Stephania Bell: Brandon Beachy
Every Monday, in this space, we'll provide updates on a variety of players to help you make your weekly lineup decisions. We'll specifically try to hit the players who are day-to-day, have just gone on the DL or are ready to return, so that you can better decide whether you can count on them or not.
All projected return timelines should be considered fluid.
Hitters:Albert Pujols, 1B, Angels (placed on DL 7/28): Pujols has been placed on the DL with a partially torn plantar fascia in his left foot. This can’t be a big surprise to anyone, including Pujols, who has been dealing with some form of the injury off and on for almost seven years. In the spring of 2006, an issue with the foot surfaced, but Pujols did not miss any time. In 2007 and 2008, he dealt with a left calf strain, spending time on the DL as a result. (Calf strains and plantar fascia injuries often go hand in hand.) In the spring of this year, Pujols was bothered by the foot off and on throughout April. The pain was so severe at one point that it led Pujols to say, "I’m dying." At the time, the plan was to try and manage his symptoms by resting him intermittently, but the possibility always existed that the condition could worsen. The partial tear means the intact fibers are left absorbing the load and are threatened with further damage every time the foot hits the ground. The pain is typically stabbing and severe, and the dense tissue is not prone to rapid healing. That translates to rest being a big part of the equation in recovery with the hope that scar tissue will form and the pain will eventually decrease. Biomechanical issues of the foot typically contribute to the condition, and various stretching and strengthening exercises along with supportive footwear are all components of treatment. Sometimes surgery to "release" the plantar fascia is an option, but even if he were to undergo such a procedure, it would not be a quick fix. Nothing about this condition in its chronic, aggravated stage is quick. It may very well be the end of the season for Pujols, but if he does manage to return for the final weeks of the year, no one should presume that that indicates a full recovery.
Carlos Gonzalez, Rockies (day-to-day): In early July, Gonzalez took an awkward swing and sprained the middle finger on his right hand. What started as a seemingly minor problem is lingering a little more than anyone would like, a reminder that a player's grip on the bat is controlled by intricate and delicate structures in the hand. Gonzalez had actually seen improvement and believed the finger was no longer a concern. Perhaps it appeared that way until last Thursday when he aggravated it during an at-bat in the first inning. He has not played since. The Denver Post reported Gonzalez was sporting thick layers of black tape around his finger and that he and the team were still evaluating options. While it sounds as if the team does not believe a DL stint will completely resolve the problem, it also sounds as if this is not likely to go away no matter what path they choose. The risk of aggravation exists with every swing of the bat. It’s unclear how much time he will miss in the near future as the Rockies are calling him day-to-day. The likelihood is that, regardless of whether he goes on the DL, he will again string together series of games where he performs well, but a setback could be lurking around the corner.
Curtis Granderson, OF, Yankees (placed on DL 5/25, could return this week): It’s almost hard to believe Granderson has played in only eight major league games this season, but he could be getting close to upping that number. Out since May with his second fracture of the year, this one in his hand, Granderson’s main challenge right now is to get comfortable at the plate. Not necessarily because he’s apprehensive about getting beaned again and suffering yet another fracture (which is how the first two happened), but because he simply hasn’t been at the plate much this year. This second fracture required surgical stabilization, and Granderson struggled to get his range of motion back initially, making it difficult to grip the bat. He has cleared that hurdle, but his time away from the game has no doubt left him rusty. According to WFAN, manager Joe Girardi says Granderson could return this weekend, but fantasy owners should not expect too much out of the gate. The risk of re-injury is low, but it may take him some time to perform consistently at the plate.
Pitchers:Brandon Beachy, SP, Braves (started season on DL, activated 7/29): He’s back. The wait has been long and was slowed by a brief setback, but Beachy will make his return from Tommy John surgery tonight. The Atlanta Journal-Constitution reports that Beachy will be capped at around 100 pitches per Braves manager Fredi Gonzalez, a number in line with his progression of increasing pitches across his rehab assignment. Expectations need to be tempered just as they would be for anyone returning from this kind of surgery, as velocity often returns more quickly and more consistently than command. It may take Beachy a bit to get comfortable again at the major league level, and he will likely be in a very good place by the second half of next season. For now, he is still a work in progress as his first few outings should really be considered the final phase of his rehab.
Every Monday, in this space, we'll provide updates on a variety of players to help you make your weekly lineup decisions. We'll specifically try to hit the players who are day-to-day, have just gone on the DL or are ready to return, so that you can better decide whether you can count on them or not.
All projected return timelines should be considered fluid.
Bryce Harper, OF, Washington Nationals (placed on DL retroactive to May 27, expected to return Monday): Last week there was some disagreement between Harper and manager Davey Johnson about the right time for Harper to return to the lineup. It now appears they are on the same page. According to the Washington Times, Harper is expected to return Monday night after completing a rehab assignment with Double-A Harrisburg. He originally injured his knee in May crashing into the outfield wall at Dodger Stadium but tried stoically to play through it. Less than two weeks later, it became apparent the knee was not improving and Harper went on the DL. Persistent swelling in the form of bursitis nagged at him until June, when he received two separate injections in the area: cortisone and PRP. Once the pain and inflammation settled, Harper was able to resume baseball activities and now, after increasing that activity to the level of playing in games, he is in line to rejoin his team.
The knee is not perfect and the chance remains that it could become aggravated with a crash, a dive or another move often associated with Harper and his style of play. For now, however, he is just anxious to get back in the lineup, posting the following on his Twitter account Monday: “I'm so blessed and thankful to be back playing the game that I love! Felt like forever.” Fantasy owners no doubt feel the same way.
Evan Longoria, 3B, Tampa Bay Rays (day-to-day): Longoria aggravated plantar fasciitis in his right foot Friday night and sat for the remainder of the weekend. The question for fantasy owners is how long the rest will continue. Manager Joe Maddon said Longoria had improved substantially by Sunday to the point where a DL stint might not be necessary, according to the Tampa Bay Times. In fact, Maddon suggested Longoria might be available to pinch hit Monday if he continued to feel better.
The problem with plantar fasciitis (pain in the fibrous tissue which reinforces the arch of the foot) is that the pain is typically provoked by load-bearing activity, including running. If Longoria does test the foot and the pain escalates, the team may have to re-evaluate the possibility of more extended rest.
Victor Decolongon/Getty Images Carl Crawford's impending return could cause a logjam in the Dodgers' outfield.
Carl Crawford, OF, Los Angeles Dodgers (placed on DL June 2, could return this week): After not hearing much about Crawford’s progress in rehab during the month of June, there’s suddenly a rather dramatic update. Crawford began a rehab assignment over the weekend and is scheduled to add playing time in the field early this week, according to the Los Angeles Times. If all goes well, he could return to the lineup this weekend when the Dodgers face the San Francisco Giants.
The risks remain the same as they are for any player coming off the DL with a significant hamstring strain, something with which the Dodgers are all too familiar. The hope is that Crawford will situationally test the hamstring as much as possible while on his rehab assignment, but that will never match the intensity of a major league contest. It wouldn’t be the worst thing for the health of their outfielders if the Dodgers choose to rotate among them all (Crawford, Matt Kemp, Andre Ethier and Yasiel Puig). With Kemp coming off a recent hamstring injury (which appears to be fully recovered) and still trying to regain his form following shoulder surgery, Ethier’s recently sore knee and Puig playing every game as if it might be his last, the addition of Crawford -- who has yet to stay healthy for more than eight weeks over the past two years -- could provide the sort of insurance the Dodgers’ outfield needs. For fantasy owners, however, it will be worth monitoring how the workload is divided up once Crawford is back in the mix.
Mike Trout, OF, Los Angeles Angels (day-to-day): Right now there seems to be little concern on the part of the Angels about the “minor” hamstring issue that kept Trout out of the lineup Sunday. At nearly the halfway point of the season, Trout had yet to miss a game, so perhaps a day of rest was in order, especially if that day keeps him healthy going forward. Trout is expected to play Tuesday after the team’s day off on Monday but, as we have seen with other hamstring ailments around the league, sometimes even a seemingly minor issue can resurface if provoked. Everyone is hoping this will not be the case for Trout.
Everth Cabrera, SS, San Diego Padres (placed on DL June 17, could return this week): When Cabrera was first injured, he sounded like someone who knew it would take more than a few days off to recover. The good news is that he likely he will not miss much beyond the minimum DL time with his strained left hamstring. Cabrera has been making progress with his conventional rehab and, according to the Padres' official website, could head out on a rehab assignment early this week with their Class A affiliate in Fort Wayne, Ind. If he plays without incident there, the Padres could see him back in their lineup as soon as Thursday in Boston or for the weekend series in Washington against the Nationals. Given Cabrera’s value in base stealing and the fact he was injured while attempting a stolen base, he probably would want to test that skill in a game situation before returning to the majors. Not every scenario can be forced, so his return may not hinge on it, but a successful minor league steal would help instill confidence -- both for Cabrera and fantasy owners -- that he will not be hesitant to do so upon return.
Peter Bourjos, OF, Los Angeles Angels (day-to-day, likely to be placed on DL): Bourjos broke a bone “just below his right wrist” and is now expected to miss two to three weeks minimum, according to the Los Angeles Times. The fracture occurred Saturday when he was hit by a pitch in the fourth inning of a game against the Astros. Fortunately for Bourjos, this is a nondisplaced fracture (bony ends remain in alignment), which doesn’t require surgery. Assuming the bone shows good early healing and he is able to grip and swing a bat effectively, his timetable for return is projected at under a month. Bourjos has already spent as much time on the DL this season as he has on the playing field, so the news of another significant injury is particularly discouraging. At least he knows the drill.
Ryan Sweeney, OF, Cubs (placed on DL June 30): Sweeney had been seeing regular playing time since mid-June, filling in for the injured David DeJesus, who is out with a shoulder sprain. Sweeney will now be joining DeJesus on the DL after a crash into the outfield wall Saturday resulted in a left-sided rib fracture. (DeJesus also injured himself when he collided with the outfield wall.) Originally labeled a contusion (deep bruise), the injury turned out to be more severe upon further examination. The broken bone will require four to six weeks to heal and Sweeney’s activity will be determined both by that healing process and his discomfort. It now looks as if recently called up Brian Bogusevic will see regular playing time until DeJesus returns (not expected until late July). Note to Bogusevic: Avoid the outfield walls.
Melky Cabrera, OF, Blue Jays (placed on DL June 28): It was a bit surprising to see Cabrera placed on the DL Thursday when there hadn’t been much chatter about a problem. Apparently a midweek tweak of his knee during a game against the Rays had Cabrera laboring a bit with his movement, according to manager John Gibbons, prompting the DL designation. The injury was originally reported to have been tendinitis in his left knee, and the diagnosis was supported by a subsequent MRI, according to Sportsnet. The diagnosis remains unspecific given it is not clear which tendon is aggravated, but it sounds as if the Jays expect he could return when eligible.
Jedd Gyorko, 2B, San Diego Padres (placed on DL June 10, could return this week): Gyorko was expected back last week assuming his two scheduled rehab games went as planned. They did not. He felt his right groin tighten up while running hard during a rehab game Wednesday and exited early as a precaution. As of Saturday, Gyorko reported feeling improvement, according to the Padres’ official website, but he remains without a definitive timetable for return. If anything, the experience of the setback, however minor it was deemed to be, reinforced the need to test Gyorko’s response to baserunning. Before he returns, it would seem likely the team would send him on a rehab assignment to test the area not only in-game, but to see how he responds the following day. A specific plan has not been outlined as of yet, but fantasy owners should not expect him before late in the week.
Chris Humphreys/USA TODAY Sports Troy Tulowitzki likely won't be back for the All-Star Game, but he could return not long after.
Troy Tulowitzki, SS, Rockies (placed on DL June 13): Tulowitzki has just recently passed the 15-day mark of his DL placement but he will be staying put for a while longer. Still, his progress thus far has been encouraging. Tulowitzki has resumed some light baseball activities, including fielding, playing catch and, as the Denver Post reported, hitting off a tee as of Saturday. He’s still on the projected four-to-six week time frame and he’s not entirely pain-free, but his ramped-up work is a good sign. Assuming the healing of the rib itself cooperates, Tulowitzki could get clearance to further advance his activity in the coming days.
Corey Hart, 1B, Milwaukee Brewers (opened season on DL, now done for the season): Just when it seemed the news for Hart couldn’t get any worse, somehow it did. Hart, who has struggled to return from offseason surgery on his right knee, will now undergo surgery on his left knee, ensuring his absence for the remainder of the 2013 season. It was only last week that Hart revealed his frustration to the Milwaukee Journal-Sentinel at a constantly changing return date and his continued lack of strength. Return following any procedure involving cartilage resurfacing can vary widely depending on the individual’s healing response and whether any setbacks are encountered along the way. Hart had several setbacks with his right knee, but his biggest comes in the form of an entirely different blow. On the other hand, the forced scaling back of the rehab for his right knee while he undergoes surgery on the left may end up having a beneficial effect. He will have to ramp up his activity gradually to accommodate the left knee and the adjusted program may be just what his right knee needs to fully recover. Another surgery is not the news any athlete wants to hear, but it was beginning to look worrisome as to whether Hart would be able to make it back this year anyway. At least this way he has the opportunity for a fresh start in 2014.
Johnny Cueto, SP, Cincinnati Reds (placed on DL June 29): This is now the third time that Cueto has been bothered enough by a lat strain to be forced out of the rotation. Cueto went on the DL in mid-April, then returned a month later and looked sharp. But shortly thereafter he aggravated the area behind his shoulder and was sidelined for another 15 days. Now, after less than two weeks of being back in the mix, Cueto has again suffered a setback. The repeat nature of this has to raise concerns for his ability to truly get past the injury in-season. After a diagnostic ultrasound confirmed the injury is to the same spot within the same (latissimus dorsi) muscle, the team’s plan is to completely shut down his throwing for several weeks and slow down his rehab process, according to the Cincinnati Enquirer. It’s hard to argue with the plan when the problem has been as recurrent in nature as it has for Cueto. The Reds have to be hoping that the third time’s the charm in terms of keeping Cueto off the DL, but as Reds athletic trainer Paul Lessard told the Enquirer, “It’s probably going to be an issue the rest of the season.”
David Price, SP, Tampa Bay Rays (placed on DL May 16, expected to return Tuesday): From start to finish, this injury episode has been a bit unusual. It started with the vague diagnosis of “triceps tightness” for Price which manager Joe Maddon initially projected would cost him merely two to three starts. A month later, Price is just approaching a return from the DL. His rehab has progressed fairly cautiously, but Price has not been beset by setbacks. Still, the team was careful not to place any expectations on his return date and offered very little in the way of specifics about Price’s injury. Muscular tightness is generally not the cause of a 45-day absence. The concern is that this incidence reflects a greater underlying issue with Price’s throwing shoulder. But his fairly linear recovery and strong performance in rehab outings provides some reassurance that he is indeed returning healthy. Only if Price lasts the remainder of the season without any recurrence of symptoms, however, will we be able to breathe a sigh of relief about his health. Until then this is an exercise in cautious optimism.
J. Meric/Getty Images David Price's absence was a lot longer than many had expected.
Anibal Sanchez, SP, Detroit Tigers (placed on DL June 16, could return this week): The plan was for Sanchez to make a rehab start Monday to assess his readiness to return. If all went well, it was conceivable he could be activated by the weekend. Unfortunately, Sanchez took a line drive to his left leg during this rehab outing and had to exit the game. According to James R. Chipman of Scout.com, Sanchez appeared to be in a fair amount of pain. There is no word yet as to the seriousness of this injury. The issue here with regards to Sanchez's shoulder is not necessarily the severity of this episode per se, but rather the lengthy history of shoulder problems that Sanchez has dealt with across his career. His near return is encouraging but it remains to be seen whether this was a minor bump in the road or a signal that his shoulder is fatiguing.
A.J. Burnett, SP, Pittsburgh Pirates (placed on DL June 9): Burnett has been working his way back from a Grade 1 calf strain and has resumed throwing downhill. After a successful couple of bullpen sessions, Burnett is expected to throw a simulated game Tuesday according to the Pittsburgh Tribune-Review. Burnett’s challenges following this injury have as much (if not more) to do with running to cover first base and fielding as anything with his push leg. Even if his throwing sessions are uneventful, until he tests those activities, it will be difficult to gauge his readiness to return. A rehab assignment could be in his near future which will provide the situational play necessary to test the calf. If all goes well, Burnett could be eyeing a return within the next couple weeks, although the Pirates have not specified a timetable.
AP Photo/Michael Dwyer Fantasy owners are definitely missing Clay Buchholz, who's 9-0 with a 1.71 ERA.
Clay Buchholz, SP, Boston Red Sox (placed on DL retroactive to June 9): An MRI on Buchholz’s shoulder reportedly revealed inflammation in the bursa sac of his right shoulder, or simply, bursitis. While the diagnosis is relatively benign, it doesn’t fully explain the neck pain Buchholz has been experiencing recently. Buchholz’s issues began in the shoulder in late May, but recently his complaints have been closer to the neck and he was reported to be dealing with a trapezius strain (large muscle between the neck and the shoulder). Whether that area was symptomatic as a result of origination of a problem elsewhere is the ultimate question the Red Sox need to answer. Perhaps Buchholz’s response to the next round of treatment will do just that. The bottom line in terms of activity is that the plan for Buchholz is to gradually resume his throwing program. Again. This latest effort started with a session of catch before last Saturday’s game and will likely progress, as previously, based on what his level of comfort allows. In other words, it’s a matter of wait and see. Again.
Josh Beckett, SP, Los Angeles Dodgers (placed on DL May 14, now expected to miss remainder of season): Beckett has barely been present for the Dodgers this season and the appearances he did make were forgettable. His season has been marred by injury -- predominantly connected to numbness in his throwing hand -- and he is now heading to surgery for thoracic outlet syndrome (compression of nerve and/or blood vessels between the neck and shoulder, generally by a rib which is then resected in surgery). This is similar to the surgery St. Louis Cardinals ace Chris Carpenter underwent, and we have witnessed his ups and downs in trying to return to pitching. It is no easy rehab process and Beckett has expressed concern at various points about what his future holds. For now the only certainty is that he is not expected back on the mound for the Dodgers this year.
Brandon Beachy, SP, Atlanta Braves (opened season on DL): Just as Beachy appeared to be on the verge of making his season debut following Tommy John surgery, he suffered a setback in mid-June which threw him off his timeline. Fortunately, an MRI revealed only inflammation but no significant structural damage in the area of his recently reconstructed ligament. After a week of rest, Beachy gradually resumed throwing and has again worked his way back to throwing off a mound. His recent bullpen sessions have gone smoothly and the next step appears to be re-engaging in a rehab assignment. Given that his setback happened after what was to be his final rehab outing, it’s likely the team will want him to make several rehab starts before bringing him to the big league setting. So far, so good given how things looked just two weeks ago, but fantasy owners should not expect him to join the Braves for a while yet. Even then it may take him awhile to accumulate substantial innings.
Joakim Soria, RP, Texas Rangers (opened season on DL): It is really nice to see Soria doing so well in his road back from Tommy John surgery, especially since this is his second time undergoing the procedure. He has yet to appear in back-to-back games, likely the final step before re-emerging in the majors. Bear in mind that Soria has been out for over a year and he may be gradually integrated into relief work once he joins the team. Still, it’s nice to have a feel-good story on the injury front, especially after a player has been down such a long recovery road twice.
All projected return timelines should be considered fluid.
It certainly seems that is the case now. Teixeira was removed from Saturday's game in the fourth inning, not so much because of a specific incident that aggravated the injury, but because of continuing discomfort and weakness. According to ESPN New York, an MRI on Sunday revealed inflammation in the area, but no new tear. Teixeira received a cortisone shot and will sit out for a few days. No move to the disabled list is specifically planned, though it has not been ruled out.
The bigger issue for the Yankees is what they can expect from Teixeira going forward. Manager Joe Girardi's comments from Saturday evening were very telling. "He came to us and said he just feels like there's not a lot of strength there," Girardi said. "I think he just doesn't feel he has the whip that he normally has hitting left-handed." Since the injury is to Teixeira's right wrist, the strain on the injured sheath is greatest when he bats from the left side of the plate, which is also how he hurt himself in the first place. If his strength is impaired and the wrist remains irritated months after sustaining the original injury, not to mention after having nearly two full months off, it's hard to envision it improving significantly now. It's possible the "S" word (surgery) could start to enter the conversation.
After getting hurt Sunday while trying to steal yet another base, Cabrera has been scheduled for further evaluation of his left hamstring. Although the results have not yet been reported, Cabrera had the sound of someone who knew from prior experience that this was not good. According to the Padres' official website, Cabrera said, "I knew something was wrong right away. I have experience with hamstring problems, and this one is unfortunate." Fantasy owners should be prepared for a DL stint.
According to the Washington Post, manager Davey Johnson said he expects Harper to test the knee with some on-field activities early in the week, then potentially begin a rehab assignment later in the week. Of course, everything depends on how Harper's knee responds to the uptick in work. If all goes well, it sounds like the Nationals could be eyeing a return in the not-too-distant future, but considering Harper's path has been a little bumpy so far, no timetable can be set in stone.
Kemp looked as if he was inching closer to rejoining his teammates when he did some pregame running work with them last weekend. He was still experiencing symptoms, however, which led to the Dodgers pushing back more aggressive activity. A rehab assignment date remains fluid, although it could begin late this week if Kemp is showing signs of progress.
There is little doubt that Kemp's major setback to his opposite hamstring after trying to return too soon last year is likely causing some apprehension this time around. And his performance at the plate certainly hasn't been encouraging. Fantasy owners should not plan on having Kemp available this week, and even if next week starts to look like a possibility, it might be worth waiting to see how he performs first.
It sounds as if the Brewers expect him to resume playing in the presence of the symptoms, even if they remain unresolved when the DL window is up. The only problem there is that even if they don't expect the injury to worsen, there's no guarantee his power at the plate will return, at least on a consistent basis. Braun acknowledged that the thumb was bothering him enough to affect his performance, even after trying to make adjustments to his grip. It sounds as if Braun might return when eligible, but whether he's the Braun fantasy owners have come to expect is anybody's guess.
When it was discovered that Hill had a non-union fracture in his hand, the plan became to try to progress his activity to see how well he could function despite the condition and any associated discomfort. So far, so good. Good enough, in fact, for the Diamondbacks to allow Hill to progress from a simulated game to a rehab assignment with Triple-A Reno. Hill played seven innings Saturday for Reno and will be in line for more innings early this week. It is not clear how many rehab games he will require before he's ready to return to his team, but there finally appears to be hope that it could come soon.
Fantasy owners should keep in mind that he will not be 100 percent recovered from the injury, although he might be able to function at or close to his normal level. There is the possibility the hand could become painful again at any time, and Hill may still require an offseason procedure. For now, however, it just comes down to whether he can do enough to contribute to the team. It sounds like we shall soon see.
Utley's strain was originally diagnosed as a Grade 1 (mild) type, but the Phillies have been understandably cautious, not wanting him to exacerbate the injury and have it turn into something more severe. If he returns this weekend, it will mark just about a month since the injury or just under the average length of DL stay for an oblique strain. Given that his injury was minor, there is a good chance that it will be completely behind him when he does make his return.
Given the number of pitchers who are entering 2013 coming off injuries to their throwing arms, we decided to craft a quick status update list on some of the more intriguing names as the season gets underway. Given that some of these players still have a ways to go in their recovery, consider the timeline fluid and subject to change. For the purposes of ascertaining where these players stand coming out of spring training however, this is our guide.
With elbow surgery becoming virtually commonplace in pitchers, we almost take for granted that they will return to their prior level of performance. But the complexity of the surgery and the variables which can impact recovery affect each athlete differently and should not be overlooked. For more detail on the process of ulnar collateral ligament reconstruction, commonly referred to as Tommy John (TJ) surgery, please see below.
Brandon Beachy, RHP, Atlanta Braves: TJ surgery, June 21, 2012. Has thrown several bullpens this spring without incident; will continue on throwing progression with targeted return in June/July.
Chad Billingsley, RHP, Los Angeles Dodgers: elbow inflammation and sprained UCL in 2012. Underwent PRP injections in fall and threw eight bullpens in offseason without incident, saying his elbow felt "normal" entering the spring; this spring he has sustained a groin ailment and a bruised index finger; Billingsley is still hopeful to start the season on time or close to it, but the recent history of a partial UCL tear warrants caution.
Jaime Garcia, LHP, St. Louis Cardinals: rotator cuff tear (small), no surgery, injured June 2012. Garcia opted for rehab over surgery and so far it seems to be working out for him; his shoulder has not given him any trouble this spring and he is expected to be ready to start the season as a part of the Cards rotation. The concern is whether his shoulder will hold up to a full season of pitching demands.
Daniel Hudson, RHP, Arizona Diamondbacks: TJ surgery, July 9, 2012. Has been making steady progress and threw his first bullpen the last week of March; targeting a return around the All-Star Break.
C.J. Wilson, LHP, Los Angeles Angels: surgery to address bone spur, Oct. 23, 2012. Has had no issues with the elbow this spring, although his performance has not been up to par; the latter should improve and his overall durability record should be an encouraging sign going forward.
Colby Lewis, RHP, Texas Rangers: flexor tendon repair, July 27, 2012. Progress has been steady and, after throwing bullpen sessions this spring, he is hoping to progress to live batting practice in early April; so far he remains on track for a late May/early June return. If he continues to progress this well, there could be a nice second half of the season in store.
Michael Pineda, RHP, New York Yankees: labral repair, May 1, 2012. Began throwing from a mound in February and added some breaking pitches in March; he won't be ready to return until around the middle of the season but he seems to be committed to the rehab and to being in better shape in general (reportedly having dropped about 20 pounds by this spring); it remains to be seen whether he can rediscover his dominant style but he's young enough that there's a reason to believe he can.
Ted Lilly, LHP, Los Angeles Dodgers: labral repair, Sep. 21, 2012. Lilly has been remarkably durable but all good things must come to an end; his shoulder issues required surgery and at age 37 it's hard to know just how he'll bounce back; his spring outings have been limited by flu complications and he'll likely start the season on the DL with a chance to continue to progress his arm; hard to count on when his status appears uncertain.
Scott Baker, RHP, Chicago Cubs: TJ surgery April 17, 2012. Made spring debut in mid-March but inflammation afterward resulted in a shutdown for at least a month; will have to gradually resume throwing and continue to build strength. No firm timetable but could miss first couple months of season.
John Danks, LHP, Chicago White Sox: shoulder surgery Aug. 6, 2012. The surgery was for debridement of biceps tendon and rotator cuff and to repair a small capsular tear. Danks threw bullpens and live batting practice sessions this spring without incident but, as is often the case, struggled in game outings, particularly with velocity. Will open the season on the DL and it's unclear just how long he'll stay there.
John Lackey, RHP, Boston Red Sox: TJ surgery Nov. 1, 2011. If there's an upside to tearing your ulnar collateral ligament late in the year it's that you benefit from the season schedule to gain extra recovery time; Lackey is now almost 17 months post-surgery so recovery is not an issue, but he'll still need to regain the feel of competitive throwing; results may be inconsistent initially but he should be able to get through a full season.
Cory Luebke, LHP, San Diego Padres: TJ surgery and flexor tendon repair, May 23, 2012. Experienced some pain in his reconstructed elbow this spring, forcing a temporary shutdown. This is not unusual but it reinforces the notion that these recoveries cannot be rushed; his timetable suggests a return around midseason but that could always fluctuate, as could his performance in the early stages.
Casey Janssen, RHP, Toronto Blue Jays: AC joint surgery Nov. 16, 2012. Progressed slowly this spring but has recently gained ground and appears ready for Opening Day; his overall workload has been light so will need to see how he responds in season, but the Jays have help if he needs an occasional day off.
Ryan Madson, RHP, Los Angeles Angels: TJ surgery, April 2012. Experienced some soreness this spring and had to be scaled back; will open the season on the DL but may not stay there long. Now that the arm is feeling better, he still needs to build some endurance and currently looks on track to return at some point in April.
Sergio Santos, RHP, Toronto Blue Jays: labral debridement surgery, July 24, 2012. Expected to be ready for Opening Day. Other than some minor triceps soreness this spring, has had a smooth progression back to the mound; Janssen is expected to function as the Jays' closer but Santos could get opportunities if Janssen is initially unable to tolerate a full workload.
Joakim Soria, RHP, Texas Rangers: TJ surgery April 2, 2012. This is Soria's second TJ surgery, making the road to recovery less certain, but so far the process has been smooth. He began throwing long toss in early October and from a mound in February, added breaking pitches in March and appears headed for a late May/early June return.
Tommy John Surgery: An updated primer
Ulnar Collateral Ligament (UCL) Reconstruction was originally performed by Dr. Frank Jobe in 1974 and is now known by the name of Jobe's first subject, pitcher Tommy John. It has become such a part of the baseball vernacular that it's a common topic of discussion amongst even casual fans. That doesn't mean there isn't more to learn about optimizing the surgical techniques or the rehab process to help ensure success or, more importantly, how to ultimately prevent or even reduce the incidence of these injuries.
The basics: The UCL is not a simple ligament. It is comprised of three bands which blend together to reinforce the medial (inner) elbow joint and runs from the medial epicondyle of the humerus (a bony prominence on the arm bone) to the medial forearm bone (ulna). Not all tears are created equal. In fact, it is rarely the case where the ligament is completely blown out. A partial tear in a critical location however can make it virtually impossible to throw because of pain, loss of control, or both. This is one of the reasons an MRI does not tell the entire picture; clinical examination will substantiate any instability in the elbow and the athlete needs to have symptoms of a magnitude sufficient to warrant surgery. This is not a procedure one enters into lightly given the intensive recovery time. One of the reasons a trial of conservative therapy is typically the first option when there is a suspected UCL tear (beyond the obvious scenario where the athlete's injury was mild and he recovers enough to return to play), is to validate for all involved the need for surgical repair.
The procedure: Typically a tendon is harvested from the forearm (most common) to serve as the replacement ligament. The tendon of choice (palmaris longus) is not present in everyone (hence the reason removing it will not hinder the athlete's function) in which case the option becomes a hamstring tendon. The surgeon drills holes in the bone (tunnels) where the new "ligament" will be implanted. In a fancy method of looping the ligament through the tunnels and tying it together, along with repairing the remaining components of the original ligament for reinforcement, the reconstruction is performed. One tricky element involves the location of the ulnar nerve in the forearm. This nerve runs adjacent to the ligament and supplies the fourth and fifth fingers in the hand. In other words, if the nerve becomes compromised, the athlete could lose feeling and muscular function in that area. (Ulnar neuritis, inflammation of the nerve, is not an uncommon ailment amongst pitchers simply due to the stress on the nerve from pitching.) Surgeons take great care to protect the nerve during surgery and in some cases will actually transpose (move the location of) the nerve to another spot on the forearm. Even when care is taken, complications related to the nerve are a risk factor with this surgery.
The unknowns: It is unclear just how much an athlete should throw in his first season returning from this procedure. Look no further than the case of Stephen Strasburg in 2012 to find arguments on either side of the Nationals' decision to shut him down early. The fact is there is no definitive research at present to outline a specific number of pitches to target or other such criteria for the first year post-surgery. There is some consensus amongst the medical community that the reconstructed ligament is stronger in the second year following the procedure.
Return to prior level of function, especially at the professional level, is remarkably high. Life expectancy of the reconstructed ligament, however, is unknown and may depend on a number of factors including severity of the injury and whether any of the athlete's original ligament remained intact. In recent years there has been an increase in athletes undergoing a second UCL reconstruction but the numbers are still small making meaningful analysis challenging. Based on preliminary research, it appears the success rate (defined as return to prior level of function) following a second procedure is significantly lower. It also appears that pitchers returning to a relief role fare better than those attempting to return as starters.
The prospect of facing Tommy John surgery is not viewed as career-threatening as it once was but it is still a daunting process. Although many athletes return to their prior level of function, it is not an easy path. Non-pitchers can return at a slightly faster rate, although outfielders may require additional time to make the biggest throws (outfield to home without a cutoff). For pitchers, even after they return to action, there is a high degree of variability as to when they actually return to form. As many similarities as there are among surgical techniques and rehabilitation programs, there are just as many individual variables which make each athlete's recovery unique. Prior injury history, overall tissue health, specific biomechanical demands of the athlete, follow-through with rehab and the surgical procedure itself can all impact the pace and the degree of recovery. In the end, outcomes are largely favorable but nothing should be taken for granted.
With the regular season just about to start, here's a list of notable injury situations and their timetable for a return. Fantasy owners can and should adjust their lineups or draft strategies accordingly.
1. All projections reflect expectations as of March 29 and should be considered fluid after that date.
2. Opening Day ready = Expected to be "active" on Opening Day, not necessarily in lineup on Opening Day. For pitchers, first game depends on where slotted in rotation.
Brett Lawrie, 3B, Toronto Blue Jays (due back April): Intercostal strain will sideline him into the first week or two of the season, but a cautious return should help prevent a setback. Bigger concern is tendency to play with reckless abandon. Fun to watch, but may increase risk.
Pablo Sandoval, 3B, San Francisco Giants (Opening Day ready): An irritated ulnar nerve forced Panda to rest for several days in March, but he claims he's ready to return. I admire his enthusiasm but can't say definitively that this is behind him.
Chase Headley, 3B, San Diego Padres (due back late April): Left thumb fracture will delay Headley's regular-season debut by about a month. The good news is that it shouldn't hinder him after he returns.
Curtis Granderson, OF, New York Yankees (due back mid-May): No surgery needed for Granderson's small fracture. No reason to worry about his ability to produce once he returns to the lineup.
Hanley Ramirez, SS/3B, Los Angeles Dodgers (due back mid- to late-May): Ramirez will miss a couple months of playing time following surgery to repair his torn thumb ligament. The concern is that his performance at the plate could suffer a bit longer.
David Freese, 3B, St. Louis Cardinals (due back April): His back injury doesn't appear serious, but the Cardinals want Freese to see more at-bats before his regular-season debut. Recurrence is possible, but the minor nature of this episode keeps the worry factor low.
Derek Jeter, SS, New York Yankees (due back April): Jeter's post-surgery soreness is not unusual. In fact, it will likely take a few months for his ankle to feel normal again. He may return in April but he may not really return until June.
Mark Teixeira, 1B, New York Yankees (due back May/June): A partially torn tendon sheath is what Jose Bautista had ... and then he had surgery. Teixeira's wrist may heal with rest, but if it doesn't, the power on the left side of the plate won't be there and he may not last long, either.
Corey Hart, 1B/OF, Milwaukee Brewers (due back May): The key to Hart's post-surgical knee staying healthy is not returning too soon. The team has been good about controlling his activity thus far, so don't expect them to rush him now. Late May is the most likely scenario.
Brian McCann, C, Atlanta Braves (due back April/May): He's recently returned to hitting, but restrictions on McCann's post-labral repaired throwing shoulder remain in place. Once he returns, it may take a bit to ramp up, but look for a strong second half.
Alex Rodriguez, 3B, New York Yankees (due back around All-Star Break): If he's rehabbing as diligently as he says, Rodriguez should be poised for an uneventful return. The hip may be healthy, but he's still an aging player with mounting injury concerns.
For a more thorough progress report of pitchers returning from injury or surgery, see this blog entry.
Jaime Garcia, St. Louis Cardinals (Opening Day ready): He opted for rehab instead of surgery for a small (left) rotator cuff tear and has been fine through a handful of spring outings. Starting season strong, but will he last?
Roy Halladay, Philadelphia Phillies (Opening Day ready): Halladay insists there's no injury, but his performance this spring is a concern. Last year he said there was no injury, either. Then he went on the DL and missed nearly two months. This could be the start of the talented veteran's decline.
C.J. Wilson, Los Angeles Angels (Opening Day ready): Underwent arthroscopic surgery in October to address a bone spur and has had no issues with the elbow this spring. Consider this: He's had only two DL stints in his big league career. Aging but durable. Low level of concern.
Phil Hughes, New York Yankees (due back early April): A bulging disc in his back derailed Hughes' spring. He has bounced back quickly, but let's face it, injuries are always going to be a concern with Hughes.
Matt Garza, Chicago Cubs (due back May): Ended last season with stress fracture in right elbow, started this spring with strained lat. Sum total of injuries raises concern.
Shaun Marcum, New York Mets (Opening Day uncertain): Elbow issues last year, now shoulder and neck this spring. Don't like where this is headed. Even if he avoids the DL now, it may only be a matter of time.
Brandon Beachy, Atlanta Braves (due back June/July): On track post-Tommy John surgery. No major concerns, just temper expectations to the typical ups and downs of the first year back.
Relief PitchersJason Motte, St. Louis Cardinals (no timetable, expected to start season on DL): Diagnosed with a "small" tear in his flexor tendon, Motte is reportedly feeling better. He will have to prove he can throw without pain before returning, then hope the injury doesn't worsen across the season.
Ryan Madson, Los Angeles Angels (due back April): After Tommy John surgery last April, Madson is closing in on a return. But the normal inconsistencies that a pitcher first displays after this operation -- and a guy named Ernesto Frieri -- suggest Madson isn't a lock to close.
Casey Janssen, Toronto Blue Jays (Opening Day ready): After November surgery on his AC joint, a slow spring initially threatened Janssen's Opening Day status. He's recently turned a corner but there's still a bit of concern about how an uptick in work (think: frequency) will affect him.
Groin Surgery for TulowitzkiColorado Rockies shortstop Troy Tulowitzki underwent surgery in Philadelphia Thursday with Dr. William Meyers to address an injury in the left groin region. The injury has been described as baseball pitcher/hockey goalie syndrome, one of the many variants of a cluster of injuries that fall under the header "athletic pubalgia." The word "athletic" is easy enough to understand. "Pubalgia" refers to pain in the pelvic region, specifically injuries involving the abdominal and pelvic musculature in the front of the pelvis that are not part of the ball-and-socket hip joint. Injuries in this area have commonly been termed "sports hernias" in the past, but the medical experts who treat these conditions seek to do away with the term. The sports hernia is not a true hernia at all, nor is it one single injury but rather myriad syndromes that require careful evaluation and individualized treatment. The more descriptive term "core muscle injuries" is preferred by experts such as Meyers to describe these ailments, instead of the less accurate "sports hernia" or more difficult to pronounce "athletic pubalgia."
Tulowitzki's recovery has been projected at about six to eight weeks. The rehab is not particularly different from that of a significant muscle strain. Controlled activity in the early stages with a focus on mobility is followed by gradually increasing intensity of workouts and an eventual return to baseball-specific activities. The key is achieving a balance of flexibility and strength throughout the entire core system and the lower extremity muscles. Tulowitzki's history of a torn quadriceps in 2008 is not insignificant here, as it may have led to compensations that contributed to this injury. The hope is that the surgery will provide some immediate relief, but maintaining core stability and flexibility going forward will be key to keeping Tulowitzki on the field.
Tommy John Surgery for Beachy
Brandon Beachy's partial ulnar collateral ligament tear turned into a full-blown ligament reconstruction surgery Thursday. Beachy underwent Tommy John surgery with Dr. James Andrews after consulting with the renowned orthopedist just the day before. The swift move to surgery suggests there was little doubt that the confluence of findings made surgery the only option for Beachy. After all, the 25-year-old had been performing well for the Braves this year, with a 5-5 record and a major-league-leading 2.00 ERA. An abrupt halt to a strong season is rarely recommended unless the evidence points clearly in that direction.
We often hear of pitchers with partial tears opting for a rehab-first course of treatment, which typically involves a period of rest followed by a gradual return to a throwing program. Sometimes the pitcher is able to return to competitive pitching (e.g., Adam Wainwright, who had a partial tear in 2004 during his minor league days and not only returned to pitching but moved up to the majors for five years before his elbow finally gave out in 2011, requiring Tommy John surgery). Other times the ligament fails during the rehab course and surgery is then required (e.g., Jamie Moyer, who, after injuring his elbow in 2010, attempted to return until his elbow gave out completely during an outing in Dominican winter ball). Either way, the opportunity to attempt a course of rehabilitation helps ensure that should the time come for the pitcher to undergo reconstructive surgery, he is convinced there are no other alternatives and is committed to the lengthy recovery process.
Sometimes, however, the circumstances are such that the need for surgery is immediately apparent. Contributing factors may include imaging suggestive of a substantial ligamentous tear, perhaps in a critical portion of the ligament or accompanied by other tissue damage in the area, a clinical exam (series of movements and tests the surgeon puts the athlete through designed to reproduce pain and/or instability) that confirms the injury, the athlete's history (such as underlying discomfort or difficulty throwing for a period of time prior to the actual injury episode) and his current ability to function in the presence of the injury. Any or all of these variables can point to surgery as the best option for an athlete, even in the presence of a tear classified as partial.
The good news for Beachy (there's always good news) is that youth is on his side and surgery now allows for the possibility of a return next year. Allowing for a timetable of approximately one year, Beachy could potentially be a second-half contributor in 2013.
As hard as it is to go through the process of Tommy John surgery and the subsequent lengthy recovery, imagine going through it twice. This year there have been a few notable pitchers who have undergone a second such procedure, including closers Joakim Soria and Brian Wilson. The outcome on second procedures is not nearly as encouraging as the outcome following an initial surgery, and starters seem to not fare as well as closers. On the bright side, Drabek is still just 24 years old, and youth is always a bonus when it comes to a long, intensive rehab. He also has a teammate, Jason Frasor, who has undergone Tommy John surgery twice and successfully returned to pitching. Frasor's second surgery was 10 years ago and he has done well since then, but -- and it's a significant "but," given the recent statistics -- Frasor has the advantage of being a relief pitcher. Maybe Drabek should chat with Dodgers pitcher Chris Capuano, one of the few starting pitchers who has successfully returned to the same workload following a second Tommy John surgery.
Meanwhile, Brandon Morrow, who we discussed last week when he went on the DL for an oblique strain, is still in the early phase of his rehabilitation efforts (typically about a month for pitchers). Drew Hutchison is out with an elbow strain, but it does not appear to be on par with Drabek's. Still, Hutchison is scheduled to consult with Dr. Tim Kremchek in Cincinnati for further evaluation.
The Jays have to be holding out hope that this sudden injury streak has truly come to an end.
Beachy's bad elbow
Atlanta Braves pitcher Brandon Beachy has a partial tear of his ulnar collateral ligament; this much we know. What is not yet known is what the next step is as far as treatment. Beachy, who currently leads the league with a 2.00 ERA, is scheduled to consult with both the Braves' team physician and Dr. James Andrews, after which those steps should be outlined.
The choices would seem to be either an attempted rehab course to see if Beachy can return to throwing, or reconstructive surgery. A partial tear does not automatically dictate surgery; the location and the degree of the tear can influence the ability of the tissue to heal. If a pitcher is anything less than convinced that he absolutely requires surgery, a course of rehab may be in order. If that rehab course is unsuccessful, the timetable for recovery has been pushed back only 6-8 weeks, not necessarily significant in the context of an approximate one-year recovery from surgery. That said, the timing within the season can play a role. A year from June allows for a likely return the following year. A year from August makes a return in the subsequent season a little less certain. These variables will undoubtedly be considered as Beachy proceeds through the evaluation process. Beachy is already on the DL, but an update to his status should be forthcoming this week.
Weaver returnsLast Tuesday, I noted the big step Jered Weaver had taken in his recovery as he began throwing from a mound. Only a week later, Weaver is set to return to competition. After progressing from throwing halfway up the mound to throwing from the rubber, Weaver had no complications, and he went on to throw a simulated game and a follow-up bullpen session.
Considering how serious his injury appeared to be when it happened less than a month ago, Weaver's return has been impressive. There are no guarantees that the issue is completely behind him, though, and Weaver appears wise to that fact. According to the Orange County Register, Weaver said, "I'm 6-foot-7 and lanky, and I have a lot of torque going on. I'm sure it's not the last time there's going to be some back issues going on." Apparently Weaver has now made some of his rehab exercises part of his regular routine. Both his recognition of the potential for symptom recurrence and his efforts to protect his back with a maintenance exercise program work in Weaver's favor from a prevention standpoint going forward.
Before Longoria began his assignment, Rays manager Joe Maddon had hinted at a lengthier rehab stint to allow him to get his legs in game shape (and undoubtedly to provide multiple opportunities for him to really test the health of his hamstring). It took only two days for Longoria's hamstring to let him know it wasn't ready. According to the Tampa Bay Times, Longoria felt soreness running to first base and did not want to push the issue. He was removed from the game in the third inning, a wise move that might have protected him from truly aggravating the injury. He is set to rejoin the team Tuesday in Washington, D.C., where he will resume a rehabilitation program. As of now, there is no renewed timetable for his return. It has been said many times in this blog space, but it's worth saying again: Until an athlete returns to competition, there is no way to truly test the readiness of a healing hamstring. Consider this episode a gentle warning for Longoria issued by his hamstring, one that told him not to rush back. It might not be so kind to him the next time.
• Colorado Rockies shortstop Troy Tulowitzki paid a visit to Dr. William Meyers in Philadelphia for further evaluation of his left-sided groin injury. Like Longoria, Tulowitzki had initiated a rehab assignment when he felt pain in the injured area, which prevented him from continuing. Meyers is considered a leading expert in the area of athletic pubalgia, or athletic injuries in the groin and abdominal region which result in pain and loss of function. These injuries are often grouped in the category of sports hernias, which are not true hernias, but rather defects in the abdominal wall that typically require surgery to repair. There are multiple potential causes of chronic groin pain (Tulowitzki's injury dates back to the start of the season), and a full evaluation by Meyers is aimed at getting to the root of the problem. Unfortunately, it sounds as though there are no definitive answers just yet. According to the Denver Post, Tulowitzki summed it up this way: "We're not sure what's wrong." For now, Tulowitzki remains sidelined, and there is no timeline to discuss until more information emerges.
• Minnesota Twins catcher Joe Mauer is day-to-day with a bruised quadriceps, the result of a Rickie Weeks knee to Mauer's thigh in a collision at home plate. Mauer was already dealing with soreness in the hamstring of the same leg, which he was playing through despite not being able to run at full speed. After injuries limited Mauer to just 82 games last year, his 2012 campaign was off to an impressive start. Before injuring his thumb in an at-bat, Mauer had played in 52 of 53 games. The thumb did not require a DL stint, but it did force him to sit four games. Then the sore hamstring came along. He didn't miss a game but served only as a pinch hitter this past Saturday. On Sunday, Mauer returned to his normal spot behind the plate, where he sustained the bruised quad. Mauer looks as though he will again avoid the DL, despite some lingering stiffness and soreness in the thigh. So far, so good.
• The Chicago Cubs have placed pitcher Ryan Dempster on the DL with tightness in the latissimus dorsi muscle on his right (throwing) side. He had been throwing well despite the presence of soreness in his past couple starts. "It's just gotten harder and harder to get loose and maintain," Dempster told reporters. This doesn't sound like a serious strain, such as the one sidelining Phillies ace Roy Halladay, but anything affecting a pitcher's throwing arm raises eyebrows. In Dempster's case, given the potential trade interest surrounding him, the topic becomes even more relevant. The best way to avoid a significant injury is to proactively address a minor ailment, and that seems to be what the Cubs are doing with Dempster. If a brief break from throwing allows the issue to resolve itself, there should not be any significant concern going forward.
Meanwhile, teammate Matt Holliday has a sore hip flexor, per Joe Strauss of the St. Louis Post-Dispatch. Holliday left Sunday's game because of the injury, but this reportedly has been bothering him intermittently for several months, with this being the latest flare-up. While it doesn't appear as though he's headed to the DL just yet, this could affect his availability at least this week. Hip flexor strains can be difficult to completely resolve in-season so this is something that could continue to impact him on an intermittent basis. On a positive note, second baseman/centerfielder Skip Schumaker has been activated from the DL after missing time since late May because of a hamstring injury. The Cardinals' official Twitter site has announced that Schumaker is "uniformed" for Tuesday night's game in Detroit.
• One player who won't be active Tuesday night is Milwaukee Brewers ace Shaun Marcum. He has been scratched from his scheduled Tuesday start due to tightness in his throwing elbow. The Milwaukee Journal-Sentinel reports Marcum is going to be evaluated by Brewers team physician William Raasch, after which next steps will be determined. It is worth noting that Marcum underwent Tommy John surgery on this elbow in 2008.
• And finally, keep an eye on Arizona Diamondbacks shortstop Stephen Drew, who crossed a huge hurdle this past weekend in playing three consecutive rehab games. Drew, who suffered a severe ankle fracture last season, has been battling lingering soreness and stiffness in his surgically repaired ankle, which has prevented him, until now, from playing in back-to-back games. Diamondbacks manager Kirk Gibson has indicated Drew is gradually nearing a return, but as the Diamondbacks' official website reports, it might be in a part-time role. Although he is showing improvement functionally, he has not completely overcome some of the challenges associated with this type of injury, specifically the joint-related soreness that follows activity. "I don't think [when Drew returns] it will be as an everyday guy," Gibson said. "He'll have to be worked in and out of the lineup. We'll watch the whole thing with his recovery. There are going to be limitations if he comes back in the near future." Those limitations may well be the ingredient to getting -- and keeping -- Drew back with the team.