As it turns out, the Pittsburgh Pirates' All-Star outfielder was dealing with something far less common: an avulsion fracture of one of his lower ribs. In a statement from Pirates general manager Neal Huntington, the team announced McCutchen had specifically been diagnosed with “an avulsion fracture involving the costochondral cartilage of the left 11th rib.”
The breakdown of the language describing McCutchen’s injury goes something like this. An avulsion fracture occurs when a soft tissue structure attached to bone (typically tendon or ligament) is stretched beyond its normal length and pulls away, taking a tiny piece of bone with it. In McCutchen’s case, instead of the left abdominal oblique muscle fibers tearing within the substance of the soft tissue, the attachment point at the 11th rib pulled away, taking a fleck of bone with it.
The 11th rib is what is considered a floating rib as it does not attach on the front side of the rib cage (ribs 11-12 are both floaters). The rib structure is not just pure bone, however. The bone joins with a piece of cartilage on the front end. The costochondral junction is where the rib (costo) and the cartilage (chondral) meet and form a small joint. In McCutchen’s case, the news that his avulsion fracture involved the costochondral cartilage indicates the injury happened near the bone-cartilage interface, injuring both.
It certainly sounds as if this might be worse than an oblique injury, but is it?
We know oblique injuries in position players result in an average stay of 26.7 days on the disabled list, based on a study published in the American Journal of Sports Medicine in 2012. In that study, nearly three-fourths of the injuries to position players occurred on the opposite side of (contralateral to) their dominant batting side. These injuries are clearly not quick to heal and complicating matters, there is a reinjury rate of approximately 12 percent. Part of the challenge in recovery is that soft tissue healing is easily disrupted by too much tension (stretching) or by too aggressive shortening (via muscle contraction).
Bone is typically more predictable in its healing. Avulsion fractures, which are more common in the ankle or foot, often heal without surgical intervention. Treatment initially often consists of rest while allowing pain and inflammation to subside. Subsequent treatment often follows the path of what the local soft tissue would indicate. In McCutchen’s case, this would suggest that after a period of rest, he will gradually incorporate a rehab strategy similar to that for an oblique strain, progressing as his symptoms allow.
By not immediately placing him on the DL, the Pirates clearly hope that McCutchen’s injury will progress more quickly than a standard oblique injury. Unfortunately, there are virtually zero comparisons to apply. I conducted an informal poll of several medical professionals who have cared for elite baseball players for years. When asked how many avulsion fractures of this type they had ever seen, the response was universal: none.
The mechanism of McCutchen’s injury (a hard swing) and the location of his pain (contralateral lower rib cage) are typical of oblique injuries in position players, which explains why this was presumed initially by many to be the diagnosis. It would seem since the presentation has so many similarities to an oblique strain, the safest assumption would be that it will behave similarly to an oblique in its healing pattern. If that is indeed the case, McCutchen would likely miss in the neighborhood of three to four weeks.
The Pirates, however, are hoping for a different outcome. Perhaps McCutchen’s signature speed will carry over to his recovery, teaching us that avulsion fractures at the 11th rib result in a quicker return to play.
The All-Star break gives us a chance to see how teams have fared thus far and project what will happen the rest of the season. One of the big influences, if not the biggest, year in and year out, is injuries, and 2014 is no different. Much of the first three months of the season was spent talking about the number of Tommy John surgeries (including revision or second surgeries to the ulnar collateral ligament of the elbow) befalling major league pitchers this year. When pitchers’ elbows weren’t the hot injury topic, baserunners’ thumbs were. Perhaps the second most common surgery of the first half of the season also involved an ulnar collateral ligament, specifically the one found in the thumb, often injured by baserunners getting it caught on the bag while sliding. Looking ahead to after the All-Star break, teams who have been without some of their key players are hopeful of getting them back, at least for a portion of the season. But are those hopes realistic? To try to answer that question, we take a closer look at 10 of the more interesting injury scenarios for the second half.
Reds manager Bryan Price didn’t sound entirely optimistic when he offered his assessment of Votto's status going forward. “Our plan of attack will be to do everything we can to get him back to play over the course of the year," Price said. "We don't have a timetable on how long that will be, but the goal is to get him back and able to help us before the year is out.” In other words, the Reds are still looking to get a functional Votto back, not necessarily a completely healthy one. Votto went through a difficult recovery following meniscus surgery on the same knee two years ago. While it is unclear whether there are joint changes that are specifically contributing to his challenges with this year’s quad strain, the cumulative injuries in the area don’t help the overall picture. The takeaway at this stage is that even if the Reds are able to work Votto back to the playing field this season, their own assessment of the situation hints at him not returning to full strength before the year is out.
According to the Atlanta Journal-Constitution, Gattis has begun some baseball activities, including taking light batting practice. Given the torque through the trunk during a swing, the fact he was able to do so successfully is a good sign that the acute pain has settled down. The next test will be to ramp toward rehab games, presuming no setbacks from the batting practice. While there remains no formal timetable, it’s clear Gattis won’t be ready to come off the DL when first eligible immediately after the All-Star break. It remains to be seen whether he continues on this trajectory when he puts in consecutive days of swinging the bat hard and making defensive throws from behind the plate, another skill which forces rotation through the spine. Knowing how slow these problems can be to improve, his progress thus far is encouraging but the concern of a subsequent flare-up will linger.
Just a week after being placed on the DL, Cole was throwing a side session, indicating the relatively low severity of this latest soft tissue injury. Still, everything the team is doing seems to indicate caution on their part. After all, the larger lat muscle contributes to the stability of the entire upper kinetic chain (think: shoulder blade, shoulder, elbow, wrist and hand) via the extremity’s anchor to the body and can force increased reliance on the small, coordinating muscles of the shoulder (think: rotator cuff) when it fatigues. An injury to the lat can therefore influence the shoulder during throwing, both directly and indirectly. This DL stint may be as much about the Pirates working with their young pitcher to increase his arm endurance in a protected way so as to ward off a truly major problem as anything else. It still translates to more lost time for him but hopefully that remains shorter than the alternative.
The Phillies may be more interested in showcasing Lee’s return to health to other potential suitors than anything else, given their current status in the standings. From a global health perspective, it would be nice to see Lee post a strong second half of the 2014 season with no arm setbacks, something he has a decent chance of doing based on how his last month of work has gone. Flexor tendon injuries (injuries to the attachment of the muscle group on the inner aspect of the forearm which controls grip and rotation) can precede ligament injuries but an uneventful July to September -- maybe even October -- would offer some peace of mind that Lee’s decline is not imminent, despite the mileage he has accrued in his career.
Tanaka had been a bright spot in the Yankees’ rotation, leading the team in wins and inspiring confidence when he took the mound. He quickly proved the value of his offseason acquisition by the team, especially given their injuries to other starters: CC Sabathia, whose degenerative knee is likely to keep him out the remainder of the year; Ivan Nova, who is in the thick of rehabbing his own (April) Tommy John surgery; and Michael Pineda, who continues in his recovery from a teres major strain and will not return before August, at best. With the news of Tanaka’s injury, however, the question becomes how much his perceived value takes a hit. The jury remains out for now as everyone waits to see whether his prescribed trial of rest and rehab following a platelet-rich-plasma injection will succeed.
There are indeed cases where partial tears of the UCL, the ligament that stabilizes the medial elbow, do not require surgery, at least not immediately, but they are not well-documented and appear to be relatively rare at the major league level. A study published in 2013 in the American Journal of Sports Medicine examined the return-to-play status of 34 athletes with partial tears of the UCL who had undergone PRP injections and found an 88 percent success rate. It should be noted, however, that only two of the athletes in that study were professional baseball pitchers. Still, given the fact that return to prior level of performance following Tommy John surgery is not guaranteed and, at the very least, requires an extensive recovery process that typically exceeds one year, the decision to attempt conservative treatment first makes sense for Tanaka and the Yankees. The bottom line is this: By late August we should have a good idea as to whether Tanaka will be poised for a 2014 return or whether we’ll have to wait until 2016 to see him back in major league competition.
Yadier Molina, C, St. Louis Cardinals (right thumb): This year we have seen numerous thumb injuries during slides, the bulk of them coming when leading with the head and the hands. In Molina’s case, the slide was feet first and he appeared to be using his hand to help control his approach to third base. His pain was apparent right away and the tough-as-they-come Molina was forced to leave Wednesday’s game in the third inning.
On Thursday, the Cardinals delivered the bad news that this would be more than just a two-week rest-and-recovery absence. Molina is scheduled for surgery Friday to repair the ligament, and the team has issued a timetable of eight to 12 weeks for his return. There is variability in the recovery time for these injuries, but as catcher, Molina has to throw repeatedly with this hand, including hard defensive throws, potentially lengthening the time for him to return to play. He is also potentially at risk for more contact than most. From a hitting perspective, the good news is the injury is to Molina’s top hand, making restoration of his natural grip of the bat somewhat easier. While it’s certainly possible he could emerge on the short end of the timetable, the Cardinals have to prepare for the possibility that Molina may not be available before their regular season fate is sealed.
Brandon Phillips, 2B, Cincinnati Reds (left thumb): If it’s not sliding into a base, it’s the diving defensive play that puts the vulnerable thumb at risk. It happened to Los Angeles Dodgers shortstop Hanley Ramirez last year when he suffered a torn ulnar collateral ligament in his right thumb while diving for a ground ball in the World Baseball Classic.
On Wednesday, it happened to the Reds second baseman while making a diving catch in the eighth inning. Phillips was seen wearing a splint on his left thumb after the game, and on Thursday the team announced he would be undergoing surgery. It’s fair to broadly estimate an absence similar to those who have undergone similar procedures. The Reds have indicated a projection of six weeks, which in reality could range from just short of six weeks (like Ramirez) to eight weeks (like Washington Nationals outfielder Bryce Harper). In short, the Reds should expect to be without Phillips’ services until late August or early September. Phillips has not been on the DL in the past five seasons, so his absence for any length of time is a jolt to the Reds' lineup.
In the same game, Reds outfielder Billy Hamilton left early with hamstring tightness. Hamilton, who acknowledged the muscle had been bothering him for a few days before it tightened up Wednesday, anticipates missing a few games, but the All-Star break could work in his favor. With the four “free” days allotted by the break, Hamilton could avoid a DL stint.
Homer Bailey, SP, Cincinnati Reds (right knee): The Reds do seem to be taking their injury lumps all in the span of a few days, adding a pitcher to the mix in Bailey. While the team can take some comfort in the fact that he is not dealing with an injury to his throwing arm, the point remains that he could not complete his Thursday outing. Bailey had discomfort in his left knee while trying to pitch to Starlin Castro in the sixth inning, with the team calling it a strain of his patellar tendon, the broad, flat tendon that anchors the quadriceps muscle below the knee. For now, the Reds say Bailey will make his next start, but even so there will be some concern until he successfully completes that outing.
The American Orthopedic Society of Sports Medicine (AOSSM) picked an inopportune time to gather for its annual meeting. Or so it would seem for those who depend on the nation’s elite orthopedists for their services, given the rash of baseball injuries since the conference started Wednesday in Seattle. The AOSSM meeting is the annual congregation of sports medicine practitioners who come together to share their research and clinical perspectives in the interest of advancing the field. With all the injury news of the past 48 hours, some of them may be commiserating over what awaits them when they return.
Masahiro Tanaka, SP, New York Yankees (elbow): So what does a baseball player do when his team physician is attending the conference? He travels to him, of course. At least that’s what Tanaka did, traversing the country for a visit with Yankees team doctor Chris Ahmad. One could even make the case that Tanaka, who has been placed on the DL with a partial tear of his ulnar collateral ligament, benefited from the timing of the conference. With all the experts gathered in one location, Tanaka could seek multiple opinions without making another trip.
And now the plan for Tanaka has been shared with all of us. Yankees general manager Brian Cashman told reporters Thursday that Tanaka will receive a PRP (platelet-rich-plasma) injection and undergo a rehab process in the hopes that he will be able to return in approximately six weeks. Cashman did note that if the conservative treatment fails, Tanaka could be a candidate for Tommy John surgery.
The rehab course is not unusual as an initial intervention. After all, if it is successful, Tanaka will have avoided an invasive surgery and a 12-18 month recovery process. Considering the calendar, there is nothing to lose. If Tanaka were to have surgery immediately, there is no guarantee that he would be able to pitch in 2015, so why not opt for a conservative measure that might be sufficient to allow him to resume? It is true, however, that many pitchers still have lingering issues following the injection and rehab effort, thus leading them to eventual surgery. In those cases, they at least have the peace of mind of knowing that surgery was not just an option, but the option.
Although Tanaka did not complain of elbow soreness prior to his last outing, there were signs that things were not right for him of late, most notably his yielding nine runs in his past two starts. What was not known was whether an injury was responsible for his decline or whether he was contending with adjustments to the American system. Perhaps it is a little of both. Elbow injuries are rarely single-episode events. More often they are the result of cumulative wear and tear, ultimately leading to failure.
Despite his young age of 25, Tanaka has accumulated a large workload. Among all active MLB pitchers, Tanaka ranks fourth overall in total innings pitched through their age-25 season (which includes minor leagues and Japan). Given the young age by which Tanaka had acquired so much mileage on his arm, a fair portion of work presumably occurred when his throwing arm was still adapting to the stress of pitching. Research is beginning to connect the dots between early workload as a youth pitcher and elbow ligament failure. Sports Illustrated’s Tom Verducci outlined the potential risks associated with Tanaka based on his youth workload, portending future complications.
Coincidentally enough, at the very AOSSM meeting where Tanaka is traveling for evaluation, a paper was presented Thursday reporting 60 percent of MLB pitchers who have undergone Tommy John surgery did so within their first five years in the league. This would hint at earlier and more strenuous workloads resulting in earlier ligament failure in professional pitchers than what was seen even a decade ago.
There’s no denying that Tanaka is now pitching under different conditions. Four days' rest is the average for American starting pitchers, whereas Tanaka came from a system that afforded him six or seven days off between starts. As ESPN.com’s Wallace Matthews notes, the Yankees did give Tanaka an extra day off every other start as a means of helping him physically adapt to the new regimen.
The test will come when Tanaka resumes a throwing program. Will the soreness be gone? Can he effectively locate his pitches? Will he maintain his velocity? And we all know what the next step will be if the answer to those questions is no.
Carlos Beltran, New York Yankees (head): Tanaka isn’t the only Yankee to suffer an injury this week. Beltran was hit by a tipped ball during batting practice, resulting in a concussion and a broken nose. The concussion allowed the Yankees to place Beltran on the seven-day DL, and he will gain up to four additional days because of the All-Star break. Manager Joe Girardi said he did not anticipate surgery for Beltran but he was scheduled for further evaluation. The rest can only help the inflammation in his other joints, namely his knee and elbow.
Even if no facial surgery is in order, Beltran will have to pass all concussion tests in order to receive clearance to return, something the Yankees hope will happen when the team returns to action Friday following the All-Star break.
With an eye on the calendar, Wieters returned to Dr. Andrews for a follow-up consultation, anticipating the possibility of surgery. Now that the decision to operate has been made, Wieters can put all the external questions to rest and can focus on his recovery for next season.
Only 17 percent of current major league players who have undergone UCL reconstruction are not pitchers, although the Tommy John procedures performed thus far in 2014 have largely been done on pitchers. The Twins saw their star prospect, infielder Miguel Sano, opt to undergo surgery in March after conservative treatment failed. Wieters is the most prominent non-pitcher in the major leagues to elect to have the procedure so far this year.
The recovery time for non-pitchers (eight to 12 months) averages about four months less than for pitchers (12 to 16 months). As a catcher, Wieters has unique demands on his throwing arm in terms of frequency (after virtually every pitch in a game) and mechanics (throwing hard when out of position or off-balance to make a defensive play). Unleashing on defensive throws is typically the most challenging aspect of rehab of this type for a position player.
On a positive note, hitting can begin around 16 weeks if all progresses well. With that timetable in mind, Wieters should get plenty of at-bats in during the spring to build confidence for the 2015 season. Hopefully his throwing will follow suit.