Stephania Bell: Joakim Soria

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

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.

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Carl Crawford
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.

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Troy Tulowitzki
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.

Pitchers

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.

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David Price
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.

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Clay Buchholz
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.

Pitchers on the mend

March, 29, 2013
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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.

Starting Pitchers

[+] EnlargeCC Sabathia
William Perlman/THE STAR-LEDGER/US PresswireCC Sabathia's 200 innings last season were the fewest he's thrown since the 2006 season, which is also the last time he's had as few as 28 starts.
CC Sabathia, LHP, New York Yankees: Surgery to address bone spur, Oct. 25, 2012. Sabathia reluctantly went on the DL last year with swelling in his elbow, then underwent offseason surgery to address the source of the problem; his return this spring has been just how he prefers it -- uneventful -- and he is expected to be ready Opening Day; while he is racking up the years and the pitching miles, his overall durability remains impressive.

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.

Relief Pitchers

[+] EnlargeFrank Francisco
Jason Szenes/Getty ImagesFrank Francisco has to contend with both his recovery, and with a challenge to his role as closer from teammate Bobby Parnell.
Frank Francisco, RHP, New York Mets: surgery to address bone spur in right elbow, Dec. 18, 2012. Began throwing from a mound in March and has only recently begun throwing to live hitters; still with some soreness and is likely to open season on DL; could be ready by late April/early May.

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.

[+] EnlargeFrank Jobe
Nancy R. Schiff/Hulton Archive/Getty ImagesDr. Frank Jobe, pioneer of "Tommy John" surgery.
The rehab: As is the case following any new surgical procedure, the post-surgical rehab was very cautious initially. Return timetables approximated 16 months. Over time as more athletes have undergone the procedure and more is known about the healing process, that timetable has shortened to a range of nine to 12 months. The rehab schedule remains fluid as any number of factors can influence the time to return to activity, including whether the athlete is a thrower or non-thrower. Early rehab focuses on regaining elbow motion along with strengthening exercises for body parts away from the elbow and cardiovascular conditioning. Strengthening around the elbow is eventually introduced along with upper extremity coordination activities to retrain the "feel" of the arm in space. One of the biggest benefits of the rehab process is the time away from throwing. Pitchers rarely take such extended down time unless forced to do so because of injury. The rehabilitation following UCL reconstruction allows time to address shoulder imbalances, core muscle weakness, leg strength and any other areas that require attention while throwing is off limits. At approximately four months the athlete can resume light tossing and ultimately moves to a progressive throwing program. The throwing program is modified based on how the athlete responds to each outing and it is not uncommon for the progression to fluctuate at various points in the process. Even after an athlete returns to competitive throwing, it often takes time to reestablish command and consistency. So while a return to competition may occur within a year or less, a return to form can certainly take another six to eight months.

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.


The season hasn't even started, and two closers are already sidelined for the season. Over the weekend, the Cincinnati Reds announced that Ryan Madson, who was signed just this January, suffered a torn ulnar collateral ligament (UCL) and is headed for Tommy John surgery. This news came one day after the Royals announced Joakim Soria would undergo Tommy John surgery (by Dr. Lewis Yocum) on April 3.

While Madson becomes yet another pitcher to fall victim to the almost-commonplace procedure, recent statistics suggest the prospect of a successful return is quite high for him. In perhaps the largest collection of data of pitchers post-TJ surgery, Dr. James Andrews and his colleagues at the American Sports Medicine Institute in Birmingham, Ala., have found that approximately 75 percent of major league baseball pitchers are able to return to what was perceived as their prior level of performance following this surgery.

Joakim Soria
Peter G. Aiken/US PresswireRoyals closer Joakim Soria is headed for his second Tommy John surgery.
In Soria's case, however, the sample size is much smaller. This will be Soria's second TJ surgery, and fewer pitchers exist who have undergone more than one Tommy John procedure, much less returned to the major league level afterward. In a study published in the American Journal of Sports Medicine in 2008, the authors reviewed the cases of 15 patients -- 12 professional and three collegiate baseball players -- who had undergone revision surgery for a retear of a reconstructed UCL. According to the study, only one-third (5/15) were able to return to their previous level of play for at least one season.

Even that number might not tell the whole story. While a major league pitcher returning to the major league level following surgery sounds like a success story, what matters most to teams is whether that pitcher can truly perform at the same level as he did pre-surgery. There is certainly plenty of evidence that suggests pitchers can return to top form following an initial Tommy John surgery, but what about after a second procedure? Stan Conte, senior director of medical services for the Los Angeles Dodgers, tried to answer that question as the team evaluated whether to sign pitcher Chris Capuano, a member of the two-Tommy John procedure club. Conte attempted to evaluate the workload of pitchers returning from a second procedure as a measure of their success. Starting with the somewhat arbitrary premise that a team would want a pitcher to return to the mound for at least 40 percent of his previous workload in order to be willing to carry him on its roster, Conte reviewed the numbers. Under these criteria, a 30-game starter prior to injury would need to deliver at least 12 major league starts to meet 40 percent of his prior workload. For a reliever, since game starts would be irrelevant, the 40 percent of prior workload would be tied to number of appearances.

Conte found that only 14 percent of starters were able to return at a level that met these criteria, but 60 percent of relievers were able to meet the mark. Also worth noting: Two of the starters who failed to meet the criteria for return as starters were still able to return successfully as relievers.

While that data might not be perfect or absolute, it does suggest hope for Soria, who, as a reliever, appears to have better odds of a successful return than he would as a starting pitcher. Soria is only 27 years old and still could have plenty of baseball left in him, as long as his arm cooperates. There is no doubt Soria faces another lengthy road to recovery, but his ability to successfully return from his initial procedure, combined with this positive outlook for relievers, should help.

It's worth noting that Capuano was among that 14 percent of successful returning starters -- he made 31 starts for the Mets in 2011 -- thus making the Dodgers' decision to sign him an easier one. In Saturday's exhibition game, Capuano looked strong as he struck out five and allowed two runs in five innings while making his fourth start of the Cactus League exhibition season. The Dodgers are hoping he'll remain part of that 14 percent.

Joba hurt again


A player suffering two serious injuries within the span of a year just doesn't seem fair. Fair or otherwise, Yankees pitcher Joba Chamberlain, who recently suffered a significant ankle injury while still recovering from Tommy John surgery, will now be rehabilitating his right leg along with his right arm. Chamberlain suffered the injury Thursday and underwent surgery the same night. He suffered an "open" dislocation, meaning the skin was broken in the process, which required immediate treatment to help guard against infection along with the corrective surgery. Chamberlain was able to leave the hospital Sunday.

[+] EnlargeJoba Chamberlain
Noah K. Murray/The Star-Ledger/US PresswireJoba Chamberlain has been recovering from the Tommy John surgery he had in June 2011.
Chamberlain will be in a non-weight-bearing cast for six weeks, followed by a walking boot, according to Yankees general manager Brian Cashman. The keys for the rehab process and his ability to progress are pretty straightforward: Monitor against infection, hope that the tissue heals uneventfully, progress to normal walking as weight bearing is permitted, then gradually resume functional activities with an eye on returning to baseball. Even if every detail of the injury and subsequent surgery were made available, the timetable for recovery would still not be set in stone. How his body heals and whether any unexpected issues crop up (such as infection) will go a long way in determining how swiftly Chamberlain is able to progress. But if there was no significant nerve, vascular (circulatory) or cartilage damage as a result of the injury, if healing progresses at a normal rate, and if there are no major setbacks along the way, the potential exists that Chamberlain could make a 2012 return.

Assuming Chamberlain gets through the initial phase without incident, the other primary challenge will be getting full range of motion back in his ankle. These injuries can be associated with chronic stiffness and scarring in and around the joint and require aggressive work directed at restoring normal movement. There is also the issue of strengthening the muscles in the entire lower extremity, which will naturally atrophy as a result of the extended immobilization. Then there is the matter of regaining balance and proprioception (essentially awareness of where the body is in space), a critical component of a pitcher's balance while in a single-leg stance on the mound. While there is much to overcome, Chamberlain will be focused on little else other than his recovery and can dedicate himself to doing just that. On the positive side, he does not have the demands of a position player, who must routinely field the ball or turn corners while running the bases. While he does have certain fielding responsibilities as a pitcher, those requirements are not as strenuous as they might be for another position.

There is that small matter of Chamberlain simultaneously returning from Tommy John surgery, however. Fortunately for him, he was quite far along in that recovery process when the ankle injury occurred. Chamberlain was already throwing in the bullpen and had even begun mixing in some breaking pitches, indicating that the bulk of his remaining recovery centered on increasing his workload. While the throwing sessions are obviously going to be interrupted for some time, there is plenty of upper-body and core work that Chamberlain will be able to maintain. The primary measure of protecting his arm will be ensuring that he has sufficient leg strength before returning to throw.

Naturally, there is no way to definitively determine whether Chamberlain will be able to pitch this season or even whether he will pitch again. That said, it is also too soon to rule out the possibility that he not only returns, but he does so in this calendar year. "He was saying he could be back on the mound in July, that's what the doctors are telling him," Cashman told the New York Post, adding, "That's the optimistic side." Chamberlain, who is still just 26 years old, was already demonstrating a steady progression in his return from Tommy John surgery and, in the eyes of many, was ahead of schedule. Optimism could be just what he needs to get through this latest obstacle.

Age is but a number ...


Rarely do we hear about pitchers in the twilight of their career opting for Tommy John surgery. Even less frequently do we hear about their comeback afterward. Between the time necessary to progress through the various stages of rehabilitation and the energy required -- both mentally and physically -- to commit to the recovery effort, the hill is often too steep to climb for those who know the end of their playing career is drawing near anyway. So why did Jamie Moyer elect to undergo surgery and attempt a comeback? After all, while the overall success rate of a pitcher's first Tommy John surgery is quite high (see above), Moyer's age (49) makes him an outlier, not only in regard to those who undergo the procedure, but among all baseball players.

[+] EnlargeJamie Moyer
AP Photo/Marcio Jose SanchezJamie Moyer was sharp in Thursday's spring start.
But Moyer has always been an outlier. Never known for his velocity, Moyer's results have depended more on finesse and mechanics, location over heat. And he's still getting it done; from 2008 to 2010, he posted a respectable 37-26 record with a 1.29 WHIP.

Moyer, a southpaw, suffered the injury to his left elbow in 2010, then sat out the entire 2011 season while rehabilitating. During that time he worked as an analyst for ESPN, even providing firsthand insight into the recovery process during the baseball season. In January 2012, Moyer signed a minor league deal with the Colorado Rockies, and at the age of 49 he's competing for a spot in the starting rotation. Moyer has had several starts this spring, the results of which have been mixed, but Thursday's outing, which I attended, was particularly solid. Moyer pitched four perfect innings, throwing 30 of his 45 pitches for strikes, and netted four strikeouts. While the radar gun readings registered variants in the 70s, Moyer has never been known for his velocity (even he acknowledged his lifetime ceiling was probably 83 mph). And that, says Moyer, may be one of the traits that has allowed him to stay in the game so long. "I don't have to throw as hard as some guys do to come back, because I have never been that guy," said Moyer.

Last year Moyer acknowledged that the rehab process was far more extensive than simply the elbow. In fact, beyond regaining range of motion and strength about the elbow, the bulk of rehabilitation focuses on things away from the elbow, such as upper back, shoulder, core and leg strength, conditioning, flexibility, neuromuscular training and, as one begins to pick up the baseball again, proper throwing mechanics. These are all things most pitchers never have the chance to fully address while healthy because they don't have enough downtime to do so. But once injured, they are forced to reassess and rebuild.

Moyer has taken full advantage of that opportunity. Beyond the formal rehabilitation work he did immediately following surgery, along with additional training he did at the Phillies' facility in Clearwater, Fla., Moyer worked closely with a physical therapist in Southern California. "His name is Yousef, and he is an amazing man," said Moyer, adding, "I don't know if I've ever met someone who cares so much about each and every patient." Moyer was well-versed in the specifics of his particular program, explaining the attention to detail with which he conducted each exercise, even as he continues them independently. Moyer pointed out to me that the majority of the exercises are for his scapula (shoulder blade) and shoulder, noting that he has been working on strength deficits that have been present for years. And he's seeing progress. He also spent time working on conditioning in the dunes near Torrey Pines. "No running downhill, only uphill climbing," said Moyer who has a fractured patella (kneecap) in his injury history as well. Moyer knew he needed to be in superior cardiovascular shape to be able to compete, and he appears to be.

Moyer says the workout combination had him feeling "just right" before he headed to spring training. It certainly looks like it's paying off as Moyer appears calm and confident, yet intensely competitive, as he awaits his fate with the Rockies.

Angels starters very close to returning

May, 12, 2009
5/12/09
6:54
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It's about time we started with some good news for a change. We have some key players close to returning.

Josh Hamilton is expected to return to the Rangers' lineup Tuesday night, completing a stint on the disabled list caused by a strained rib-cage muscle. Hamilton played in two rehab games for Triple-A Oklahoma City and sounds confident that he's completely healed, telling the Fort Worth Star-Telegram that he tested his ribs in a multitude of ways: "I swung the bat. I had to run from first to third. In the outfield, I had to throw. Getting out of breath and breathing heavy, that was good. So we're all good." Also, the Star-Telegram pointed out that Hamilton slipped in the outfield Sunday, landing directly on his ribs, but was able to continue without hesitation. Fantasy owners should feel confident that this injury episode is behind him.

Meanwhile, the Angels have to be excited that both John Lackey and Ervin Santana could rejoin the rotation within the next week. Both aces began the season on the DL because of arm injuries -- Lackey had a forearm strain and Santana had a sprained elbow -- and both have had quiet, uneventful rehab progressions. When we don't hear much about players while they're undergoing rehab, it's usually a good sign. That means they're moving quietly from one rehab phase to the next without calling much attention to themselves. Both Lackey and Santana have made rehab starts, working on increasing their pitch counts.

The Los Angeles Times reports that the Angels will study tapes from Lackey's and Santana's most recent rehab starts to assess their readiness to return, but all evidence points to those return dates' coming sooner rather than later. And their uneventful rehab progressions make a good case for their ability to be successful upon their returns. The bigger question is whether Lackey and Santana will be able to last the remainder of the season. So far, there is good reason for their owners to be cautiously optimistic.

On that note, here are a handful of players I'm tracking this week in the world of baseball injuries:

Chipper Jones
Joe Robbins/Getty ImagesSeems like we have heard this one before: Chipper Jones is injured.
Chipper Jones, 3B, Braves: Jones sat out Monday night's game as a result of a hyperextended elbow, but he expects to return to the lineup Tuesday. Jones told the Atlanta Journal Constitution that he has been dealing with a "pretty serious case of tendinitis" in the elbow all year, and after hyperextending it during a strikeout swing Sunday, his elbow was "jacked up." Although the latter is not exactly a medical diagnosis, it pretty well conveys how Jones was feeling. Jones' injury history shows that he will press and play on through injuries whenever possible until he feels he can't perform as he should. In this case, Jones couldn't make the throw from third base to first because of the elbow, and therefore removed himself from the game. His assessment was that a little rest and anti-inflammatory medication should get him back fairly quickly, which is not an unreasonable prediction.

Jones' owners most likely knew (or should have known) when they drafted him that he is a physical player who is going to be dinged off and on throughout the season. Translation: He will miss games from time to time, but he has been fairly adept at avoiding the DL for the majority of his injuries. This incident appears to fall in the category of the one-to-three-game absences, but it's worth noting that the tendinitis has been bothering him all year. If he continues to aggravate it, this could crop up again. And next time, it could last longer.

Aramis Ramirez, 3B, Cubs: The Cubs have definitely been DL-challenged this year, with a new name seemingly added every week. Just when it looked as if Ramirez was recovering from a stiff back that had bothered him in spring training and, more recently, a calf strain that caused him to sit out a couple of games, he dislocated his left shoulder Friday night while diving to try to make a play at third. Ramirez summed it up perfectly to the Chicago Tribune: "Seems like I can't be out there right now this year. I've been hurt all the time."

Well, he's certainly right about not being able to be out there right now. A dislocated shoulder means at least a month of rehabilitation, and seeing as this was not a stable shoulder to begin with (Ramirez hyperextended the same shoulder during his rookie season in 1998 and aggravated it again in 2000), it likely will take even longer to restore enough strength around the shoulder to allow him to play with confidence. Fantasy owners need to plan on utilizing a replacement at least through the All-Star break.

Derrek Lee, 1B, Cubs: The good news is that despite his neck issues, Lee likely won't require a trip to the DL. At least not right now.

An MRI this week confirmed what was already known about Lee's neck: He has a bulging disc, which is likely responsible for the pain and spasms he has been experiencing of late. But the Cubs' decision not to place Lee on the DL can be interpreted as an encouraging sign, and the Chicago Tribune reported that Lee would return to the lineup either Tuesday night or Wednesday. The Chicago Sun-Tines reported that an anti-inflammatory injection was not deemed necessary and that the most recent MRI results "revealed no additional damage and nothing to suggest long-term injury."

While it's some relief to know that there appears to be no progression of Lee's neck problem on MRI, it is arguable that this injury is indeed long-term. Consider that Lee originally injured his neck two years ago and has dealt with this type of pain intermittently ever since. A disc problem is not the type of thing that typically goes away completely; it is more likely to be the type of condition that flares up from time to time. The treatment goal is to do as much as possible in terms of strengthening and stabilization to prevent the recurrence of symptoms, and when those symptoms do crop up, to manage them as efficiently as possible. Working in Lee's favor is the fact that the symptoms have remained localized to the neck area. In the case of a severe disc bulge, there can be accompanying nerve involvement that can manifest itself as numbness, tingling and/or weakness in the arm. The further down the symptoms progress, the more problematic and the more disabling they can be.

The fact that Lee is likely to return soon is definitely a good sign, and it is possible that this will be his only episode of neck pain this season. It is also possible, however, that these symptoms will return, if not this year then in the future, as has already been the pattern for him over the past two years. Fantasy owners need not panic, but it is worth being aware that this issue can linger beneath the surface.

Dustin Pedroia, 2B, Red Sox: Pedroia was forced to leave Sunday night's game early after straining the right side of his groin while swinging. According to the Boston Herald, Pedroia originally injured the groin earlier in the month, perhaps during cold and wet conditions at Yankee Stadium, and had been playing through it. But clearly Pedroia aggravated the injury Sunday night when, according to Pedroia's account in the Herald, his cleat "kind of got caught, and it was an inside fastball, so I tried to turn on it, and obviously it hurt." Manager Terry Francona planned to hold him out Tuesday but maintained that his return to the lineup Wednesday would be "very realistic."

Pedroia already has had one muscle strain this season, an abdominal injury that forced him to exit early from the WBC. Nonetheless, he was back in full swing within a few days and has shown himself to be not only tough, but also a quick healer. He spent much of the offseason doing intensive physical conditioning and that too might play a role in why his injuries are not as debilitating as they otherwise could be. Although there is always the concern of exacerbating a strain once it exists, Pedroia appears to have avoided serious injury thus far.

Kevin Youkilis
Jim Rogash/Getty Images"Yuuuuuuke" (Kevin Youkilis) should return to the lineup soon.
Kevin Youkilis, 1B, Red Sox: Will he or won't he? That is the question Youkilis fantasy owners have been asking over the last week in reference to whether Youk would be headed for the DL because of his "sore side." Here's the answer: Yes. This was a bit of a surprise. The Boston Herald reported Monday that Youkilis could potentially be available to play Tuesday evening. By Tuesday evening, the Boston Globe was reporting that Youkilis had just been placed on the DL. Apparently he aggravated his condition during batting practice, and the team decided he needed some extra time off. The move is retroactive to May 5 since Youkilis has been out of commission for a week already, leaving the door open for him to return in another week if he is truly healthy.

The exact nature of Youkilis' condition has been a little puzzling, but manager Terry Francona described it as a deep bruise that turned into spasms after Youkilis was hit twice in the back by pitches. Youkilis however told the Boston Globe that being hit by pitches was not the cause, and that the injury had actually occurred a couple of weeks prior, although he did not specify when. He also pointed out that the tightness he was experiencing was more in his side as opposed to his lower back. It now appears that the team is classifying it as an oblique injury.

Jose Molina, C, Yankees: Last week, Yankees catcher Jorge Posada was addressed in this column after being placed on the DL because of a Grade 2 hamstring strain. This week it was Molina who was placed on the DL because of a thigh muscle strain; in this case, it was a quadriceps injury. The quadriceps muscle, or quad as it is often called, is the large muscle group that constitutes the bulk of the front of the thigh. It is made up of four separate muscles that come together in a common tendon to attach at the shin. The quad provides the bulk of the power necessary for running, but in the case of a catcher, the quad is critical for maintaining the crouch position and being able to explode out of it when necessary.

The good news is that the team does not expect Molina to miss much beyond the 15 days. Muscle strains can be hard to predict, though, so we will check on Molina's rehab status again next week.

Joakim Soria, RP, Royals: The closer was placed on the DL because of a rotator cuff strain to his right (throwing) arm. Soria has been dealing with stiffness and soreness in his throwing arm for a few weeks, and attempts to give him a few days' rest here and there were not enough. At this point, the team has not indicated exactly how long it thinks Soria will be out, but fantasy owners should plan on some insurance at the closer position for the next month or so.

The good news is that an MRI has not indicated any specific damage. The not-so-good news is that the pain is in the back of his shoulder where the rotator cuff musculature is located. Soria last pitched Thursday, and although his shoulder reportedly did not bother him during the inning, the Royals' official Web site reported that he did feel it the next day. In the scheme of things, next-day soreness is less worrisome than soreness during activity and far less worrisome than constant soreness, even at rest. The Royals are taking a proactive approach in trying to provide Soria enough downtime to hopefully resolve the issue. Although Soria believes he can be back in 15 days, the team might opt to bring him back a little slower and place him on a graduated (read: rehab) assignment. Either way, the hope is to have him for the long haul, and that looks to be a realistic goal.

On the mend

Cardinals ace Chris Carpenter is inching closer to a return. He is scheduled to throw from a mound Tuesday, and if that goes well he will throw simulated innings, according to the St. Louis Post-Dispatch. Given that he has maintained his conditioning, the team does not anticipate a rehab assignment, and he could return as early as sometime next week.

Yankees pitcher Chien-Ming Wang is scheduled to make a rehab start Tuesday. Wang, who clearly struggled at the start of the season, was found to have lingering weakness in his hip muscles following foot surgery, but it appears this latest rehab period has really helped him. Depending on the results of his outing, Wang might be able to rejoin the Yankees' rotation within the next week.

Daisuke Matsuzaka has had two rehab starts already and is expected to have another this week. Expect him to be back in the mix when the Red Sox return from the West Coast for a homestand next week.

Angels outfielder Vladimir Guerrero can hit off a tee now. This is good progress, but he still is not throwing. The Angels have made it official that when he returns he will serve as the DH initially. That could happen within the next few weeks. Stay tuned.

And finally ...

Diamondbacks shortstop Stephen Drew could return either Tuesday or Wednesday from a hamstring strain. He played in rehab games the past two days and came out feeling OK. The slow progression appears to have worked, at least so far, and fantasy owners should plan on his being available very soon.

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