Stephania Bell: Bronson Arroyo

Ichiro Suzuki, Alex Rodriguez progressing nicely

April, 7, 2009
And they're off!

Welcome to the glorious opening week of the 2009 baseball season. Despite the optimism that reigns supreme this time of year in every clubhouse, there is no avoiding the fact that injuries are already part of the equation. In fact, the Angels have to feel like it's the middle of the season considering the number of key players they already have on their DL. Then you have teams such as the Pirates, who started out the season with nobody on the DL.

There is one injury stat worth mentioning before we jump into the specifics. In 2009, there were 69 players on the disabled list to begin the season. While that might sound like a sizable number, consider that just last season, 106 players began the season on the DL. And in 2007, the number was 97. Clearly, the number of injured players at the start of the season has dropped dramatically this year, but what's the significance?

For some insight, I spoke with Stan Conte, a physical therapist and athletic trainer who is the director of medical services for the Los Angeles Dodgers. Conte closely tracks DL stints in an effort to help those who care for ballplayers better appreciate injury trends. Conte says that although looking at the number of players on the DL can be useful, he actually prefers to study total days spent on the DL, particularly as it relates to a diagnosis, because it can help convey the severity of an injury. He did point out, however, that if past history is any indication, low DL numbers at the start of the season suggest that there will be fewer injuries throughout the year.

And that's exactly what fantasy owners want to hear.

Nonetheless, there are some injuries to report already. Here are the main stories we're tracking this week:

Ichiro Suzuki, OF, Mariners: On Friday, we learned that Ichiro had been placed on the 15-day DL because of a bleeding ulcer after experiencing severe fatigue and even light-headedness. Knowing what a workhorse Ichiro is, you figure he had to be feeling pretty poorly to even complain. This announcement came as a bit of a surprise in the baseball community for a couple of reasons: First, it's no secret that Ichiro has a stellar attendance record at work; and second, bleeding ulcers are not a common ailment for baseball players. This has many wondering what exactly caused it and what can be expected in terms of Ichiro's recovery.

The good news is that there is reason to believe Ichiro will indeed be able to come off the DL when eligible April 15. Whether he will greatly depends on his ability to regain his endurance, and there is always the possibility that the DL stint could be extended if Ichiro needs extra time. The Seattle Times is reporting, however, that the Mariners seem encouraged that he'll return on the target date.

As far as the cause, there is no way to say for certain in Ichiro's case, especially without knowing all of his specific health information. What we can say is that there are several potential causes of ulcers in general, including bacterial infection, a group of medications known as NSAIDs (non-steroidal anti-inflammatory drugs) and stress (which is more likely to delay healing or aggravate an ulcer). Increased levels of acid in the stomach can damage the stomach lining and lead to an ulcer. NSAIDs, which include medications commonly available over the counter such as ibuprofen (e.g. Advil, Motrin), naproxen (e.g. Aleve) and even aspirin, have the potential to lead to damage of the stomach lining as well (which is the reason it is always recommended to take these medications with meals).

We have no information to suggest what the source of Ichiro's ulcer was. We do not know whether or not Ichiro was taking any medication, prescription or otherwise, but any time an athlete develops this type of ailment, the question needs to be raised. The consumption of NSAIDs long term is enough of a concern that many professional teams perform blood tests at regular intervals for athletes taking these medications, just to ensure that there are no adverse effects. As far as stress, one could certainly make the case for Ichiro being under a great deal of stress in recent weeks while playing for his home country of Japan in the World Baseball Classic. Not only was the travel schedule demanding, the pressure of trying to repeat as world champions had to be intense. With no opportunity to rest afterward, Ichiro rejoined the Mariners immediately after the Classic, playing in four spring training games before reporting symptoms.

The main consequence of a bleeding ulcer is, well, blood loss. Anemia, a condition where the body lacks adequate healthy red blood cells (which are critical for delivering oxygen to tissues) can result, which explains why patients often feel fatigued, dizzy or short of breath. Treatment involves rest and medication (typically directed at either decreasing or stopping acid production in the stomach, and fighting infection if necessary). The body, which is always manufacturing new blood cells, needs time to make up for any blood loss, minus the stress of activity. Time to recover depends on the extent of anemia.

In Ichiro's case, early reports indicated that the ulcer was no longer bleeding, which is a good sign, and his excellent level of conditioning will no doubt aid in his recovery. Ichiro's activity will be heavily restricted early on and then gradually increased based on follow-up blood test results and how he reports feeling. According to the Times, Ichiro is expected to have a blood test Wednesday morning to assess his progress thus far.

Bronson Arroyo
AP Photo/Gerry BroomeSo far so good regarding Bronson Arroyo's return to the rotation.
Bronson Arroyo, SP, Reds: Well, Arroyo is not starting the season on the DL as some, including me, thought he might. Now the question arises of whether he will be able to avoid it? He is scheduled to pitch Thursday, and how he fares in that outing might provide a big clue.

Arroyo has been dealing for some time now with a condition not usually associated with pitching. He has carpal tunnel syndrome (CTS), which is known to have a high incidence among those who spend hours at their workstation typing and/or mousing, and is also relatively common among musicians. Hmm. Arroyo is also a musician. Could there be a connection? For his part, Arroyo, who plays guitar, said in an Associated Press interview that he has put the instrument aside and is also avoiding writing in an effort to rest his hand.

CTS essentially results from inflammation within the carpal tunnel, a tunnel bound by bones and ligaments on the palmar side of the wrist ("carpal" refers to wrist) through which tendons to the fingers pass along with the median nerve. Inflammation or swelling in a contained space like a tunnel results in pressure on these structures, and the hallmark symptoms come from pressure on the nerve. The median nerve supplies sensation to the thumb, index finger, third finger and part of the fourth finger and palm, so most often people will complain of numbness, tingling or electric shock-like pain in these areas. If there is enough compression of the nerve, the hand will also become weak, obviously problematic when trying to grip a ball or control its spin. Arroyo struggled with his command late in spring training, which could have been related to his hand issues.

At this point, Arroyo claims to be feeling much better after a cortisone shot -- he apparently proved as much to management -- and reportedly is even throwing breaking pitches again in the bullpen. Consequently, he was rewarded with his originally slated Thursday start. The cortisone will certainly help the inflammation in Arroyo's wrist in the short term, but the issue will be how he holds up in the long term. After all, the concern here is not only for Arroyo's hand. Any weakness that affects a pitcher's control might cause him to attempt to compensate by making an adjustment in his mechanics. Even subtle changes can then lead to injuries further up the chain, in the elbow or shoulder for example, and that's potentially even more worrisome in the whole scheme of things. Keep a close eye on Arroyo over the first few weeks of the season.

Alex Rodriguez, 3B, Yankees: How can we not talk about the most talked-about guy in baseball? By now everyone is aware that A-Rod underwent surgery in early March to address a labral tear in his hip. The labral repair was performed, but additional bone work in the joint remains to be done in the offseason. Since the surgery, Rodriguez has been in Vail, Colo., rehabbing diligently, under close supervision and with minimal distraction. Not surprisingly, Rodriguez is doing very well (after all, he is a great athlete and is very physically fit) and could soon move to Tampa for the next phase of his rehab.

Much has been made recently of the suggestion that A-Rod could rejoin the Yankees by late April. Relax, everyone. This is not news. All along, Rodriguez was operating within a timetable that projected his return at anywhere from six to nine weeks. The Yankees originally set their goal as mid-May because they wanted to allow plenty of time for Rodriguez to recover and not force him back too soon, with the risk of then losing him to reinjury.

Whatever the timetable ends up being, it is not so much when Rodriguez rejoins the lineup, but how he performs once he gets there. Remember, he still has a long ways to go. Going to Tampa means A-Rod will initiate baseball activities, which begin with light drills and gradually become more vigorous. He will need to show that he can hit, field and slide. Then there will be minor league games to allow Rodriguez to re-engage in competition. Each step must be successful before he ultimately returns to the Yankees. One day at a time ...

On the mend

How about some good news for a change? Angels pitcher Kelvim Escobar is reportedly doing very well in his progression back to the mound since having surgery to repair a torn labrum in his right (throwing) shoulder. He threw 41 pitches Friday night in San Diego and is expected to make a rehab start for Class A Rancho Cucamonga on Thursday. If all goes well, he likely will make several minor league starts and could rejoin the Angels by late April, according to the Los Angeles Daily News.

Although manager Mike Scioscia remains optimistic that his other two injured starters, John Lackey and Ervin Santana, will return to the team by May 1, there is reason to be more cautious with both. Lackey is experiencing his second round of elbow problems in two years. He started last season on the DL but was able to return without incident. But it's more worrisome when it's the second time around, and on an arm that has thrown as many innings as Lackey's. Lackey is in a contract year, and I expect him to return, but I'm not convinced that the remainder of the season will be as uneventful as last year.

As far as Santana, we already know that he has a sprain of his ulnar collateral (Tommy John) ligament. Sure, he was throwing well until he was shut down because of pain in the elbow, but now we know that the elbow is damaged goods. It's definitely worth noting that there are plenty of pitchers out there throwing with less than fully intact elbows and shoulders. But a lack of structural integrity does not bode well for the long haul, no matter how you slice it. So yes, even if he returns, I'm concerned about Santana's ability to stay healthy throughout the season.

Across town, Dodgers pitcher Jason Schmidt is continuing his efforts to rehabilitate his ailing right (throwing) shoulder. Schmidt remains a work in progress; he is slowly and steadily trying to return, but slow remains the operative word. Consider that his original surgery to repair a torn labrum was way back in 2007. Schmidt tried to return last year, and did get as far as rehab starts for a brief period of time, but couldn't make his way past the 90 percent level, which is not good enough to compete at the major league level.

The big issue for Schmidt is that he has often felt worse in the days after throwing and has not been able to put together consecutive strong outings. Schmidt underwent another arthroscopic surgery this past year to clean up the shoulder, and he's working diligently to get his strength, and confidence, back. He is expected to throw in a simulated game this week, and the outing itself will not be as critical as how Schmidt feels the day after, and the day after that. If he continues the steady progress, though, there is reason to believe that he could eventually find his way back to the rotation. But no one is saying that out loud just yet.

Twins catchers appear to be snakebitten. Joe Mauer is still recovering from his less-than-common sacroiliac inflammation. Although the St. Paul Pioneer Press reports that Mauer says he is feeling better since he started taking the new (unnamed) medication, he has yet to try running, the one thing that really limited him this spring. Call me a bit skeptical, but until he's doing those activities, I'm still concerned. Mauer's replacement while he's on the DL, Mike Redmond, was only halfway through the first game before he suffered a blow -- from a bat. Redmond was hit in the neck by a shard of a broken bat in the fifth inning, which caused him to lose feeling in his arm for a few minutes. Not long afterward, Redmond hurt his right groin while trying to run out a double. Uh-oh. Redmond told the Minneapolis Star-Tribune that he was "a little concerned," and his manager, Ron Gardenhire, has to be more than a little concerned. Meanwhile, backup to the backup, Jose Morales, starts Tuesday night. Stay tuned.

And finally, I'm not worried about Diamondbacks ace Brandon Webb's shoulder stiffness -- yet. If he has a strong outing his next time out, let it go. Meanwhile, teammate Max Scherzer is pitching well and should be ready to go by mid-April when he is eligible to be activated from the DL. John Smoltz continues to progress toward a June return for the Red Sox. He is coming off major shoulder surgery but has met every target so far and feels good about where he is. I find it fascinating that one of his closest friends is Tiger Woods. Same competitive fire. Same determination. Pretty soon, we can probably say "same amazing comeback."

Don't worry about Hanley Ramirez's injuries

April, 5, 2009

NL East

Florida Marlins: Hanley Ramirez

Last year Ramirez made this list because there were concerns about his left (non-throwing) shoulder after offseason surgery to repair a torn labrum. Ramirez held up in 2008, although his productivity languished a bit compared to 2007. This year there are new concerns about his shoulder ... the other one. The Miami Herald reported that Ramirez came to camp much bigger this year after an offseason weight-training and swimming program. He then developed some right-side rotator cuff tendinitis which caused him to sit out a few games. Not to worry. By the close of spring training Ramirez was back playing shortstop and hitting homers, even stealing a base or two for good measure. He is 25, so his best years are still ahead of him.

Washington Nationals: Nick Johnson

After missing more than a full year with a slow-to-heal leg injury, Johnson made an emotional comeback in 2008, only to exit in June with a wrist injury. Johnson underwent surgery to address a ligament injury in his right (non-throwing) wrist and spent the remainder of the offseason rehabbing and retooling his swing under the watchful eye of Nationals hitting coach Rick Eckstein. Johnson has shown that his swing is healthy this spring; if his body can hold up its end of the bargain in 2009, the Nationals could be in for a treat.

[+] EnlargeChipper Jones
Scott Rovak/US PresswireJones' owners won't get 160 games, but the games they do get will be quite productive.
Atlanta Braves: Chipper Jones

Like that Energizer Bunny, Jones takes a lickin' and, well, minus a few days off here and there, just keeps on tickin' with remarkable consistency. Sure, he'll get banged up, but as a team leader, he's going to play through as much pain as he can. Last year's nagging quadriceps and hamstring strains finally forced him onto the DL in July, but he still finished the season batting .364. This spring an oblique strain squeezed him out of the World Baseball Classic, but fear not: Despite being 37 years old, he'll be back in the lineup come Opening Day. Yes, he remains an injury risk, but the Braves' willingness to extend his contract indicates their belief that the reward outweighs that risk.

New York Mets: Johan Santana

Some worried that Santana's offseason arthroscopic knee procedure might affect him, but it was a bout of elbow pain that set off alarm bells earlier this spring. A few weeks later, those alarms have all but subsided thanks to Santana's performance in recent outings, along with his declaration that he is symptom-free. The Mets certainly have to hope so. He is set to pitch on Opening Day in Cincinnati and will no doubt be a big draw to the new Citi Field, not to mention a key to the Mets' postseason aspirations. Whenever a pitcher has elbow pain there's reason to be cautious, but in Santana's case it's not time to be overly concerned -- yet.

Philadelphia Phillies: Chase Utley

Much was made of Utley's offseason hip surgery and how far into the 2009 season it would be before he could return. Well, surprise, surprise. Utley has been a model patient, working diligently to exceed his rehab targets while being mindful not to overdo it and create a potential setback. Utley has clearly demonstrated his readiness to return by not only offensively hitting for power this spring, but also defensively by sliding, throwing hard across his body and even diving for balls without hesitation. Manager Charlie Manuel has already proclaimed Utley a member of the Opening Day lineup, and he will continue to be a regular fixture thereafter.

NL Central

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Chicago Cubs: Rich Harden

He is awesome when he plays. But his health history leaves everyone on the edge of their seats wondering when the injury bug is going to strike again. Harden had his highest number of starts in four years in 2008, and his shoulder, which had limited him previously, appeared much improved. It's also worth noting that his outings were carefully managed, and he will continue to be monitored for pitch counts in 2009. So far this spring, the only thing to affect him was an unpleasant round of food poisoning. The Cubs have to be keeping their fingers crossed that this is the worst thing Harden has to deal with this year.

Milwaukee Brewers: Trevor Hoffman

Yes, Hoffman might be older than a couple of his teammates combined. Sure, he's starting the season on the DL with a strained oblique. But don't count this guy out. The all-time saves leader appears to have a relatively minor version of this injury and has already returned to playing catch. As a closer he needs fewer innings to prepare for the season, so he could join the club within the first two weeks. Baseball years do add wear and tear to the arm, however, and oblique injuries can recur. Hoffman will be consistent when present; the Brewers just hope he can be consistently present.

St. Louis Cardinals: Chris Carpenter

Carpenter's past two seasons can be summed up as follows: bone spur removal, Tommy John surgery, nerve problems in shoulder, nerve transposition surgery at the elbow. After more than two years, Carpenter can finally say that he feels good. And it shows. His performance this spring has been both impressive and inspiring. The Cardinals are optimistic, albeit cautiously so, but it does appear that Carpenter is headed for a stellar season.

Houston Astros: Lance Berkman

The Astros' first baseman began experiencing soreness in his left (throwing) shoulder in February. As recently as last week he was having trouble lifting his hand above his shoulder. The team is calling it biceps tendinitis, and Berkman is brushing it off as no big deal. They had better hope it is just a little spring training aggravation and not a sign of something that continues to flare up during the season. After all, those chronic, nagging injuries generally start out as small annoyances. Only time will tell, but there is reason to keep a close watch on Berkman's status; it may become more of an issue if he cannot get back to the field at the season's start.

Cincinnati Reds: Bronson Arroyo

When you hear the diagnosis of "carpal tunnel syndrome" it usually conjures up the image of an overworked software programmer whose hands are going numb from endless hours at the keyboard. But this injury is affecting the Reds in a different way. The electric-shock-like pain in Arroyo's thumb and index finger is keeping him from writing; playing guitar; and, most important for the Reds, pitching well. The plan, along with anti-inflammatories and intermittent rest, is for Arroyo to pitch through this, something he has done in the past. But the level of symptoms he is experiencing, on top of the fact that this is a chronic condition, makes it impossible to guarantee that Arroyo will be able to do so. Don't be surprised if he is forced to endure a stint on the DL early on.

Where should they go? Insider
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Pittsburgh Pirates: Jack Wilson

Wilson was at an all-time low in 2008. He played in his fewest games, largely as a result of injury. After a torn calf muscle and broken right (throwing) index finger derailed most of his season, Wilson wasn't sure he would still be in Pittsburgh this year. But in Pittsburgh he remains, and although he's not going to be a rock star, the hope is that he'll be healthy enough to continue to provide primarily a solid defensive presence. Despite missing a few days with a bruised knee in spring training, he's hoping he'll have his best attendance record in years in 2009.

NL West

Arizona Diamondbacks: Eric Byrnes

Byrnes, formerly known for his speed, had a terrible 2008 when both wheels came off, as in both hamstring muscles were injured. Byrnes opted for a conservative treatment approach (meaning no surgery) and has recently been showing that his legs are healthy this spring. Although Byrnes is not currently slated to be an everyday player for the Diamondbacks, the ability to slot him in anywhere in the outfield makes him valuable off the bench. He still has plenty left in the tank, and is already looking speedier than before he was injured last year. Don't overlook him.

Los Angeles Dodgers: Manny Ramirez

With all the concern apparent in Dodgerland when it initially seemed as if Manny might not be signed in 2009, there had to be similar concern when Manny was sidelined by a hamstring strain almost as soon as he joined the team. No doubt beads of collective sweat began to form in the Dodgers' front office. That concern has been for the most part alleviated as Manny has returned to both hitting and fielding duties. But, you may ask, don't hamstring problems tend to recur? Yes -- more beads of sweat -- but in this case, there are several things working in the Dodgers' favor. First, the injury was a minor strain. Second, because of the timing of the World Baseball Classic, Manny could actually be brought along more slowly, limiting his running early in his recovery, enhancing the healing process. Third, the Dodgers have an all-star medical staff. Relax. Manny can just be Manny.

Colorado Rockies: Troy Tulowitzki

Tulowitzki had a rough 2008 season. First, he was sidelined for weeks with a torn left quadriceps (not his fault). Shortly after his return from that injury, a laceration requiring 16 stitches to his right (throwing) hand kept him out for two additional weeks (his fault -- he slammed his bat, and it broke and bit him back). After an offseason to heal his leg fully and to settle down his frustration with last year's numbers, Tulowitzki should be in good shape for a strong 2009 season.

San Francisco Giants: Noah Lowry

Health issues have challenged Lowry in the last few years, most recently wiping out his entire 2008 season. This has to be disheartening for a young pitcher who showed so much promise when he first joined the bigs. Remembering that first season is perhaps why he continues to plod along through each rehab stint. Lowry, shut down last year with compartment syndrome in his left (throwing) forearm followed by elbow surgery, has already been bothered by shoulder pain this spring. A visit to Dr. James Andrews resulted in an injection into what was otherwise termed a structurally sound shoulder. Lowry is still optimistic that he can provide an option for the Giants later this season, but cumulative arm injuries do not historically bode well for pitchers.

San Diego Padres: Chris Young

Young has Ivy League smarts and toughness. No one could doubt the mental fortitude of this Princeton graduate after he came back to the mound just 10 weeks after taking a pitch to the face. The impact resulted in not only a broken nose, but also a skull fracture. Despite post-surgical sinus and ear infections, a strain in his throwing forearm forced him onto the DL again in August. Given his injuries last year, Young's spring tendinitis and poor outings have some concerned. For his part, Young says that both are typical of his spring performance and that he will warm up as the season approaches. Last year's injuries should have no carryover effect. Young has every reason to be optimistic in 2009.