Stephania Bell: Xavier Nady

I just like to start with some good news. Any good news. Trust me, some weeks -- like this one -- it's slim pickings. Nonetheless, I feel responsible to fantasy owners to keep the glass half-full, and so I scoured amidst all the downers of guys headed to the DL (including a record number of repeat customers!) and I managed to find a bit of encouraging news this week.

Jose Reyes could make his return from the DL on Friday. I always recommend the cautiously optimistic approach when it comes to returning from a muscle strain or an "-itis" (as in something inflammatory). In fact, Reyes hasn't had the opportunity to test the leg in a game situation because Tuesday's planned extended spring training game was rained out. So much for the glass being half-full. There is another game scheduled for Wednesday when the Mets hopefully will be able to put Reyes to the test. Until he proves he can run without difficulty, Friday's target remains in the category of wishful thinking.

But let's face it, we want to get to the information about who's hurt. Here's who we're talking about this week in the world of baseball injuries. ...

Josh Hamilton
Aaron M. Sprecher/Icon SMIJosh Hamilton is making his second trip to the disabled list this year, and this could be a lot longer.
Josh Hamilton, OF, Rangers: Hamilton underwent an MRI on Monday in an attempt to clarify the cause of his persistent groin pain, which has been with him since his most recent collision with an outfield wall at Rangers Ballpark. On Tuesday, he met with Dr. John Preskitt, who performed a sports hernia repair on Ian Kinsler last season. According to the Fort Worth Star-Telegram, Rangers general manager Jon Daniels indicated that Hamilton's visit with Preskitt was to help rule out a hernia.

If this all sounds confusing, it is. Arriving at a diagnosis of a sports hernia is really a process of ruling out other diagnoses. Here's what we know so far.

1. First and foremost for fantasy owners, Hamilton is on the DL for the second time this season. That means you have to make alternate plans for at least another two weeks. I would recommend that you make plans for another couple of months. Continue reading.

2. Hamilton's injury started out as a groin strain and was later called an abdominal strain, according to the team's official Web site. This is the case with many of the injuries that are eventually diagnosed as sports hernias. Pain begins near the groin, then moves closer to the lower abdominal wall. With all of these muscles converging to attach at the pelvis, the pain patterns can be similar.

3. It is not a hernia. A true (abdominal) hernia represents a protrusion (herniation) of abdominal contents through a weak spot in the soft tissue around it. The hernia can often be palpable (the examining physician can feel it) and can generally be seen on imaging (via ultrasound or MRI). Since many of the symptoms can be similar, it is important to rule out a true hernia. Many sports hernias do not show any visible findings on MRI. If Hamilton had a hernia, he would be having surgery while I'm writing this column.

4. Hamilton has indicated that he faces the most difficulty when trying to run. The hallmark of a sports hernia is an athlete's inability to run. It can be a frustrating diagnosis in this regard because, depending on the degree of injury, the athlete can actually feel quite good ... until he tries to run. Because of the muscles involved and their attachment near the pelvis, the power required to run places a demand on the area that cannot be met. The athlete typically complains of pain and weakness when attempting to run. According to the Dallas Morning News, Hamilton said "I'm hurt and sore and can't run," estimating his running since the groin injury at 50 percent of normal.

The evidence here would suggest that Hamilton is, indeed, dealing with a sports hernia, which is, in essence, what the team is saying. According to the Ranger's official Web site, assistant general manager Thad Levine "likened the injury to a sports hernia" and hopes Hamilton can avoid surgery after a period of rest and anti-inflammatory medication. Hamilton will be re-evaluated at that point and, if he has not improved, likely will face sports hernia surgery that would require six to eight weeks of recovery. Although Hamilton's mechanism of injury is somewhat atypical (these injuries often seem to come on out of nowhere, with no particular incident as the cause), his symptom pattern has many features that fit the bill.

For those wondering why surgery isn't done right away, this rest period is a step in ultimately arriving at the conclusion that surgery is necessary. Since sports hernia diagnosis is often one of exclusion -- figuring out everything that the injury "isn't" -- the decision to proceed with surgery is easier if conservative measures have failed. Fantasy owners can hope for the best, but should prepare for the worst, in the event that Hamilton is headed under the knife.

Evan Longoria, 3B, Rays: Longoria was serving as the DH for the past couple days as a result of elbow soreness; now there's something of potentially bigger concern. Longoria left Tuesday's game with a left hamstring strain after running out a ground ball, and we know how these injuries can go (read: linger).

He is expected to undergo an MRI on Wednesday to determine the extent of damage, but there are a few notes of encouragement. Longoria's description of what he did NOT experience suggests that the strain is on the minor end. Longoria told the team's official Web site Tuesday after the game, "I didn't feel a pop, I didn't feel a pull, I was able to walk and ride the bike and everything." Longoria added that he considers himself day-to-day. Rays manager Joe Maddon indicated that he will act with caution, so don't be surprised if Longoria is given a couple days to rest, even if the MRI turns up nothing significant.

Edinson Volquez
AP Photo/Jeff RobersonEdinson Volquez lasted just one inning in Monday's start before returning to the disabled list.
Edinson Volquez, P, Reds: Volquez may hold the record for shortest return from a DL stint before exiting a game only to be returned to the DL. Not a record he or his fantasy owners really want. And it's not as though he wasn't recovered from the first problem (back spasms) and aggravated the injury. Sadly, this is something altogether different.

Volquez lasted all of a single inning in his return Monday night before being forced out with what he described as "tingling from my elbow down to my fingers," according to the Dayton Daily News. Volquez went on to say that he had "never had this happen ... never had pain in my arm." Specifically, Volquez experienced the sensation in his ring and pinky (fourth and fifth) fingers in his right (throwing) hand. The location tells us that his ulnar nerve was talking to him, and clearly it was not happy.

According to the Cincinnati Enquirer, Volquez has been placed on the DL with tendinitis in his elbow. In that scenario, inflammation in the soft tissue around his pitching elbow could result in increased pressure on the ulnar nerve (which passes just behind the bony part of the inside of the elbow, coming very near to the surface, making it an easy target for injury). The pressure would then result in irritation of the nerve, which shows up as numbness and tingling in the fourth and fifth fingers in the hand. The ulnar nerve is often problematic for pitchers because of its location and its vulnerability when there are problems at the elbow. If the joint is hypermobile, if spurs are present, if there is any ligamentous injury (yes, ulnar collateral or Tommy John ligament) or even in the presence of swelling alone, the ulnar nerve can be affected.

The hope for Volquez is that this truly is a minor condition and not the beginnings of a major problem with his throwing elbow. The plan is for him to rest for at least a week (no throwing at all) and then be re-evaluated. Stay tuned.

Joey Votto, 1B, Reds: A week ago it appeared promising that the team had been able to identify the source of Votto's frustrating intermittent dizziness. He was reportedly dealing with an ear infection and had been placed on anti-inflammatory medication. The problem, however, was that every time Votto got on a plane, the symptoms were exacerbated the next day.

On Saturday, Votto was placed on the DL with what the team is calling "stress-related issues." It's fairly safe to assume that the stress Votto is experiencing is from the on-again, off-again nature of this dizziness. I can tell you that patients who experience chronic dizziness describe it as an extremely debilitating and frustrating condition. We've all experienced feeling dizzy or light-headed at some point, and I have yet to find anyone who thinks it pleasant. Now imagine trying to do your job and performing at the same level to which you and your co-workers are accustomed, with the world spinning around you. It's just not possible.

This trip to the DL is a good move for Votto until he can truly get his symptoms under control. Let's hope that the 15-day period is all he needs.

Asdrubal Cabrera, 2B, Indians: Cabrera left Tuesday's game against the Twins in the first inning with a shoulder injury. He was clearly in pain when he left the field after taking the brunt of Twins shortstop Brendan Harris' weight on his left shoulder as he slid into second base.

The Cleveland Plain-Dealer is reporting that Cabrera suffered a dislocated left shoulder that was "put back into place." X-rays taken at Hennepin County Medical Center were reportedly inconclusive and Cabrera is scheduled to undergo an MRI Wednesday. The description makes it sound as if Cabrera actually subluxed his shoulder (in which it slips slightly off the joint but quickly pops back in) because a true dislocation is often difficult to reduce (put back), unless the athlete has a very unstable shoulder with a history of repeat dislocations. As far as I can tell, this is not the case with Cabrera.

Cabrera also told the Plain-Dealer that he did not think he would need to go on the DL, another sign that he may not have suffered that severe of an injury. It's worth noting though that players often feel far worse the next day once there is post-injury pain and inflammation. There's still a chance, either with or without a complete dislocation, that Cabrera could have suffered enough soft tissue damage to require a minimum two-week absence. Let's see how Cabrera feels over the next few days. That will probably go a lot further in determining just how long it will be before he's back in the lineup.

On the Mend

Alex Gordon has to be pleased with the results of his latest visit with his surgeon. According to the Royals' official Web site, Gordon, who is recovering from surgery to address a torn labrum, got "glowing reports" on his trip to Colorado. His latest activity includes limited tee swings and very light, easy ground balls, so he is still a ways from truly testing his hip (hard swings, fielding bunts, throwing across his body and, ultimately, sliding). Although Gordon was originally given a timetable of 10 weeks (which would mean a return in late June), I have suspected all along that a return after the All-Star break would make the most sense. It seems that Gordon's progress has him on track for that so far.

• Rays ace Scott Kazmir is recovering from his quad strain while simultaneously addressing mechanical faults he attributes to last year's elbow injury. There is no official timetable for his return, but according to the St. Petersburg Times, Kazmir is throwing in the bullpen and hoping to avoid a minor league assignment. It's possible he could be back within another two weeks. Between the quadriceps recovery and the adjustments Kazmir is making, the hope is that his performance will improve when he rejoins the rotation.

Brandon Webb continues to work his way back gradually from the shoulder problem that has kept him out since Opening Day. According to the Arizona Republic, he's throwing on flat ground (with another session planned for Wednesday) and will hopefully progress to a bullpen session Saturday. Don't get too excited; the Diamondbacks haven't brought him along this slowly only to speed him up now. Due to all the missed time, Webb likely will be brought along through every step in the standard return to throwing progression, including several minor league starts to build up endurance. The most encouraging words are from Webb himself, "It took a while to get there, but I feel like we're moving forward." I would not expect much before the All-Star break, but assuming he continues well, it would be a good time to think about picking him up.

Xavier Nady
G Fiume/Getty ImagesXavier Nady likely isn't done for the year, but he isn't coming back in the near future, either.
• In the not so smooth recovery department, Yankees players have endured a couple of setbacks. Outfielder Xavier Nady, who suffered an injury to his previously reconstructed ulnar collateral ligament in April, threw for the first time on Monday and it apparently did not go so well. According to the Newark Star-Ledger, Nady experienced discomfort in his elbow when attempting throws from 50 to 60 feet. Although manager Joe Girardi indicated he would play Nady even if he wasn't at full strength, it's a recipe for disaster if the player and the manager are uncertain whether every throw will result in pain. Nady did throw Tuesday and, according to, only felt minor discomfort this time. When he's throwing consistently without any discomfort, then we can really be encouraged. Until then, everyone should temper expectations.

• Meanwhile, Nady's teammate Jose Molina is having a repeat MRI on his injured left quadriceps after being pulled from an extended spring training game Monday. Those results are expected to guide the next steps. Even without the results, just the fact that he had to be pulled because the muscle became painful tells you what you need to know. He will not be ready to return anytime soon.

• On the other coast, Angels pitcher Kelvim Escobar faced challenges of his own as he recovers from surgery last year to repair a torn labrum. After being ahead of schedule throughout his rehab, he had a setback near the start of the season that has delayed his return. Escobar's shoulder is recovering and he is throwing without pain, but his latest rehab start Monday revealed that he does not have full control of his delivery. The Los Angeles Times reports that, as a result, Escobar has stopped throwing the slider for now. From a rehab perspective, how his shoulder feels is the most important thing. The fact that he is not experiencing pain is critical. A slider is one of the more physically demanding pitches, so it makes sense that it would take longer to get it back. Look for Escobar to rejoin the rotation within the week, perhaps Saturday, but without his slider.

• And finally ... expect John Smoltz back in mid-June. No one will commit to it, but he looks good. Get ready, he's going to be great.

Updates on Carpenter, Nady and others

April, 22, 2009

It's a busy, busy week in the world of sports. The playoffs have started in the NBA and NHL, the NFL draft is upon us and baseball is in full swing all around the country.

What strikes me is that the injuries just seem to keep on coming. Some teams are already looking at possible personnel moves simply to accommodate the rash of injuries they have already sustained. And it's only April!

On that note, here's who we're focusing on this week in the world of baseball injuries ...

Chris Carpenter, P, Cardinals: It was just a short time ago when we were celebrating Carpenter's return to the mound after virtually two years of absence due to injury. The celebration was short-lived when Carpenter was again forced to the DL, this time as the result of an oblique strain. The St. Louis-Dispatch reports that an MRI confirmed Carpenter injured a left oblique muscle, and as a right-handed thrower, this is the most commonly observed pattern (opposite side of the throwing arm). The less common aspect of his injury is that he sustained it while batting. Certainly power hitters are known to suffer oblique injuries, but no one would accuse Carpenter of being a power hitter. Pitchers, who rely on their oblique muscles to help generate the torque required to deliver the ball, often sustain the injury during throwing.

Nonetheless, whether the injury is sustained during batting or throwing, the rehab remains essentially the same. On average, an oblique injury is a six-week injury for a pitcher. In Carpenter's case, given his extensive injury history to his throwing arm, there will be no rushing his return. Any weakness in his trunk could result in compensations in his throwing arm, putting him at risk for injury. Expect Carpenter to be out for two months, but expect him to come back strong once he's ready.

Daisuke Matsuzaka
Jim Rogash/Getty ImagesDice-K's tired arm is a strong argument against the WBC.
Daisuke Matsuzaka, P, Red Sox: Arm fatigue? OK, so it's not a fancy medical diagnosis. But it does a pretty good job of accurately conveying the nature of the problem. Officially termed a shoulder strain by the Red Sox, his ailment manifested itself as a lack of control and command. Based on his recent struggles, the Red Sox wisely chose to place him on the DL to allow his arm some rest, perhaps pre-empting a more serious problem down the line.

Fatigue often leads to a change in mechanics as pitchers try to compensate for less power by an alteration in their delivery. Even subtle changes, over time, can lead to significant injury. Rest now, followed by a gradual, progressive return to throwing, should allow Matsuzaka to work his way back to his normal self within a relatively short time frame. Had he tried to press through this, it might have ultimately translated into a more prolonged absence.

The good news is the Boston Globe is reporting that Matsuzaka has been cleared to begin light throwing (think: playing catch), signaling that his arm felt good enough that very little down time was required. He will work through a typical throwing progression, but barring any setbacks, he should not be absent for a protracted period.

Jed Lowrie, SS, Red Sox: Last week we talked about Lowrie's ailing wrist and the unknown path ahead. After multiple consultations, with the final stop taking him to Dr. Donald Sheridan in Arizona, Lowrie's fate has finally been decided. He opted to undergo arthroscopic surgery Tuesday to address his wrist problem. According to the Boston Herald, Lowrie's procedure involved removal of the ulnar styloid, a projection of bone at the tip of the ulna (the forearm bone that runs from the elbow to the pinky side of the hand). Lowrie told the Herald that he is scheduled to return in six to eight weeks.

The concern with any wrist surgery is not just how long it will take a player to get back into the game, but how long it will truly take for him to return to form, particularly at the plate. It is not uncommon to see hitters struggle to regain their power following a wrist injury. Lowrie fans and fantasy owners will want to plan on having insurance for three months. Meanwhile Julio Lugo, recovering from meniscal surgery, is beginning a rehab assignment at Triple-A Pawtucket on Tuesday. According to the Red Sox's official Web site, he could return within another week or so. Keep in mind that the Red Sox will not rush him simply because Lowrie is out and Lugo is still having some soreness in the knee. Best to plan on at least two weeks for Lugo's return to the lineup.

Alex Gordon, 3B, Royals: It seems like the injury du jour for third basemen is hip labral tears. Mike Lowell started the trend with his injury last season. Alex Rodriguez, who underwent hip labral surgery in early March, is perhaps the biggest celebrity of the group. Gordon is the latest addition to the list.

The Kansas City Star reported that Gordon first felt "tightness" in the hip on Opening Day. Earlier reports suggested that he first injured his hip sliding into second base a week ago, then further aggravated it during an at-bat. Either way, the limitations in his hip appeared to be impacting him at the plate. Gordon had his hip operated on Friday by Dr. Marc Philippon, the same surgeon who operated on Rodriguez. According to the Royals, Gordon is expected to miss anywhere from 10 to 12 weeks. This timetable suggests that the labral repair was the primary issue and that he did not require extensive bone work (like Lowell for instance, who had a rehab timetable that extended for several months).

The good news for the Royals here is that Gordon is young and healthy, which should aid in his recovery. Given his timetable, expect to see him back in the lineup just after the All-Star break.

[+] EnlargeVladimir Guerrero
Otto Greule Jr/Getty ImagesVlad may be a DH only when he comes back, which could impact next season's fantasy eligibility.
Vladimir Guerrero, OF, Angels: What was initially described as a pectoral muscle strain (suggesting minor tissue damage) turned into a more serious torn pectoral muscle (suggesting more extensive bleeding and soft tissue injury), landing Guerrero on the DL for at least a month. According to the Los Angeles Times, he may not even return to the outfield once he's eligible to rejoin the lineup. Instead, the Angels may opt to keep him in a designated hitter role.

The risk with any muscle tear is that a return too soon will result in reinjury, perhaps even more serious than the first time around. Depending on the location and extent of Guerrero's tear, the Angels could be concerned that further damage could lead to a surgical situation. He has said that the injury does not affect his swing, but the concern for further injury is likely the reason Guerrero is being forced to completely rest at this time.

Muscle tears can vary widely in terms of healing time, so it is very difficult to project a true timetable from afar. The level of the Angels' concern, though, reflects the seriousness of Guerrero's injury. Fantasy owners should make alternate plans knowing that his return is up in the air.

Xavier Nady, OF, Yankees: It's not as bad as it could have been. That's what the Yankees are saying now that it appears Nady will not undergo what would have been his second Tommy John surgery on his right elbow. The outfielder first underwent an ulnar collateral ligament (UCL) reconstruction in 2001 and was clearly able to enjoy a successful return to baseball. The joy of embarking on a new season in a new stadium was brought to a crashing halt last week, however, when Nady experienced sharp pain in his right elbow while making a throw.

It had all the makings of an UCL tear, and a second surgery seemed imminent. There was definitely cause for concern, since a return to baseball following a second UCL reconstruction has a much lower success rate than the return following a first-time procedure. Team physician Chris Ahmad performed various studies to image the soft tissue and the bone, and consulted with Dr. Lewis Yocum, who performed Nady's original surgery. The decision about how to proceed provided some good news for Nady and the Yankees.

According to the New York Post, Nady does have a partial tear of the ligament, but the decision has been made to have Nady undergo a course of conservative rehab instead of heading under the knife again. Given the lengthy rehab following surgery and the low success rate, this is a very reasonable course of action. After all, consider that the Angels' Ervin Santana is working on returning to pitching despite the presence of a partial tear in his UCL.

Nady is not a pitcher, so the demands on his arm are significantly less, and the Yankees do have the option of bringing him back as a DH initially while he works his way back to the outfield. Also, the presence of scar tissue in his elbow that has built up since his first UCL surgery might help provide some additional stability to the joint despite a tear in the ligament itself. Whether Nady can successfully return remains to be seen, and it will be at least a month before that happens, but at least he and his teammates can hold out some hope that he will be able to test out the new stadium after all.

On the mend

Despite the increasing body count on the DL of late, there is reason for a number of teams to be smiling this week. A number of players who started their season on the DL are seeing the light at the end of the rehab tunnel, with return dates to their major league lineups fast approaching.

In Milwaukee, the Brewers hope to have closer Trevor Hoffman back by the end of the week. Hoffman, who began the season on the DL because of an oblique strain, pitched for Triple-A Nashville on Tuesday, with no ill effects. He will throw one more rehab outing before rejoining the Brewers. There is always a risk for recurrence with oblique injuries, but Hoffman has been brought back slowly, and the fact he is a closer and throws fewer pitches per outing works in his favor. Despite his age and injury, I'm optimistic about Hoffman once he returns.

Joe Mauer
AP Photo/Charles KrupaAfter plenty of down time, Joe Mauer's rehab is clicking right along.
The Minnesota Twins have been quietly keeping their fingers crossed as catcher Joe Mauer passes incremental tests in his rehabilitation from an inflamed sacroiliac joint. The one thing Mauer couldn't do in spring training was run because it was simply too painful. After several months of non-impact training on an elliptical machine and a stationary bike, along with new medication, Mauer was finally given clearance to test his back with light running. He was able to run for consecutive days and was then cleared to begin running the bases. After successfully passing those tests and, perhaps more importantly, feeling well the day after running, Mauer was cleared to play in a simulated game, which he did Monday. That was the first game situation he had been in since the end of last season. The Minnesota Star-Tribune reports that Mauer will head to Class A Fort Myers on Friday for approximately six games. The goal now is to build up Mauer's endurance to ready him for a return to major league action.

So far this is good news for Mauer; the primary things that were limiting him (most notably running) appear to not be hindering him at all right now. But keep in mind that his activity has still been very controlled. And it is still somewhat of a mystery why he developed inflammation in the sacroiliac area, a highly unusual injury for a baseball player. The true proof that he is beyond this episode will be when he can last the season without any recurrence of symptoms. Until then, there will always be some concern as to whether the issue has truly been resolved or has just subsided for a period of time as a result of less activity.

Brandon Webb has started throwing again, making the Arizona Diamondbacks and his fantasy owners very happy. Webb was placed on the DL on April 13 because of shoulder bursitis. Webb had reported some stiffness in his shoulder, and the team opted to proactively rest him to prevent it from turning into a more serious situation. The news on Webb has been good so far, and despite the workload he has turned in over the past few years, I am not any more concerned about Webb's shoulder than that of any other pitcher. His next test likely will come Friday, when, according to the Diamondbacks' Web site, Webb will throw another bullpen session, perhaps incorporating inning breaks to see how his shoulder responds to periods of rest between throwing.

Tampa Bay's Jason Isringhausen threw two innings in an extended spring training game Saturday, followed by an outing for Double-A Montgomery on Monday. Izzy has dealt with injuries to his hip in the past and is now returning from surgery to repair a torn flexor tendon in his forearm. Look for him to potentially contribute to the Rays' bullpen by June. Despite his injury history, Isringhausen still has something to contribute, and the flexor tendon surgery he had is not nearly as serious as ulnar collateral ligament reconstruction. He will no doubt come in under the radar but could be a valuable addition.

The Angels have been hit hard by injuries, most dramatically in their pitching staff. The loss of Nick Adenhart stands alone. Three other aces were ailing to start the season, however, and all three are working toward a return. Kelvim Escobar, who was far ahead of schedule in his return from labral surgery, had a minor setback. But he is playing catch again and should be back on a more-significant throwing progression soon.

Meanwhile Ervin Santana, who has a partially torn UCL, has been able to throw his full complement of pitches in bullpen sessions. Santana's program is very structured and gradual, because the fact remains that he has tissue damage, and the team wants to bring him along slowly. So far, he has passed every test. Although the signs are encouraging, especially the fact Santana is reporting no pain, he still has some big hurdles to pass to return to major league action.

John Lackey, who started the season with inflammation in his throwing elbow, has been able to throw all of his pitches in bullpen sessions. Lackey told the Los Angeles Times that he still is "feeling something" in his elbow but feels he needs to push through it. He is expected to throw a simulated game Wednesday, and the Times notes he could begin a minor league assignment later this week. Lackey and Santana could rejoin the team at some point in May if their progressions continue well. I would not be surprised to see Lackey first, while Santana might be held out a little longer.

Last but not least, Royals outfielder Jose Guillen, who reluctantly went on the DL because of a hip flexor injury earlier this month, plans to rejoin the lineup when eligible Saturday. He told the Kansas City Star, "I'll be ready." This injury did not appear serious when it happened so I'm inclined to agree with Guillen's assessment.