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Wednesday, June 8, 2011
Heyward's injury situation very tricky


It looked like it might come to this. Atlanta Braves outfielder Jason Heyward had been sounding increasingly uncomfortable over the past week with the status of his injured shoulder, and just as he headed to Orlando for an expected rehab assignment, he told David O'Brien of the Atlanta Journal-Constitution that he did not plan to return until his shoulder had completely recovered.

Jason Heyward
Jason Heyward had a down year in 2011, as he hit just .227 with 14 home runs in 128 games.

A declarative statement by an athlete as to when he will or will not return to action, particularly if that statement sounds at all disconnected from what the team has indicated, is bound to draw a line in the sand between that athlete and his organization along with perhaps his teammates. In this case, Chipper Jones said a less-than-100-percent-healthy Jason Heyward was still a better option for the team than an absent Jason Heyward. (The complete article by O'Brien is a must-read to appreciate the entirety of Jones' comments.) Notably, Jones said, "There are a bunch of his teammates that are out there playing with discomfort and not healthy."

One need not limit these scenarios to the scope of athletics. These situations play out every day in the world of worker injury; the worker believes he risks at the least poor performance and at the worst further injury if he returns to his station even in a modified capacity while injured, while the employer would prefer to have the employee contributing in some form even if he is not 100 percent healthy. There is often no clear right or wrong position, in part because there is rarely anything black or white in any realm of medicine, but the perceptions of both the employer and employee in the areas of loyalty, work ethic and commitment might come into question and can create very real and lasting animosity. Fellow employees also can become divided in their loyalties when they see a colleague they value on the job out on disability, even as they might be working despite injuries or issues of their own. The end result can be a bitter parting of the ways between an employer and employee, sometimes with legal action or compensation involved. Other times an employee might eventually return to the job, but the relationship between employee and employer -- or even between employee and fellow colleagues -- is permanently damaged. Or, the employee can return, ultimately become more productive than ever before and everyone lives happily ever after.

So how will this chapter between Jason Heyward and the Atlanta Braves be written? While it is too soon to know the outcome, all the attention this is drawing requires a look back at the events over the past month.

The Injury

In brief, here is a summary of what has been reported regarding Heyward's shoulder injury.

• Heyward made an early exit from a May 10 game because of discomfort in his right shoulder (non-throwing shoulder, but his lead shoulder when batting). Heyward indicated he also experienced numbness in his hand and forearm. In addition, he revealed the shoulder had been bothering him intermittently since spring training, which had contributed to his inconsistent swing.

• Heyward underwent an MRI, which revealed "inflammation" in his shoulder. He was given a cortisone shot and rested several days.

• Heyward returned to the lineup but lasted only a few days. He said his shoulder still did not feel right.

• Heyward was placed on the DL on May 22. He underwent a contrast MRI later in May, and the Braves referred to the results as "normal wear and tear." According to O'Brien, Heyward clarified that the inflammation was in the area of the labrum.

• Heyward was sent to the team facility in Orlando to continue work on his shoulder and ultimately begin a rehab assignment. According to O'Brien, Heyward indicated he would not return before the shoulder was fully recovered.

The Analysis

The more vague the injury, the more challenging it is to provide any detailed analysis from a distance, specifically because it is the interaction with and examination of the patient that provides the best information.

First and foremost, anyone who works in sports medicine will remind people that you treat the patient, not the picture (such as an MRI). A surgeon could view two shoulder MRIs side by side -- one with myriad findings including, for instance, wearing of the rotator cuff, a labral tear and inflammation, alongside another that looks pristine -- only to find out the MRI with findings belonged to a patient with no symptoms and the clean MRI went with the patient who could no longer throw a baseball. If a surgeon chose to operate on the patient based solely on the bad MRI, it would be a poor choice. To borrow a phrase from Dr. James Andrews, "If you're looking for a reason to operate, get an MRI." In other words, most baseball players are going to have some type of positive findings on MRI but many, if not most of them, do not need surgery.

This is where the patient with his description of what's happening and how it's limiting him comes into critical play during the evaluation. When the patient's complaints, the examination in the clinic AND the MRI findings all match, it becomes much easier to isolate the problem and determine the correct course of action. Unfortunately, that is not always the case. So when we hear reports that the MRI of an athlete who has suffered some type of injury showed "no structural damage, just inflammation," it might be encouraging that there are no catastrophic findings, but it might yield a far less definitive course of action. Unfortunately for a patient, the tendency is to use the MRI findings to justify the injury. If there are devastating findings, the player's suffering is understandable; if the findings are unremarkable, garden variety wear and tear, the player is often expected to press onward, despite the disparity that often exists (especially in shoulders) between an athlete's symptoms and his MRI.

Take Heyward's case. The diagnostic findings are relatively non-specific. Yet he has been having trouble with his swing all spring, and as it turns out, his shoulder has been bothering him intermittently throughout that time. Anyone who follows his numbers can see that he has been inconsistent in terms of productivity, something he relates to his shoulder causing an inconsistent swing. Heyward's own description of his shoulder feeling "like it's loose, like there is space in there" are words patients often use when describing instability. While he was not diagnosed specifically with a labral tear, according to Heyward, the inflammation was near the labrum.

Even minor wear-and-tear damage to the labrum, a cartilage ring that helps enhance stability of the joint, can result in feelings of instability, which often translate as a loss of power at the plate. Again, this is NOT to state that this is the case for Heyward, but it is food for thought.

The Management

Here comes the tricky part. The medical staff has the incredibly difficult task of caring for the injured athlete and returning him to play as quickly as possible without risking further injury. Clearly, this is not a precise science, and the staff's expertise and experience go a long way in determining just when it is safe for an athlete to return to competition, even if he might not be at 100 percent.

Enter Chipper's comments. As a veteran, Jones knows that many times players are on the field when not fully healthy, perhaps even putting up subpar numbers. Jones also knows from personal experience that sometimes injuries can sideline even the most earnest of players, whether or not those injuries appear outwardly to be particularly serious.

The question becomes, in the absence of an easy decision (for instance, when an athlete has a broken bone and he has to sit out until the bone heals, something clearly measurable and identifiable on X-ray), when does the athlete play and when does he rest? If he plays through injury and performs poorly, is that better than not playing at all? If he plays and his condition worsens, was it still a good idea to play? Perhaps the answer to those questions depends on who is being asked. Teammates might initially appreciate the athlete who is gutting it out and playing through pain … but will that appreciation last when he is failing to drive in runs? If given the choice, would players rather wait several weeks for a fully healthy teammate or have that teammate on the field for the remainder of the season but at only 70 percent? If an athlete's numbers drop dramatically and he is perceived as having lost his edge or being a bust, was it wise for him to press in the face of injury?

These are questions without answers, at least not universal answers upon which everyone could agree. But they are the types of questions that if not asked, are at least pondered, regularly by any athlete in any sport who suffers an injury, along with his teammates and perhaps the entire organization. The higher profile and more valuable the athlete is to his team, the more likelihood that the situation plays out in a very public way, as is the case with Heyward.

As far as his next steps, the most recent reports indicate Heyward is feeling improved and could start swinging a bat within a few days. Until he swings the bat again, it's impossible to know how his shoulder will respond and what the next chapter will be.

One thing is certain. No matter how long the drama over this episode persists, no one is planning on an end to the Jason Heyward story coming anytime soon.