Stephania Bell: Alfonso Soriano



It doesn't take much in the way of a medical background to recognize the seriousness of what's ailing Florida Marlins shortstop Hanley Ramirez. Just look at his own description of the extreme pain he's experiencing and how it's affecting him, as told to the Palm Beach Post.

[+] EnlargeHanley Ramirez
Steve Mitchell/US PresswireHanley Ramirez has struggled this year, hitting just .210 with four homers and six steals.
"I feel it doing anything. I can't even put my shoes on. To get up from bed I have to take 10, 15 seconds. I have to do everything slow,' Ramirez said. "That's the worst pain I've ever had in my life, in my career."

Ramirez was removed from Sunday's game after experiencing increased back stiffness, but the bigger concern now is the pain radiating into his leg. As Ramirez told the Post, "I'm getting tingles in my leg. That's not a good sign." Right you are, Hanley.



Ramirez is exhibiting classic symptoms of nerve root irritation in his lumbar spine, commonly called a pinched nerve. The progression of his symptoms is also classic. He acknowledges the presence of stiffness in his back for several weeks, which then worsened during Sunday's game. Shortly afterward, the pain began migrating in the form of "tingles" into his upper left leg. Tingling is a hallmark nerve symptom as anyone who has bumped his or her "funny bone" (and thus tweaked his or her ulnar nerve, sending tingling into the hand) can attest. The location of the tingling indicates which nerve is affected. The most common presentation associated with the low back is pain radiating into the back of the thigh and downward which represents the pathway of the sciatic nerve. Pain and tingling, which spread into the leg after starting in just the area of the spine, indicates a relative worsening of the condition.



The condition can be associated with a disc bulge, bony changes (such as spurs) resulting in narrowing of the opening where the nerve root exits the spine, or even simply inflammation in the area. The challenge is that once the symptoms present themselves in this manner, they are typically slow to resolve. Every movement becomes painful, few positions are tolerable (much less comfortable), and the individual has to move very slowly to avoid flaring the symptoms even further. Everyone out there who has experienced sciatica or other radiating nerve pain -- and there are a lot of you as this condition is extremely common -- can relate to Ramirez's agony. If the condition further worsens, the tingling can change to numbness and the muscles in the affected area of the leg can develop weakness. The goal is to try to prevent that next step from happening.

Unfortunately, there's no magic rapid cure. The time it takes for the symptoms to disappear is highly variable. Anti-inflammatories, controlled movement, manual therapy and rest are typically the best defense. Sometimes an epidural injection (a steroid injection into the spine near the nerve root) is indicated and can help calm the inflammation. Philadelphia Phillies pitcher Roy Oswalt has dealt with a disc bulge and associated leg pain off and on for several years, including an episode earlier this year that sent him to the disabled list. Ramirez may not want to go on the DL for the first time in his career, but it would be no surprise if he ends up there given the severity of his current symptoms.

While fantasy owners wait to learn whether Ramirez will end up on the DL, several other key players were already transferred there in recent days.

[+] EnlargeSoriano
Jonathan Daniel/Getty ImagesAlfonso Soriano lands on the DL tied for second in the National League with 12 homers.
Chicago Cubs outfielder Alfonso Soriano pulled up limping in the first inning of Monday's game while trying to run out a ground ball, and immediately his hand went to his left quadriceps (front of his thigh). His sudden, halting steps as soon as he felt the injury made it clear he would be done not only for the day but likely a couple of weeks. Soriano was placed on the DL soon after. Everyone familiar with Soriano knows he has a significant history of muscular strains, including injuries to his hamstring, quadriceps and calf. Perhaps most notable was the time Soriano strained his right quadriceps in August 2007. An MRI at that time revealed an actual defect in the muscle, and it took him the better part of a year to recover. According to the Chicago Tribune, Soriano's MRI this time around did not demonstrate tearing of the muscle, and the Cubs hope this will be a far quicker healing process. Still, when an athlete has a history of soft tissue injuries and has reached the age of 35, there has to be some concern as to how quickly (and effectively) he will return.

• Several pitchers found their way onto the DL this weekend. Minnesota Twins reliever Joe Nathan is experiencing some soreness in his surgically-repaired elbow and the team prudently opted to place him on the DL. The team is calling it a flexor strain (strain of the muscles on the undersurface of the forearm that anchor near the surgical site) and speed bumps like this in the course of recovery are not uncommon. There's a reason that the timetable standardly issued following Tommy John surgery is given as a range from 12 to 16 months (sometimes longer) because it allows for setbacks such as this. Nathan told reporters that he expects to be out anywhere from 10 days to a month and in the interest of his long-term health, there is no reason to rush, nor is there reason for huge concern.

• Nathan's teammate, Francisco Liriano, was also placed on the DL this weekend because of soreness in his left (throwing) shoulder. Liriano first experienced soreness during spring training and it became an issue again last week. According to the Minneapolis Star-Tribune, an MRI revealed inflammation, but Liriano did not respond well to a session of catch on Monday, hence the move to the DL. The move is retroactive to May 23, suggesting Liriano could return after missing just one more start, but given that this is his second episode in three months (leading to a second MRI), there's reason to be concerned as to whether he will be truly healthy once he returns.



• The Houston Astros placed Wandy Rodriguez on the DL over the weekend due to fluid in his left (throwing) elbow. According to MLB.com, Rodriguez underwent an MRI, which revealed the fluid, after being scratched for Saturday's start due to discomfort. Fluid within a joint is a result of irritation within that joint, not an injury in and of itself. There has been no indication as to what the team suspects might be causing the problem, although officials do not appear overly concerned. In fact, general manager Ed Wade told MLB.com that the only pitch bothering Rodriguez during his last side session was the breaking ball. However, pitchers over the age of 30 with swelling in their throwing elbow should still raise a caution flag. Time will tell how Rodriguez responds to the rest.

• Finally, collisions at the plate are likely to remain a hot topic for the remainder of this season. After San Francisco Giants catcher Buster Posey suffered a season-ending injury while blocking the plate Wednesday, Pittsburgh Pirates catcher Ryan Doumit found himself on the DL performing the same task. Fortunately, Doumit's injury is less severe. The Pittsburgh Tribune-Review reported the injury as an ankle sprain (no fracture), but Doumit is in a protective boot and on crutches for the time being. Ankle injuries are clearly problematic for catchers given their routine squat position, so it will not be surprising if it takes more than 15 days for Doumit to return.

And just when no one thought it could get any worse for the Mets ... Johan Santana is now done for the season. Let's get right down to business:

Johan Santana, SP, Mets: Despite the trauma of losing yet another player to the DL -- and in this case, it's a definitive season-ender -- it appears to be overall relatively good news for Santana and the Mets. Santana, whose left (throwing) elbow has been bothering him for quite some time, will not be undergoing Tommy John ligament reconstruction, which would keep him out for most of next season. Instead he will undergo a far less extensive procedure to remove bone chips and should be ready for spring training in 2010. But this is not a cut-and-dried situation.

Johan Santana
Noah K. Murray/The Star-Ledger/US PresswireJohan Santana is done for this season, but the Mets are hopeful surgery now will prevent problems in 2010.
The presence of bone spurs can be suggestive of subtle instability in the elbow. The spurs themselves form in response to stress within the joint. They can become painful and limit motion. They can also fragment and form chips or loose bodies. Removing the spurs or chips can help reduce pain and restore motion. There is some speculation, though, that the spurs provide additional stability, and that once removed, the increased motion in the elbow could place additional strain on the all-important ulnar collateral (Tommy John) ligament. Cardinals ace Chris Carpenter had bone spurs removed in 2007, only to end up having Tommy John surgery a few months later. Of course, there are other pitchers who have gone on to pitch successfully after bone spur/chip removal.

One of the advantages of doing the scope is that the surgeon will be able to visually inspect the ligament to see just how healthy it is at this point. Occasionally, during surgery the ligament is shown to be torn, despite not being visible on MRI, and then a reconstruction would be in order. Surely the Mets are not even considering that as a possible outcome because it might just be too much to take. The more likely scenario is that some stretching or fraying of the ligament might be evident, which would be expected in a veteran pitcher, and although it provides some information, it doesn't really change the next steps. In this case, the bone chips are removed, the athlete will undergo rehabilitation and everyone remains hopeful that there will be no further issues.

The Mets have to be hoping this arthroscopic procedure will be the only one Santana will need.

Jake Peavy, SP, White Sox: Peavy had a very scary moment in what the team was hoping would be his final rehab start. Peavy, who has been working his way back from a partially torn posterior tibial tendon in his right lower leg, was hit in his throwing elbow by a line drive Monday night. He managed to stay in the game to throw out the next batter he faced and close out the fifth inning (which was the scheduled length of his appearance), but the elbow swelled as the night went on.

Peavy has since joined the White Sox, but whether he makes a start for them this week or not will depend on how the elbow responds. Until the blow to the elbow, Peavy appeared to be in line to start for the White Sox Saturday at Yankee Stadium. "Every part of me wants to be out there Saturday in a great venue against a great team, giving my team a chance to win," Peavy told the Chicago Sun-Times on Tuesday. In the whole scheme of things, this appears to be a minor road bump that shouldn't interfere much, if at all, with his ultimate return. Most importantly, he does not appear to have any residual issues with the ankle and has looked strong in his rehab outings.

Freddy Sanchez, 2B, Giants: Although the decision to place Sanchez on the DL because of his sore left shoulder might concern fantasy owners, it's worth noting that this move is retroactive to Aug. 18. If Sanchez can come off the DL when eligible, he could rejoin his team during the series in Philadelphia.

Sanchez originally strained the shoulder two weeks ago while swinging. He returned for a couple games, but the soreness persisted, forcing him out of the lineup for six games before he was ultimately placed on the DL. The good news is that this is not the same shoulder that gave Sanchez trouble last year. It is also not his throwing shoulder. The main issue with his inflamed left shoulder is that it hinders his ability to swing the bat. As long as it is just inflammation -- there is no reason to think otherwise at this point -- Sanchez should be able to work his way back following the 15-day DL period.

Alfonso Soriano, OF, Cubs: The Cubs' injury concerns have been overshadowed by the Mets', but the Cubs have had their share of troubles. This time it's Soriano, who faces a possible trip to the DL for an ailing knee. Soriano's left knee has apparently been bothering him since he collided with the outfield wall in late April. According to the Chicago Sun-Times, Soriano says he has been told that he has tendinitis, although it's worth noting that trauma is not the most common mechanism of the onset of tendinitis. It's possible, though, that trying to play through pain could create a chronic inflammation of soft tissue in the area, which might be one reason Soriano could head to the DL for some forced rest.

The Sun-Times reports that Soriano was planning to see the doctor and anticipated a possible MRI. He says he's experiencing pain when he has to run or unexpectedly put weight on the leg, neither of which is avoidable while playing his position. While it's unclear just how much time he might miss, if any, knowing that Soriano has a history of leg muscle strains that have kept him out for extended periods is definitely a concern. Fantasy owners should get insurance now, just in case.

On the Mend


• Diamondbacks outfielder Justin Upton appears to be swinging the bat quite nicely, thank you. Recovering from a right oblique strain, Upton played in his second rehab game Tuesday and delivered a grand slam. It sounds like the oblique is no longer an issue and he should rejoin the team within days.

• Mariners outfielder Ichiro Suzuki, known for his durability, is sitting out for a few days with a calf strain. Although the Mariners initially thought he would return Wednesday, it appears that they will hold off a little longer. This should not be interpreted as anything other than the team's taking a cautious approach with one of its stars. We have seen other players try to test their calf (Lance Berkman comes to mind) only to find out that trying to push off while running sets them back. The Mariners would hate to see Ichiro's tightness turn into a more serious muscle tear. That said, it appears he will avoid a DL stint and will return late this week. Fantasy owners may want to see how he looks in his first outing back to ensure he's up to speed before returning him to the lineup.

• Here's something new! I'm going to use the words "good news" and "Mets" in the same sentence. The good news for the Mets is that third baseman David Wright, who took a scary pitch to the head and suffered a concussion, has been able to increase his activity. This is a good sign because there are certain targets a player has to meet in order to begin physical exertion following a brain injury. According to the Daily News, Wright has been able to do some light running and is hopeful to come off the DL when eligible next week. There is still more that he needs to do, but the fact that he has been able to progress to running is extremely positive. Meanwhile, the Daily News reports that Wright's teammate Carlos Beltran, still recovering from a bone bruise in his knee, has had no pain with outfield running but has not yet been cleared to run the bases. Call me skeptical, but I'm still not convinced that we will see him back this season, despite his desire to return.

• According to the Rockies' official Web site, there is reason to be relieved about Aaron Cook's shoulder: An MRI showed no major structural damage. With the team flying high and Cook being critical to their rotation, the news that he could return to help his team down the stretch is encouraging. The plan is to allow him to rest his throwing arm while undergoing treatment, and then gradually resume a throwing program next week as his symptoms permit. As we all know, throwing shoulders can be unpredictable, but so far this looks good for the Rockies.

• And finally, it looks as if Red Sox pitcher Daisuke Matsuzaka is making the case for a return early next month. His most recent rehab start had him throwing three innings, and the Red Sox staff is happy with what they're seeing. Manager Terry Francona seemed to be absolutely glowing when he told the Boston Globe, "The last two months have gone, in my opinion, as good as possibly expected. He's not only met, but exceeded, every milestone that's been put in front of him." Matsuzaka has been out with a shoulder strain after having arm fatigue near the very start of the season. Bringing him back slowly may well pay off in the late season for the Red Sox, as Matsuzaka may have avoided a more significant injury. Fantasy owners in a playoff run may be able to take advantage here.
Seriously. I think Major League Baseball just set the record for the highest number of players being placed on the disabled list in a given week.

Of course, I don't have any official statistics to back that up. In fact, I'm fairly confident that such a statistic has not been tracked to date. But when your job is to track who is moving onto and off the DL, and the movement is happening so fast and with such a high volume that your head spins, you kinda get a hunch that a record might be broken. Sheesh.

Of course, when you're playing fantasy baseball and you lose a key guy to injury, that feeling is less of a gut feeling and more like a punch in the gut. And when you have so many players at different stages of their injuries, it's hard to know sometimes who's coming and who's going. Let's try to make sense of a few recent injuries:

Matt Capps
Jim McIsaac/Getty ImagesMatt Capps' shoulder injury sounds bad, but at least he'll avoid surgery for now.
Matt Capps, RP, Pittsburgh Pirates: Right shoulder problems reportedly will sideline Capps for the better part of two months. The first part of the diagnosis issued by the team is bursitis, or inflammation of the bursa, a small fluid-filled sac that serves to decrease friction between adjacent tissues. There are many bursae throughout the body, but those in the shoulder are commonly associated with throwers' injuries. Bursitis is also an everyman's injury, in that you certainly don't have to be a ballplayer to suffer from it.

But what about the second part of Capps' diagnosis? According to the Pittsburgh Post-Gazette, general manager Neal Huntington indicated that Capps also has internal rotation deficit, a less familiar term that describes a condition primarily associated with baseball pitchers. External rotation describes the position of the shoulder joint where the head (top) of the humerus (arm bone) is rotated to face outward. Internal rotation is just the opposite, where the head of the humerus rotates inward. Normal range of motion for the average person is a roughly equivalent distribution of external and internal rotation. In order to pitch a baseball effectively, however, an athlete requires external rotation above and beyond that of a nonpitcher in order to get his arm in a position to achieve maximum windup. There is only so much total rotation within the shoulder joint. When an athlete achieves excess external rotation, he typically sacrifices internal rotation.

Why does this matter? Well, because the body requires balance to stay healthy. A thrower will almost always have more external rotation than internal rotation. It is important for the health of the throwing shoulder, though, that the total motion in the throwing shoulder joint (external rotation plus internal rotation) is relatively equal to that of the nonthrowing joint. In other words, 120 degrees of external rotation and 60 degrees of internal rotation in the joint of an athlete's throwing arm, and 100 degrees of external rotation and 80 degrees of internal rotation in the same athlete's non-throwing arm are considered equal. If the total motion on the throwing side is less than that on the nonthrowing side, with the deficit being primarily on the internal side, it is considered internal rotation deficit. In the example above, an athlete with internal rotation deficit might have the same range of motion in his nonthrowing arm, but his throwing arm might have 100 degrees of external rotation and 40 degrees of internal rotation, resulting in a 40-degree differential from one arm to the other.

What causes it and what can be done about it? There is some debate within the medical community as to what, in fact, causes internal rotation deficit. Some believe that tightness in the rotator cuff muscles, which sit on the back of the shoulder and therefore are stretched when the shoulder internally rotates, is responsible. Others believe that the joint capsule, the fibrous tissue that encases the joint, is tight and does not allow the humerus to move freely within the joint. And of course it could be a combination of these two variables. The primary treatment consists of stretching, either stretching muscle tissue or joint tissue, and then following that stretching with a set of exercises designed to enhance strength in the new range of motion and to maintain the motion. Either way, Capps is looking at a significant period of time away from the game (the team expects him to be out until at least September). The good news, however, is that this is a nonsurgical approach, and he should be able to manage the condition after he returns.

Alfonso Soriano, OF, Chicago Cubs: Soriano (fractured fourth metacarpal in his left hand) took his first batting practice Saturday and has been making a case for returning in time to play in the All-Star Game. The good news: According to the Cubs' official Web site, Soriano reported having no pain at all in his hand. The bad news: He did acknowledge that his hand still felt weak, making it unlikely that he would be able to appear in the All-Star Game next Tuesday. Originally projected to be out six weeks, Soriano may yet be able to beat that timetable, but there is no incentive to bring him back early. The Cubs would prefer to have him healthy and at full strength down the stretch.

Johnny Damon
AP Photo/Julie JacobsonJohnny Damon has been placed on the DL for the first time in his career.
Johnny Damon, OF, New York Yankees: Every now and then, this space will detail the injuries caused by an outfielder sacrificing his body and running into a wall or fence. Well, you can add Damon to that list after a weekend crash into the Yankee Stadium fence Friday forced him to the DL for the first time in his career. Damon has what the Yankees are calling a sprained and contused (bruised) left shoulder, and the 34-year-old is adjusting to the idea of being out of the starting lineup for a while. The New York Times reported Damon's injury as a sprained AC (acromioclavicular) joint, which is the joint formed where the clavicle (collarbone) meets the point of the shoulder (acromion). A sprain (ligament injury) in this area, when severe enough, is often called a separated shoulder because if there is enough ligament damage, the two bones can move apart, or separate. It really is a question of degree, and we likely won't get that answer officially. In the end, the treatment is essentially the same. Rest, get rid of the inflammation, and gradually work on increasing the range of motion so Damon can do what he needs to do. Damon indicated he could not raise his arm above his shoulder after the injury because of the pain, which is typical for this type of injury. Two weeks to return to full activity is optimistic for this type of injury, and I would not be surprised if Damon cannot play the field for an additional two to three weeks beyond that. He might be able to hit sooner if his arm recovers well, though, so you might see the Yankees bring him back initially as a designated hitter. We should know more about his status after the All-Star break.

Elijah Dukes, OF, Washington Nationals: Speaking of an outfielder sacrificing his body while running into the outfield wall, Dukes did just that Saturday and came away with a torn meniscus (fibrocartilage disk in the knee) and a partially torn patellar tendon (the thick tendon that anchors the quadriceps muscle to the lower leg) in his right knee. According to the Washington Post, Dukes had arthroscopic surgery Monday and is expected to miss at least the next four to six weeks. This might be a conservative estimate, depending how his rehabilitation goes. The tendon must be at full strength to handle the forceful contractions of the quadriceps muscle, particularly when decelerating or jumping and landing, such as one does when leaping into an outfield wall. How disappointed the Nationals must have been to see yet another youngster go out with a significant injury.

Mike Napoli, C, Los Angeles Angels: Napoli was placed on the disabled list Sunday with what the Angels are calling right shoulder inflammation. According to the Angels' official Web site, Napoli was scheduled to undergo an MRI on Monday to help determine the nature of the problem. For his part, Napoli said he has been having good days and bad days for a while now, but that on the bad days it hurt just throwing the ball back to the pitcher. The nonspecific nature of his injury makes it difficult to project how much time he will need to recover. Once his MRI results are known, there might be better clues as to what the club plans for him. Stay tuned.

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Jeff Suppan, SP, Milwaukee Brewers: Looks as though the arrival of C.C. Sabathia is coming just in the nick of time for the Brewers, who just placed Suppan on the DL with irritation in his right elbow. Sabathia will take Suppan's place in the rotation and is expected to make his first start for the Brewers on Tuesday. Suppan told the Los Angeles Times he initially injured his elbow during an at-bat on May 23 and that it just wasn't getting better. For his part, Suppan says he wasn't sure whether the injury was affecting his pitching or not; he just knew the problem was not improving. It makes one wonder, though, how much Suppan's elbow has been bothering him, given his poor performances recently. Control issues for a pitcher are often a sign that something is amiss, and Suppan's situation appears no different. The timing is good for Suppan to give the elbow a rest, with the arrival of Sabathia and the All-Star break. In fact, he could return just after the All-Star break, with little harm done to the rotation. A pitcher's elbow can be a little tricky, but at this point there is no evidence that this is something more serious.

And in the good news department ...

Felix Hernandez, SP, Seattle Mariners: It looks as if the return of the King is imminent. After an uneventful bullpen session Monday, he is expected to start Friday. This will be his first start since he sprained his left ankle on June 23.

David Ortiz, DH, Boston Red Sox: Before you get too excited about him returning, note that he still has some time before he's back in the Red Sox lineup. But the news is encouraging here. Big Papi took live batting practice Monday for the first time since injuring his wrist in late May. He still has some hurdles to cross but is feeling good swinging the bat. Despite his election to the All-Star roster for the American League, Ortiz will not be able to play, since the wrist is still healing.

Let's hope the All-Star break will come just in time to give the injuries a chance to heal, not to mention slow down the pace of new injuries the league seems to be on now! Stay healthy everyone.

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