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Wednesday, June 3, 2009
Hamilton, Volquez return to DL

By Stephania Bell



I just like to start with some good news. Any good news. Trust me, some weeks -- like this one -- it's slim pickings. Nonetheless, I feel responsible to fantasy owners to keep the glass half-full, and so I scoured amidst all the downers of guys headed to the DL (including a record number of repeat customers!) and I managed to find a bit of encouraging news this week.

Jose Reyes could make his return from the DL on Friday. I always recommend the cautiously optimistic approach when it comes to returning from a muscle strain or an "-itis" (as in something inflammatory). In fact, Reyes hasn't had the opportunity to test the leg in a game situation because Tuesday's planned extended spring training game was rained out. So much for the glass being half-full. There is another game scheduled for Wednesday when the Mets hopefully will be able to put Reyes to the test. Until he proves he can run without difficulty, Friday's target remains in the category of wishful thinking.

But let's face it, we want to get to the information about who's hurt. Here's who we're talking about this week in the world of baseball injuries. ...

Josh Hamilton
Josh Hamilton is making his second trip to the disabled list this year, and this could be a lot longer.
Josh Hamilton, OF, Rangers: Hamilton underwent an MRI on Monday in an attempt to clarify the cause of his persistent groin pain, which has been with him since his most recent collision with an outfield wall at Rangers Ballpark. On Tuesday, he met with Dr. John Preskitt, who performed a sports hernia repair on Ian Kinsler last season. According to the Fort Worth Star-Telegram, Rangers general manager Jon Daniels indicated that Hamilton's visit with Preskitt was to help rule out a hernia.

If this all sounds confusing, it is. Arriving at a diagnosis of a sports hernia is really a process of ruling out other diagnoses. Here's what we know so far.

1. First and foremost for fantasy owners, Hamilton is on the DL for the second time this season. That means you have to make alternate plans for at least another two weeks. I would recommend that you make plans for another couple of months. Continue reading.

2. Hamilton's injury started out as a groin strain and was later called an abdominal strain, according to the team's official Web site. This is the case with many of the injuries that are eventually diagnosed as sports hernias. Pain begins near the groin, then moves closer to the lower abdominal wall. With all of these muscles converging to attach at the pelvis, the pain patterns can be similar.

3. It is not a hernia. A true (abdominal) hernia represents a protrusion (herniation) of abdominal contents through a weak spot in the soft tissue around it. The hernia can often be palpable (the examining physician can feel it) and can generally be seen on imaging (via ultrasound or MRI). Since many of the symptoms can be similar, it is important to rule out a true hernia. Many sports hernias do not show any visible findings on MRI. If Hamilton had a hernia, he would be having surgery while I'm writing this column.

4. Hamilton has indicated that he faces the most difficulty when trying to run. The hallmark of a sports hernia is an athlete's inability to run. It can be a frustrating diagnosis in this regard because, depending on the degree of injury, the athlete can actually feel quite good ... until he tries to run. Because of the muscles involved and their attachment near the pelvis, the power required to run places a demand on the area that cannot be met. The athlete typically complains of pain and weakness when attempting to run. According to the Dallas Morning News, Hamilton said "I'm hurt and sore and can't run," estimating his running since the groin injury at 50 percent of normal.

The evidence here would suggest that Hamilton is, indeed, dealing with a sports hernia, which is, in essence, what the team is saying. According to the Ranger's official Web site, assistant general manager Thad Levine "likened the injury to a sports hernia" and hopes Hamilton can avoid surgery after a period of rest and anti-inflammatory medication. Hamilton will be re-evaluated at that point and, if he has not improved, likely will face sports hernia surgery that would require six to eight weeks of recovery. Although Hamilton's mechanism of injury is somewhat atypical (these injuries often seem to come on out of nowhere, with no particular incident as the cause), his symptom pattern has many features that fit the bill.

For those wondering why surgery isn't done right away, this rest period is a step in ultimately arriving at the conclusion that surgery is necessary. Since sports hernia diagnosis is often one of exclusion -- figuring out everything that the injury "isn't" -- the decision to proceed with surgery is easier if conservative measures have failed. Fantasy owners can hope for the best, but should prepare for the worst, in the event that Hamilton is headed under the knife.

Evan Longoria, 3B, Rays: Longoria was serving as the DH for the past couple days as a result of elbow soreness; now there's something of potentially bigger concern. Longoria left Tuesday's game with a left hamstring strain after running out a ground ball, and we know how these injuries can go (read: linger).



He is expected to undergo an MRI on Wednesday to determine the extent of damage, but there are a few notes of encouragement. Longoria's description of what he did NOT experience suggests that the strain is on the minor end. Longoria told the team's official Web site Tuesday after the game, "I didn't feel a pop, I didn't feel a pull, I was able to walk and ride the bike and everything." Longoria added that he considers himself day-to-day. Rays manager Joe Maddon indicated that he will act with caution, so don't be surprised if Longoria is given a couple days to rest, even if the MRI turns up nothing significant.

Edinson Volquez
Edinson Volquez lasted just one inning in Monday's start before returning to the disabled list.
Edinson Volquez, P, Reds: Volquez may hold the record for shortest return from a DL stint before exiting a game only to be returned to the DL. Not a record he or his fantasy owners really want. And it's not as though he wasn't recovered from the first problem (back spasms) and aggravated the injury. Sadly, this is something altogether different.

Volquez lasted all of a single inning in his return Monday night before being forced out with what he described as "tingling from my elbow down to my fingers," according to the Dayton Daily News. Volquez went on to say that he had "never had this happen ... never had pain in my arm." Specifically, Volquez experienced the sensation in his ring and pinky (fourth and fifth) fingers in his right (throwing) hand. The location tells us that his ulnar nerve was talking to him, and clearly it was not happy.

According to the Cincinnati Enquirer, Volquez has been placed on the DL with tendinitis in his elbow. In that scenario, inflammation in the soft tissue around his pitching elbow could result in increased pressure on the ulnar nerve (which passes just behind the bony part of the inside of the elbow, coming very near to the surface, making it an easy target for injury). The pressure would then result in irritation of the nerve, which shows up as numbness and tingling in the fourth and fifth fingers in the hand. The ulnar nerve is often problematic for pitchers because of its location and its vulnerability when there are problems at the elbow. If the joint is hypermobile, if spurs are present, if there is any ligamentous injury (yes, ulnar collateral or Tommy John ligament) or even in the presence of swelling alone, the ulnar nerve can be affected.



The hope for Volquez is that this truly is a minor condition and not the beginnings of a major problem with his throwing elbow. The plan is for him to rest for at least a week (no throwing at all) and then be re-evaluated. Stay tuned.

Joey Votto, 1B, Reds: A week ago it appeared promising that the team had been able to identify the source of Votto's frustrating intermittent dizziness. He was reportedly dealing with an ear infection and had been placed on anti-inflammatory medication. The problem, however, was that every time Votto got on a plane, the symptoms were exacerbated the next day.

On Saturday, Votto was placed on the DL with what the team is calling "stress-related issues." It's fairly safe to assume that the stress Votto is experiencing is from the on-again, off-again nature of this dizziness. I can tell you that patients who experience chronic dizziness describe it as an extremely debilitating and frustrating condition. We've all experienced feeling dizzy or light-headed at some point, and I have yet to find anyone who thinks it pleasant. Now imagine trying to do your job and performing at the same level to which you and your co-workers are accustomed, with the world spinning around you. It's just not possible.



This trip to the DL is a good move for Votto until he can truly get his symptoms under control. Let's hope that the 15-day period is all he needs.

Asdrubal Cabrera, 2B, Indians: Cabrera left Tuesday's game against the Twins in the first inning with a shoulder injury. He was clearly in pain when he left the field after taking the brunt of Twins shortstop Brendan Harris' weight on his left shoulder as he slid into second base.

The Cleveland Plain-Dealer is reporting that Cabrera suffered a dislocated left shoulder that was "put back into place." X-rays taken at Hennepin County Medical Center were reportedly inconclusive and Cabrera is scheduled to undergo an MRI Wednesday. The description makes it sound as if Cabrera actually subluxed his shoulder (in which it slips slightly off the joint but quickly pops back in) because a true dislocation is often difficult to reduce (put back), unless the athlete has a very unstable shoulder with a history of repeat dislocations. As far as I can tell, this is not the case with Cabrera.

Cabrera also told the Plain-Dealer that he did not think he would need to go on the DL, another sign that he may not have suffered that severe of an injury. It's worth noting though that players often feel far worse the next day once there is post-injury pain and inflammation. There's still a chance, either with or without a complete dislocation, that Cabrera could have suffered enough soft tissue damage to require a minimum two-week absence. Let's see how Cabrera feels over the next few days. That will probably go a lot further in determining just how long it will be before he's back in the lineup.

On the Mend


Alex Gordon has to be pleased with the results of his latest visit with his surgeon. According to the Royals' official Web site, Gordon, who is recovering from surgery to address a torn labrum, got "glowing reports" on his trip to Colorado. His latest activity includes limited tee swings and very light, easy ground balls, so he is still a ways from truly testing his hip (hard swings, fielding bunts, throwing across his body and, ultimately, sliding). Although Gordon was originally given a timetable of 10 weeks (which would mean a return in late June), I have suspected all along that a return after the All-Star break would make the most sense. It seems that Gordon's progress has him on track for that so far.

• Rays ace Scott Kazmir is recovering from his quad strain while simultaneously addressing mechanical faults he attributes to last year's elbow injury. There is no official timetable for his return, but according to the St. Petersburg Times, Kazmir is throwing in the bullpen and hoping to avoid a minor league assignment. It's possible he could be back within another two weeks. Between the quadriceps recovery and the adjustments Kazmir is making, the hope is that his performance will improve when he rejoins the rotation.

Brandon Webb continues to work his way back gradually from the shoulder problem that has kept him out since Opening Day. According to the Arizona Republic, he's throwing on flat ground (with another session planned for Wednesday) and will hopefully progress to a bullpen session Saturday. Don't get too excited; the Diamondbacks haven't brought him along this slowly only to speed him up now. Due to all the missed time, Webb likely will be brought along through every step in the standard return to throwing progression, including several minor league starts to build up endurance. The most encouraging words are from Webb himself, "It took a while to get there, but I feel like we're moving forward." I would not expect much before the All-Star break, but assuming he continues well, it would be a good time to think about picking him up.

Xavier Nady
Xavier Nady likely isn't done for the year, but he isn't coming back in the near future, either.
• In the not so smooth recovery department, Yankees players have endured a couple of setbacks. Outfielder Xavier Nady, who suffered an injury to his previously reconstructed ulnar collateral ligament in April, threw for the first time on Monday and it apparently did not go so well. According to the Newark Star-Ledger, Nady experienced discomfort in his elbow when attempting throws from 50 to 60 feet. Although manager Joe Girardi indicated he would play Nady even if he wasn't at full strength, it's a recipe for disaster if the player and the manager are uncertain whether every throw will result in pain. Nady did throw Tuesday and, according to Newsday.com, only felt minor discomfort this time. When he's throwing consistently without any discomfort, then we can really be encouraged. Until then, everyone should temper expectations.

• Meanwhile, Nady's teammate Jose Molina is having a repeat MRI on his injured left quadriceps after being pulled from an extended spring training game Monday. Those results are expected to guide the next steps. Even without the results, just the fact that he had to be pulled because the muscle became painful tells you what you need to know. He will not be ready to return anytime soon.

• On the other coast, Angels pitcher Kelvim Escobar faced challenges of his own as he recovers from surgery last year to repair a torn labrum. After being ahead of schedule throughout his rehab, he had a setback near the start of the season that has delayed his return. Escobar's shoulder is recovering and he is throwing without pain, but his latest rehab start Monday revealed that he does not have full control of his delivery. The Los Angeles Times reports that, as a result, Escobar has stopped throwing the slider for now. From a rehab perspective, how his shoulder feels is the most important thing. The fact that he is not experiencing pain is critical. A slider is one of the more physically demanding pitches, so it makes sense that it would take longer to get it back. Look for Escobar to rejoin the rotation within the week, perhaps Saturday, but without his slider.



• And finally ... expect John Smoltz back in mid-June. No one will commit to it, but he looks good. Get ready, he's going to be great.