingement? Hip impingement is another term for what orthopedists call ‘femoroacetabular impingement’ or FAI. This term basically means pinching of the hip labrum tissue between the bone of the ball and the bone of the socket of the hip. The hip is a ball and socket joint. Around the rim of the socket is a tissue called ‘labrum’ which acts as a cushion, and also seals the ball into the socket. In an ideal world, the ball is perfectly round and the socket is perfectly hemispherical. In this case, when people move the hip around, there is no pinching. However, in some people, rather than being round the ball is more shaped like a grape or an egg. In these cases the extra bone can cause a pinching of the labrum when the hip is flexed (for example, when seated). Over time, this repetitive minor injury can cause damage to the labrum. There can also be extra bone on the socket side, which can have a similar effect. These two situations are called CAM impingement (extra bone on the ball) and PINCER impingement (extra bone on the socket). In many cases, both CAM and PINCER impingement coexist. Question 2: I don’t remember LoMo getting hurt. When did the labrum get torn? Typically, this is not an injury that results from a single incident (though it can happen that way). It is much more common for this to be the result of an accumulation of ‘microtraumas’ over a long period of time. In addition, the CAM and PINCER deformities are quite common in people who don’t have any pain in their hips. In some studies, >50% of asymptomatic patients have some signs of CAM or PINCER deformity on hip xrays. Simply having the ‘extra bone’ doesn’t automatically mean it is going to be a problem. Our understanding of why people develop these deformities is improving, but we don’t know the cause at this time. It appears to be more common in people participating in athletics (particularly hockey), so we think it has something to do with low-level trauma to the area during growth years. Question 3: Does a labrum tear always need surgery? No. A labrum tear is also a very common finding in patients with no hip pain. In one study of patients between 18-40 years old who had no hip pain, MRI’s of the hip showed a labrum tear about 40% of the time. So clearly not every labrum tear causes pain or requires surgery. There are also a number of conditions that can cause similar pain to hip impingement (ranging from hernias to pinched nerves in the spine to ‘sports hernias’ and many others). Therefore, time is often spent trying to decipher what the actual cause of the pain is in these patients, as it isn’t always as straightforward as we would like it to be. Question 4: How do we tell which labrum tears need surgery and which do not? This can be difficult, but typically rest, anti inflammatory medication, physical therapy and/or injections of cortisone are tried prior to surgery. Many patients can find success with these treatments. However, some do not, and surgery may be warranted. Question 5: What is done during surgery? There has been a significant evolution of techniques in hip surgery over the past decade as surgery for this condition has become more common. It can be done either open (through an incision) or arthroscopically (through the scope). Arthroscopic treatment is much more common, particularly in the United States. The hip is stretched apart by use of a special table that pulls the joint open about 1cm. The scope is put in to the joint and tools are used to examine the joint space. We look at the surface cartilage, labrum and other structures in and around the hip. Once we have looked at everything, any ‘extra’ bone on the socket side is carefully removed with a tool called a burr. The labrum tear is often repaired with small anchors back to the rim of the socket (from where it tore away). The ball is then released back into the socket and we use the burr to reshape the ball, removing extra bone in that area as well. Surgery often takes 2-4 hours depending on the extent of injury. Question 6: How long is the recovery? As with any surgery, the recovery is variable, but most high-level athletes are back to full sports around 6-8 months after the operation. There have been several studies examining the performance of professional athletes in different sports after return from this hip surgery. Most have shown little or no diminished performance after recovery. I’m certain even Morrison would say he didn’t have the season he was hoping to have for the Twins, and this hip issue certainly could’ve been part of the reason. Hopefully he can improve after surgery and get back to his 2017 form, whether for the Twins or elsewhere. Click here to view the article

Logan Morrison Hip Impingement Q&A Heezy1323 Twins DH/1B Logan Morrison was recently shut down for the remainder of the season and, by reports, is expected to undergo surgery for a hip condition that has been bothering him for much of the year. The problem is being reported as ‘hip impingement’, which is a fairly common diagnosis. Some may recall that the NBA’s Isaiah Thomas dealt with this problem over the past couple seasons and underwent surgery more recently. So what is ‘hip impingement’? And when does it need surgery? And what happens during surgery? Let’s dive in and see what we can find out: Question 1: What is hip impingement? Hip impingement is another term for what orthopedists call ‘femoroacetabular impingement’ or FAI. This term basically means pinching of the hip labrum tissue between the bone of the ball and the bone of the socket of the hip. The hip is a ball and socket joint. Around the rim of the socket is a tissue called ‘labrum’ which acts as a cushion, and also seals the ball into the socket. In an ideal world, the ball is perfectly round and the socket is perfectly hemispherical. In this case, when people move the hip around, there is no pinching. However, in some people, rather than being round the ball is more shaped like a grape or an egg. In these cases the extra bone can cause a pinching of the labrum when the hip is flexed (for example, when seated). Over time, this repetitive minor injury can cause damage to the labrum. There can also be extra bone on the socket side, which can have a similar effect. These two situations are called CAM impingement (extra bone on the ball) and PINCER impingement (extra bone on the socket). In many cases, both CAM and PINCER impingement coexist. Question 2: I don’t remember LoMo getting hurt. When did the labrum get torn? Typically, this is not an injury that results from a single incident (though it can happen that way). It is much more common for this to be the result of an accumulation of ‘microtraumas’ over a long period of time. In addition, the CAM and PINCER deformities are quite common in people who don’t have any pain in their hips. In some studies, >50% of asymptomatic patients have some signs of CAM or PINCER deformity on hip xrays. Simply having the ‘extra bone’ doesn’t automatically mean it is going to be a problem. Our understanding of why people develop these deformities is improving, but we don’t know the cause at this time. It appears to be more common in people participating in athletics (particularly hockey), so we think it has something to do with low-level trauma to the area during growth years. Question 3: Does a labrum tear always need surgery? No. A labrum tear is also a very common finding in patients with no hip pain. In one study of patients between 18-40 years old who had no hip pain, MRI’s of the hip showed a labrum tear about 40% of the time. So clearly not every labrum tear causes pain or requires surgery. There are also a number of conditions that can cause similar pain to hip impingement (ranging from hernias to pinched nerves in the spine to ‘sports hernias’ and many others). Therefore, time is often spent trying to decipher what the actual cause of the pain is in these patients, as it isn’t always as straightforward as we would like it to be. Question 4: How do we tell which labrum tears need surgery and which do not? This can be difficult, but typically rest, anti inflammatory medication, physical therapy and/or injections of cortisone are tried prior to surgery. Many patients can find success with these treatments. However, some do not, and surgery may be warranted. Question 5: What is done during surgery? There has been a significant evolution of techniques in hip surgery over the past decade as surgery for this condition has become more common. It can be done either open (through an incision) or arthroscopically (through the scope). Arthroscopic treatment is much more common, particularly in the United States. The hip is stretched apart by use of a special table that pulls the joint open about 1cm. The scope is put in to the joint and tools are used to examine the joint space. We look at the surface cartilage, labrum and other structures in and around the hip. Once we have looked at everything, any ‘extra’ bone on the socket side is carefully removed with a tool called a burr. The labrum tear is often repaired with small anchors back to the rim of the socket (from where it tore away). The ball is then released back into the socket and we use the burr to reshape the ball, removing extra bone in that area as well. Surgery often takes 2-4 hours depending on the extent of injury. Question 6: How long is the recovery? As with any surgery, the recovery is variable, but most high-level athletes are back to full sports around 6-8 months after the operation. There have been several studies examining the performance of professional athletes in different sports after return from this hip surgery. Most have shown little or no diminished performance after recovery. I’m certain even Morrison would say he didn’t have the season he was hoping to have for the Twins, and this hip issue certainly could’ve been part of the reason. Hopefully he can improve after surgery and get back to his 2017 form, whether for the Twins or elsewhere.

I took my 3 year old son to his first game today. He did pretty well until about the 8th inning (which was over 3:10 from first pitch) so we left after the Twins gave up the lead. Heard them take it back on the radio, then I got home just in time to see them blow the lead in the 9th, then Dozier's slam. Would've been great to see the slam in person, but 4.5 hrs for a ten inning game just ain't happening for a 3 year old. Glad they could pull this one out- would've been a shame to let it slip away as much as they battled.