Heezy1323

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!!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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!

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.

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.

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.

Royce Lewis: Patellar Tendinopathy
Heezy1323
 
The Twins community recently received some concerning news about highly-regarded prospect Royce Lewis. Lewis left the Cedar Rapids Kernels Saturday game with what is being reported as ‘patellar tendinitis’, which has been causing him trouble off-and-on for about a month. But what is ‘patellar tendinitis’ exactly? And what might it mean for Royce going forward? Let’s discuss:
 
Question 1: Where is the ‘patella tendon’?
The patella tendon is the tendon that goes from your kneecap (also called the patella) down to the upper part of your shin bone (tibia). It is the attachment of your quadriceps muscle group to your lower leg, and it is what allows people to extend the knee.
 


 
Question 2: What is ‘patellar tendinitis’?
Patella tendinitis is a term commonly used to refer to activity-related pain that occurs near the attachment of the patella tendon to the patella. The suffix ‘-itis’ is used to indicate inflammation. While the term is commonly used, in actuality a more appropriate term is ‘patella tendinopathy’, which refers to degenerative changes within the tendon in the absence of inflammation (which is more accurately the case in this diagnosis). This difference is important when considering treatment options.
 


Question 3: Royce is clearly a high-level athlete. Why did he get this problem?
Patellar tendinopathy is also commonly called ‘jumper’s knee’ since it occurs most frequently in athletes that do a lot of jumping. In some studies of professional volleyball and basketball players, the incidence of jumper’s knee has been shown to be more than 30%. It is much less common in non-jumping athletes, but still occurs in around 2-3% of soccer players. I was not able to find any information specifically discussing the incidence in baseball players.
It is unclear exactly why this problem occurs. It is most likely a combination of factors including BMI, flat feet, muscle imbalance in the quad/hamstrings, low flexibility, and intrinsic properties of the patellar tendon. There are likely other factors as well, including overuse.
The area involved is usually located directly at the bottom end of the patella/top part of the tendon. Symptoms usually come on gradually over time. Initially, the knee typically hurts only with activity. Over time, if the condition worsens, pain may begin to be present even at rest.
 
Question 4: How is patella tendinopathy diagnosed?
The diagnosis is usually fairly clear from the history and physical exam of the athlete. Xrays are usually normal, though in some cases calcifications of the tendon may be visible. An MRI is the standard test to identify the extent of the problem and also to rule out other problems inside the knee. The area of the tendon involved in the problem is typically fairly small- around the size of a couple tic-tacs.
 


Question 5: How is patella tendinopathy treated?
The most commonly prescribed treatment for patellar tendinopathy is rest from vigorous activity and specific physical therapy exercises (called eccentric exercises). These exercises are designed to strengthen the quad muscles, stretch the hamstrings and ultimately cause favorable adaptation of the knee. The time needed for symptoms to resolve can be highly variable, but often takes at least a few weeks.
When therapy isn’t effective, other treatments can be tried including various injections and ultrasound. At this time, there is no significant evidence that PRP (platelet rich plasma) injections are helpful for this condition, though I suspect it is being considered. There is, to my knowledge, no significant data on stem cell injections for this problem.
 
Question 6: Is surgery ever needed for patellar tendinopathy?
Rarely, yes. In most studies, around 10% of patients will fail to respond to appropriate conservative treatment. In these cases, surgery may be needed. There are two main options: open surgery and arthroscopic surgery. In either case, the procedure is similar- the area of affected tendon is excised and a small (a few millimeters) part of the patella bone is removed to stimulate healing. Therapy is begun soon after surgery. The success rate for return to sports is around 80% for both surgeries, with return after the arthroscopic version being quicker on average. Usually, 4-6 months is needed for full return to sports after surgery.
 
Question 7: Is Royce at increased risk of rupturing the patella tendon because of this problem?
No. Having patella tendinopathy does not appear to place anyone at increased risk of having a patella tendon rupture when compared to those without the problem.
 
Overall, I believe the most likely scenario to be that Lewis’ body is adjusting to playing professional baseball every day and he is having some minor issues as a result. I don’t expect this to be a substantial problem going forward, though the possibility that this requires surgery in the future does exist. Hopefully he will get through rehab quickly and be back on the field soon.

Royce Lewis: Patellar Tendinopathy
Heezy1323
 
The Twins community recently received some concerning news about highly-regarded prospect Royce Lewis. Lewis left the Cedar Rapids Kernels Saturday game with what is being reported as ‘patellar tendinitis’, which has been causing him trouble off-and-on for about a month. But what is ‘patellar tendinitis’ exactly? And what might it mean for Royce going forward? Let’s discuss:
 
Question 1: Where is the ‘patella tendon’?
The patella tendon is the tendon that goes from your kneecap (also called the patella) down to the upper part of your shin bone (tibia). It is the attachment of your quadriceps muscle group to your lower leg, and it is what allows people to extend the knee.
 


 
Question 2: What is ‘patellar tendinitis’?
Patella tendinitis is a term commonly used to refer to activity-related pain that occurs near the attachment of the patella tendon to the patella. The suffix ‘-itis’ is used to indicate inflammation. While the term is commonly used, in actuality a more appropriate term is ‘patella tendinopathy’, which refers to degenerative changes within the tendon in the absence of inflammation (which is more accurately the case in this diagnosis). This difference is important when considering treatment options.
 


Question 3: Royce is clearly a high-level athlete. Why did he get this problem?
Patellar tendinopathy is also commonly called ‘jumper’s knee’ since it occurs most frequently in athletes that do a lot of jumping. In some studies of professional volleyball and basketball players, the incidence of jumper’s knee has been shown to be more than 30%. It is much less common in non-jumping athletes, but still occurs in around 2-3% of soccer players. I was not able to find any information specifically discussing the incidence in baseball players.
It is unclear exactly why this problem occurs. It is most likely a combination of factors including BMI, flat feet, muscle imbalance in the quad/hamstrings, low flexibility, and intrinsic properties of the patellar tendon. There are likely other factors as well, including overuse.
The area involved is usually located directly at the bottom end of the patella/top part of the tendon. Symptoms usually come on gradually over time. Initially, the knee typically hurts only with activity. Over time, if the condition worsens, pain may begin to be present even at rest.
 
Question 4: How is patella tendinopathy diagnosed?
The diagnosis is usually fairly clear from the history and physical exam of the athlete. Xrays are usually normal, though in some cases calcifications of the tendon may be visible. An MRI is the standard test to identify the extent of the problem and also to rule out other problems inside the knee. The area of the tendon involved in the problem is typically fairly small- around the size of a couple tic-tacs.
 


Question 5: How is patella tendinopathy treated?
The most commonly prescribed treatment for patellar tendinopathy is rest from vigorous activity and specific physical therapy exercises (called eccentric exercises). These exercises are designed to strengthen the quad muscles, stretch the hamstrings and ultimately cause favorable adaptation of the knee. The time needed for symptoms to resolve can be highly variable, but often takes at least a few weeks.
When therapy isn’t effective, other treatments can be tried including various injections and ultrasound. At this time, there is no significant evidence that PRP (platelet rich plasma) injections are helpful for this condition, though I suspect it is being considered. There is, to my knowledge, no significant data on stem cell injections for this problem.
 
Question 6: Is surgery ever needed for patellar tendinopathy?
Rarely, yes. In most studies, around 10% of patients will fail to respond to appropriate conservative treatment. In these cases, surgery may be needed. There are two main options: open surgery and arthroscopic surgery. In either case, the procedure is similar- the area of affected tendon is excised and a small (a few millimeters) part of the patella bone is removed to stimulate healing. Therapy is begun soon after surgery. The success rate for return to sports is around 80% for both surgeries, with return after the arthroscopic version being quicker on average. Usually, 4-6 months is needed for full return to sports after surgery.
 
Question 7: Is Royce at increased risk of rupturing the patella tendon because of this problem?
No. Having patella tendinopathy does not appear to place anyone at increased risk of having a patella tendon rupture when compared to those without the problem.
 
Overall, I believe the most likely scenario to be that Lewis’ body is adjusting to playing professional baseball every day and he is having some minor issues as a result. I don’t expect this to be a substantial problem going forward, though the possibility that this requires surgery in the future does exist. Hopefully he will get through rehab quickly and be back on the field soon.

Royce Lewis: Patellar Tendinopathy
Heezy1323
 
The Twins community recently received some concerning news about highly-regarded prospect Royce Lewis. Lewis left the Cedar Rapids Kernels Saturday game with what is being reported as ‘patellar tendinitis’, which has been causing him trouble off-and-on for about a month. But what is ‘patellar tendinitis’ exactly? And what might it mean for Royce going forward? Let’s discuss:
 
Question 1: Where is the ‘patella tendon’?
The patella tendon is the tendon that goes from your kneecap (also called the patella) down to the upper part of your shin bone (tibia). It is the attachment of your quadriceps muscle group to your lower leg, and it is what allows people to extend the knee.
 


 
Question 2: What is ‘patellar tendinitis’?
Patella tendinitis is a term commonly used to refer to activity-related pain that occurs near the attachment of the patella tendon to the patella. The suffix ‘-itis’ is used to indicate inflammation. While the term is commonly used, in actuality a more appropriate term is ‘patella tendinopathy’, which refers to degenerative changes within the tendon in the absence of inflammation (which is more accurately the case in this diagnosis). This difference is important when considering treatment options.
 


Question 3: Royce is clearly a high-level athlete. Why did he get this problem?
Patellar tendinopathy is also commonly called ‘jumper’s knee’ since it occurs most frequently in athletes that do a lot of jumping. In some studies of professional volleyball and basketball players, the incidence of jumper’s knee has been shown to be more than 30%. It is much less common in non-jumping athletes, but still occurs in around 2-3% of soccer players. I was not able to find any information specifically discussing the incidence in baseball players.
It is unclear exactly why this problem occurs. It is most likely a combination of factors including BMI, flat feet, muscle imbalance in the quad/hamstrings, low flexibility, and intrinsic properties of the patellar tendon. There are likely other factors as well, including overuse.
The area involved is usually located directly at the bottom end of the patella/top part of the tendon. Symptoms usually come on gradually over time. Initially, the knee typically hurts only with activity. Over time, if the condition worsens, pain may begin to be present even at rest.
 
Question 4: How is patella tendinopathy diagnosed?
The diagnosis is usually fairly clear from the history and physical exam of the athlete. Xrays are usually normal, though in some cases calcifications of the tendon may be visible. An MRI is the standard test to identify the extent of the problem and also to rule out other problems inside the knee. The area of the tendon involved in the problem is typically fairly small- around the size of a couple tic-tacs.
 


Question 5: How is patella tendinopathy treated?
The most commonly prescribed treatment for patellar tendinopathy is rest from vigorous activity and specific physical therapy exercises (called eccentric exercises). These exercises are designed to strengthen the quad muscles, stretch the hamstrings and ultimately cause favorable adaptation of the knee. The time needed for symptoms to resolve can be highly variable, but often takes at least a few weeks.
When therapy isn’t effective, other treatments can be tried including various injections and ultrasound. At this time, there is no significant evidence that PRP (platelet rich plasma) injections are helpful for this condition, though I suspect it is being considered. There is, to my knowledge, no significant data on stem cell injections for this problem.
 
Question 6: Is surgery ever needed for patellar tendinopathy?
Rarely, yes. In most studies, around 10% of patients will fail to respond to appropriate conservative treatment. In these cases, surgery may be needed. There are two main options: open surgery and arthroscopic surgery. In either case, the procedure is similar- the area of affected tendon is excised and a small (a few millimeters) part of the patella bone is removed to stimulate healing. Therapy is begun soon after surgery. The success rate for return to sports is around 80% for both surgeries, with return after the arthroscopic version being quicker on average. Usually, 4-6 months is needed for full return to sports after surgery.
 
Question 7: Is Royce at increased risk of rupturing the patella tendon because of this problem?
No. Having patella tendinopathy does not appear to place anyone at increased risk of having a patella tendon rupture when compared to those without the problem.
 
Overall, I believe the most likely scenario to be that Lewis’ body is adjusting to playing professional baseball every day and he is having some minor issues as a result. I don’t expect this to be a substantial problem going forward, though the possibility that this requires surgery in the future does exist. Hopefully he will get through rehab quickly and be back on the field soon.