Heezy1323

Thanks everyone. My first crack at a blog post like this- so I'm certainly open to feedback with regards to how I can make them more informative and helpful for others. Feel free to respond with any critiques or advice, or even suggested topics for future blog posts.

News came down yesterday that highly-touted Twins SS prospect Wander Javier will undergo season-ending surgery on his left (non-throwing) shoulder to repair a torn labrum. According to LEN, this was an injury that was suffered initially late last season, but initially the decision was made to attempt to treat Javier with rehabilitation. Unfortunately, he has continued to have pain in the shoulder, and he has taken the dreaded trip to Pensacola, FL to see Dr. James Andrews. It sounds like Dr. Andrews will perform surgery soon, and that Javier is expected to be out six to nine months. Shoulder injuries are common in baseball players, certainly. But they are much more common in the throwing shoulder, particularly in pitchers. Let’s discuss how this injury may be similar and different. Question 1: What is a labrum, anyway? 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. Question 2: How does a labrum get injured? There are several ways that someone could injure the labrum of the shoulder. In baseball players (and pitchers in particular), it is common for a labrum tear to occur at the top of the socket near the attachment of the biceps tendon. This is called a SLAP tear (Superior Labrum Anterior to Posterior) and is typically the cumulative result of repetitive use. However, it can also occur as a result of a dive/fall if the mechanism is just right. Another way the labrum can be injured is as a result of a shoulder dislocation. In the majority of cases, the ball dislocates out the front (anterior) of the socket, and the attachment of the labrum to the rim of the socket is damaged. A final way that I have seen labrum injuries in baseball players is in the front shoulder of hitters. Occasionally, as a result of an aggressive swing (or combination of swings) a player can damage the labrum in the back part (posterior) of the shoulder. This is also an injury that I sometimes see in golfers. In Javier’s case, the injury is to his left shoulder. As he is a right-handed hitter, this would be his front shoulder. I was not able to find any reports of him dislocating his shoulder last season (which would suggest an anterior labral tear). It is possible, then, that his labral tear is more in the back of the socket (though this is purely speculation on my part). Question 3: Why didn’t he just have surgery in the off-season to get this taken care of? This is always a difficult question to answer without knowing specifics of the situation. Hindsight is 20/20, but it is not always known at the time of an initial injury whether it is going to require surgery or whether rehab will be sufficient. Clearly, the Twins and Javier felt that rehab stood a reasonable chance of being successful, or I suspect surgery would have been undertaken previously. Question 4: What is done at surgery? There are subtle variations in technique for these type of injuries, but the majority are treated with arthroscopic surgery. This means a small fiber-optic camera is inserted into the shoulder, and the shoulder is filled with fluid. The labrum is then examined and the extent of the tear is assessed. Typically, the pre-op MRI will give the surgeon a good idea how extensive the tear is, but the precise size and location of the tear is not known until surgery. Once the tear has been assessed, the repair process begins. Small anchors (similar to plastic drywall screws) are inserted into the rim of the socket in the area of the labrum damage. These vary in size, but are typically somewhere around 3.0mm in diameter. These anchors have strong stitches attached. The stitches are passed around the labrum using special tools and the labrum is secured back to the rim of the socket. This process is repeated for as many anchors as are needed to completely repair the tear. After surgery, the small incisions are closed with suture and the patient heads to the recovery room. Surgery typically takes around 1-1.5 hours. Question 5: What happens after surgery? Why does it take so long to get back to full activity? Any time we repair a structure in orthopedics, the rate of healing is dependent on a number of factors. Some factors include the type of tissue injured, the severity of the injury, the age and health of the patient as well as numerous others. One helpful comparison in this case can be a fracture of a bone. Bone, as compared to cartilage (labrum) has a much greater blood supply. As such, most bone fractures are able to fully heal somewhere around 6-10 weeks (with some variability of course). Labrum (as with all cartilage) has a much poorer blood supply, and as a result takes a lot longer to heal. This is one of the main reasons for the lengthy rehab. In addition, the stresses placed on the shoulder are significant. The labrum has to withstand a tremendous amount of force when throwing a baseball or swinging a bat. The muscles around the shoulder tend to get weak quickly after surgery, and it takes time to rebuild the muscles. Proceeding too aggressively (before the muscles have recovered) places extra stress on the labrum, and can lead to failure of the repair to fully heal. Question 6: Will Javier’s shoulder ever be the same? This is perhaps the most difficult question to answer. Without knowing the extent and location of the damage, it is very difficult to comment on this subject. It is certainly better that this is his non-throwing shoulder, as that likely portends a better chance of full recovery. Few surgeons have done more of this type of surgery than Dr. Andrews, so he is in good hands.

I have seen a couple posters suggest a role for Joe with the team in some capacity, in lieu of playing next season (or sooner). Do we have any indication that Mauer has any desire to be a coach or other advisor-type person? What role would we like him to have? While I don't think this is necessarily in and of itself a bad idea, my take is that it is being suggested more as an "whatever it takes to get him off the field" option. Do we want him as a hitting coach? I suspect not. A veteran presence? Many have commented he seems ill-suited for this. A good clubhouse guy? Not necessarily his strength. Simply a fan ambassador? Maybe... Perhaps others have better ideas than me. Thoughts?

This was more of an academic review paper written by the surgeons out of Rush in Chicago (team doctors for the White Sox). It did not name any players who have undergone the repair procedure. I am not aware of any others aside from those you mention. I agree entirely that watching those pitchers will be interesting (whether May undergoes the procedure or not). Your take on the recovery is the same as mine- promising but lacking long-term data.

Here is a recent review of the current state of UCL repair. It is fairly technical, but thought I would post it for those who may be interested. http://journals.sagepub.com/doi/pdf/10.1177/2325967116682211

I enjoy participating in these discussions, and am happy to do my best to answer questions as they arise. I had considered starting an 'Injury' thread so that people could post there, since I may not always see posts in other threads. If people think that would be helpful, I'd be happy to do so.

Apologies for misunderstanding- now your question makes more sense. Since this procedure is fairly new (in this iteration), and obviously therefore doesn't have 10-15 years of research behind it, I don't think we know the answer to your very appropriate question. It is my belief that, carefully selected, these repair patients should do no differently from TJ patients. Now that begs the question, "how do you select?" Right now, especially at the ML level, I would say that this operation is likely only being considered for 'ideal' candidates. Meaning (possibly like Trevor) those players who have a fairly normal elbow and a then a sudden change with a UCL that looks good on MRI aside from the area of the injury at the bone. As more data is collected over time, it seems somewhat likely to me that the selection criteria will be loosened, and this operation will be done on 'less ideal' candidates. That is where we are really going to see how good this procedure is, IMHO. It's hard to know if the injured ligament is completely normal aside from the area of injury, or did the ligament get 'stretched out' a little before it tore and is therefore more likely to have recurrent trouble in the future. We can use the MRI and intra operative evaluation to help us decide, but at the end of the day there are always going to be some ligaments that fall into a gray area. Hard to know what to do with those right now. You would like to get players back to competition sooner. But you also don't want to have them undergo 6 months of rehab, only to find that the ligament was too injured to begin with, then have to resort to TJ and start the clock all over again (in effect, costing them 18 months or more).

I'm not sure how much detail you'd like me to go into (I sort of 'geek out' on this stuff), so I'll start with a little and can add more if people would like. 1) So everyone is on the same page, traditional TJ uses tissue from another source (usually either a small forearm tendon called the palmaris tendon or a hamstring tendon called gracilis) to 'reconstruct' a new ulnar collateral ligament (UCL). Repair is a similar operation, though instead of making a 'new' UCL out of other tissue, a surgeon simply repairs the injured tissue back to the bone (where it tore away from). 2) Only certain types of tears are amenable to the 'repair' surgery. The UCL can be injured at its attachment on the sublime tubercle (ulnar attachment), medial epicondyle (humeral attachment) or in-between (what we call mid-substance). Uncommonly the ligament can be injured at more than one of these locations, but usually just one. If the ligament is injured at one end, and the quality of the tissue is good, it can be considered for the 'repair' surgery, back to the bone where it tore away from. 3) The repair operation has really only gained popularity over the past 3-5 years, and has only been done a very few times on pitchers at the major league level. However, initial studies do appear promising. 4) For biologic reasons (that I can expand upon if people are interested, though it may put people asleep), a repair heals and becomes stronger more quickly than a reconstruction. Again, due to the small number of cases done at the ML level, the timeline is still somewhat unknown, but at lower levels, many players are back to pitching at around 6 months post-surgery, rather than 9-12 months as in TJ. 5) You asked about 'difference in effect', and I guess I'm not quite sure what you mean by that. The overall effect of the surgery is, of course, the same- to stabilize the elbow against the significant forces of throwing. It is only the manner in which it is done that varies. If that doesn't answer your question, please clarify and I'd be happy to try again. Hope this helps. Happy to entertain follow up questions. Too bad for May, I was certainly hoping for a bounce-back year from him (as we all were).

Sorry I'm late to the thread, at a family function presently. Will try to contribute more when I get a chance.

I can't say I'm aware of any data on switching between roles (SP/RP) but there is some fairly good data that discusses the effects of core injuries and that it can result in increased stress on the shoulder and elbow. So perhaps indirectly, if we believe his transition to the bullpen was a contributing factor to his back issues, we could say that switching may have been related to the current problem. A more interesting question to me is, since this was an acute injury, is he a candidate for a direct repair instead of TJ...

I genuinely appreciate the compliment. I really enjoy this TD community and have learned a lot about baseball by reading others' posts. I enjoy chipping in where I can offer some insight. As far as bilateral leg weakness... let's just say that I'm not sure I would've been much help then, either.

I would say that the difference is that a breast aug is cosmetic. TJ is not. I'm not saying there aren't orthopedists out there who would do it (though I don't know any). I'm just saying it's not something I would be willing to do. When I consider signing someone up for surgery, the benefit needs to outweigh the risk, or I don't recommend surgery. There are an extremely small number of circumstances under which I would operate on a normal, uninjured joint.

The usual time frame is around 4 months. It is usually around 6 weeks of initial 'active rest', followed by a return to throwing program. Usually they can resume pitching around 3 months. It then usually takes about a month for them to progress to the 80% effort range, which is where most begin to experience trouble (if they are going to have trouble).

I can assure you, the decision is rarely cut and dry. I would say around 20% of the time it is clear surgery is needed. The rest of the time, the decision on when/if to operate is challenging.

On this, we agree. Though I'm not sure SS=29 is much better. Very challenging topic.

So your contention is that a position player is at higher risk to fail non surgical treatment than a pitcher? My suspicion would be the opposite- that since a position player places less stress on the elbow than a pitcher (proven in biomechanics studies), they are more likely to be successful with non surgical treatment. You can't just conjure the non-pitchers to study. You have to study what is available and extrapolate that data as best you can to other groups.

Also, here is a link to a power point presentation from Chris Ahmad (Yankees team doc) that discusses non surgical treatment in some additional detail. https://foreonline.org/wp-content/uploads/2016/11/9-2.pdf

There is some mixed data on PRP injections- some studies showing it helps, others showing no difference. A mentor of mine once told me when I asked him if he thought PRP works for this problem "No idea. But sometimes you have to do SOMETHING to them just to get them to listen to you and actually rehab the right way." I've always remembered that. Agree 100% on the rarity in HS OF's.

As a surgeon, I hope I never reach the point in my career that I am doing preventative TJ surgery. I will hang up my scrubs the day that happens.

I posted this link in the other thread as well, but it is helpful in answering this question. The short answer is (at least according to this study), most. http://journals.sagepub.com/doi/abs/10.1177/2325967114S00021 It isn't just the Twins that take this approach- that is the approach taken by the vast majority of teams/colleges.

Well, being one of 'these guys', I feel an obligation to respond to this post (despite the fact that I think it is essentially true). Answering the question of which pitch places the most stress on the elbow has proven difficult from a scientific standpoint. The curve ball was never science based- it was based on assumption and expert opinion. Then, as technology began to improve, we began to be able to measure (with debatable accuracy) forces across the elbow. That's where some of the more recent thoughts come from (i.e. different studies have shown different numbers). There continues to be some disagreement in the medical community as to the specific cause of UCL injury. Clearly, it is multifactorial, but how much any one individual factor is responsible is difficult to say, scientifically. As to the physician's comment in the article re: a fastball being the most likely pitch to cause an injury, I think it is certainly possible, but very difficult to PROVE scientifically. Yes, I would say most pitchers that I have seen that report an acute 'pop' in the elbow with throwing were throwing a fastball. But what exactly does that mean? Was the UCL 100% normal before that pitch, and then tore completely? Seems unlikely. Also, at most levels, for most pitchers, the fastball is the most frequently thrown pitch (usually by a lot). So it certainly is a case (at least to me) of correlation not necessarily being causation. So ultimately, yes I would agree- there is much to be learned about the thrower's elbow. But I think it is somewhat unfair to characterize the professional community as being uninterested or incapable (though I can certainly understand the inclination). Finally- The Arm is a phenomenal book. I encourage anyone with an interest in the topic to read it.

Happy to answer questions as best I can. Your question re: Perkins conditioning is a good one, though obviously difficult to answer with much certainty. I would say in general that MLB pitchers are in less 'good shape' than position players, though obviously there are exceptions. In many ways, being overly muscular can be detrimental to hurling a ball 95 mph. Also, I would say there is a difference between a pitcher keeping his arm in shape but perhaps gaining some weight in the midsection, and neglecting an offseason throwing/strength program altogether. To me, the latter is more likely to be problematic than the former. All of that being said, it seems reasonable to me that significant weight gain (not sure how I would define significant) has the possibility to change mechanics, which could in turn lead to injury (I am not aware of any studies that have specifically looked at this). Another possible explanation is that the cumulative 'wear and tear' on Perkins shoulder simply became too much, and would have been problematic if he had shown up to spring training in the shape of his life. Personally, I have come to believe that every thrower's shoulder/elbow has only so many 'bullets'. For every MLB pitcher, there are 100 who were great in HS or Legion ball, but simply ran out of bullets much sooner. Sometimes the gun is just empty.

I thought I might add just a little bit to this discussion, as it is likely I look at more shoulder MRI's than most on TD (I am an orthopedic surgeon). Alarp is correct, these are difficult to diagnose. Sometimes it is because they don't show up on MRI. In other cases it is because nearly every pitcher's shoulder (particularly by the time they reach the professional level) shows signs of 'wear and tear' on MRI. So trying to differentiate 'normal' wear and tear from 'troublesome' wear and tear is also very difficult. Also, I thought a brief discussion of shoulder anatomy may be helpful for some. Many times while discussing the throwing shoulder, people lump the rotator cuff, labrum, and SLAP tears together, while in fact they are really separate (though potentially related) issues. I like to use the analogy of a golf ball sitting on a golf tee when discussing the shoulder with my patients. The shoulder is a ball and socket joint, and in many ways similar to the golf ball analogy. The rotator cuff is a group of muscles/tendons that comes off of the shoulder blade and attaches to the ball. It's job is mainly to pull on the golf ball to keep it in the center of the golf tee as the larger muscles move the arm around in space. The labrum is cartilage that runs around the circumference of the golf tee. It's job is to act as a 'bumper' to keep the golf ball centered on the golf tee. It also serves as an attachment point for ligaments that help to keep the golf ball on the golf tee (the muscles and ligaments work in concert to do this). The top of the socket is where your biceps tendon attaches and becomes confluent with the labrum. Anatomically, we call this the 'superior labrum'. So a SLAP tear (which stands for 'superior labrum anterior to posterior') is an injury where the labrum has become separated from the rim of the golf tee at this area where the biceps tendon attaches. One can also get a labrum tear at other points around the rim of the golf tee (that don't involve the biceps tendon attachment area). These injuries can commonly be in the front (anterior) or back (posterior) of the shoulder, thus often being referred to as 'anterior labrum tears' or 'posterior labrum tears' which are different than SLAP tears. However, certainly a thrower can (and often does) have more than one of these issues at a time. To add to the confusion (as if all of this wasn't confusing enough already, right?), different people can pitch with different amounts of damage/injury in the shoulder. I have seen shoulder MRI's that look TERRIBLE, and the player is still pitching at a near All-Star level. I have conversely seen MRI's that look essentially normal, and a pitcher is completely unable to throw. I hope this was helpful to some, and I apologize if it is covering known material for others. I really enjoy this site and like to pitch in here and there where some of my medical knowledge may be helpful to others. I know I have certainly learned a lot from many here- just trying to return the favor. https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjD7KGjvLHNAhWF8z4KHeiuDJMQjRwIBw&url=https%3A%2F%2Fwww.shoulderdoc.co.uk%2Farticle%2F1399&psig=AFQjCNFMBoj1JIDKkxv2TwQBWh7JPROf-w&ust=1466335474059527