Stephania Bell: Casey Janssen
As the injury news pours in this season, we'll take a quick-hit look at the fantasy-relevant players who are battling health issues. We'll be splitting them up into players who we're keeping a watchful eye on -- players who have sustained injuries recently but have not been placed on the disabled list -- as well as those who have been placed on the DL.
To the DL
Francisco Cervelli, C, New York Yankees (right hamstring): When a player instinctively grabs the back of his thigh as he pulls up while running, then falls to the ground, there is little doubt as to which muscle is injured. When the injured player does not even attempt to move, but instead sits on the ground waiting for assistance, there is little doubt the injury is severe. Cervelli did both of those things as he crossed first base Sunday, leading anyone watching to anticipate a move to the DL with a hamstring injury, probably for a lengthy period of time. On Tuesday the Yankees placed Cervelli on the 60-day DL with a Grade 2 (moderate) hamstring strain, essentially confirming early suspicions. The recovery time for a Grade 2 strain varies widely depending on the degree and location of the tissue damage. Two to three months to return to full function is not unusual. Cervelli will not be back until June at the earliest.
Juan Lagares, OF, New York Mets (right hamstring): Lagares pulled his hamstring Monday, also while running to first base. He too will require a DL stint but his is of the 15-day variety. That’s not to say he won’t require some additional time beyond the two weeks but he has the opportunity to return if the leg cooperates.
Keep a watchful eye on:
Curtis Granderson, OF, New York Mets (forearm/rib cage/knee): Granderson nearly took out three separate body parts in one play Monday, but X-rays of each proved negative. Still, Granderson was moving gingerly after the game and sat out Tuesday. He is considered day-to-day and could possibly return as soon as Wednesday. He also is considered lucky.
Josh Johnson, SP, San Diego Padres (right forearm): Things just are not getting better for Johnson. He opened the season on the DL with a flexor strain in his throwing elbow and has failed to progress to throwing. On Tuesday, the Padres announced that Johnson will travel to visit Dr. James Andrews (Johnson had Tommy John surgery in 2007 and a subsequent elbow scope this past offseason). According to the San Diego Union-Tribune, when Padres general manager Josh Byrnes was asked if Johnson would pitch this season his reply was an unsettling, "Not sure." And so we wait. Given Johnson’s storied health history, this latest news is anything but encouraging.
Nearing a return:
Jose Reyes, SS, Toronto Blue Jays: Reyes is currently on a rehab assignment after starting the season on the DL with a hamstring strain. Well, he didn’t actually open the season on the DL, but he did have tightness in his hamstring during spring training, then failed to get to first base during his first regular-season at-bat before it acted up. Apparently, things are going well enough now that Reyes could be activated this weekend for the team’s series in Cleveland. Jays manager John Gibbons told reporters if the next couple of days go well for Reyes, he should be "ready to go" Friday. Naturally, Reyes is not out of the woods, given his extensive history of hamstring injuries, but the Jays will be happy to have him back.
Casey Janssen, RP, Toronto Blue Jays: Janssen opened the season on the DL with a low back strain but worked his way back to his first rehab outing Tuesday. After one inning, Janssen suffered no apparent setbacks but the next day is always a telltale indicator. Janssen may need a few rehab appearances but could rejoin the Jays within the week.
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.