Tag Archives: Baseball

Brian Wilson – Tommy John

Its true.

Our beloved bearded wonder will not be closing this year. But long before the wonderful run in 2010 and the beard that became a San Francisco sensation, Brian Wilson’s elbow underwent significant stress to the point of a ligament rupture and the long rehabilitation of Tommy John Surgery.

I thought this would be an appropriate time to give ya’ll a run down of Tommy John surgery, what some of the main reasons for it are, why Brian Wilson may be looking at his second, and what that means for him trying to come back an All-Star closer.

First off a little about what Tommy John surgery is, and why it is used so much in baseball.  The Ulnar Collateral ligament (or medial collateral ligament) is made up of three different bundles of fibers that runs along the inner aspect of the elbow. The job of the the UCL is to provide stability at the elbow, especially when the shoulder is externally rotated like the cocking and acceleration  phases in pitching (below )

Because the UCL’s job is to protect the elbow during the throwing motion, overtime the UCL can weaken and eventually rupture, causing instability at the elbow and an inability to throw. Poor throwing mechanics and weakness in the muscles of the shoulder, trunk and even lower body, have been found to relate to a pitchers likelihood of injury at the elbow.  The number 1 factor in UCL tear is bad mechanics, and the number 2 is overuse. You put them together and you are an injury waiting to happen.

The details of poor mechanics are for another blog, but one thing that stands out and is something you can look for when watching for mechanical flaws is where the elbow and shoulder are when the lead foot makes contact. You want the arm up and in what we would call external roation, meaning it is just about ready to come forward and release the ball. When you see the arm below the shoulder it means the shoulder and elbow are behind the trunk and legs and puts a tremendous amount of stress on the shoulder and elbow. Looking at Strausburg (tore UCL in first season in the majors) and Cain ( hasn’t missed a start in his 7 years in majors) you can see a difference.

Tommy John surgery is used for a player that has significantly torn or even ruptured their UCL. The repair involves using an unimportant ligament from the  opposite forearm, threading it through the ulna and humerus of the dominant arm, and allowing the new ligament to scar down and add stability to the elbow. Many times the player may have increased velocity following the surgery secondary to the ability of the new ligament to withstand more force than the original. I learned personally in my time interning with the padres that many players view tommy john surgery as a positive, thinking that they will have the surgery and a year later will be throwing 3-5 mph harder.

Not necessarily the case.

AT BEST a player will throw off the mound for the first time a year after having TOmmy John, however it can be up to 18 months, and only 80% of pitchers that have the surgery make it back the level they were throwing at before. However over time that graft can deteriorate, and without changing the mechanics, one can find themselves right back where they started.

Brian Wilson was pitching on borrowed time. And if you look at how his release point has changed in the last three years, you can see this damage to his elbow started a while back.  The graph below represents his horizontal release point and you can see the release point continued to decrease dramatically and that puts tremendous stress on the elbow.

Now lucky for Wilson he stopped pitching before it ruptured and it sounds the the MRI is showing only grade II sprain. In a pitcher that hadn’t had the surgery yet Tommy John might be appropriate, however Brian Wilson may opt out of it and try and rehab it without surgery secondary to the much poorer outcomes of a second surgery.

Of course, all of baseball hopes he comes back.

Moral of the story though?

If it breaks and you fix it, make sure you address WHY it broke to begin with.

GO GIANTS,

House

Athletic Pubalgia – Nick Markakis and Ryan Zimmerman

A surgery this week to Baltimore Orioles outfielder Nick Markakis caught my attention. His case is very interesting and something I thought I’d share with you all. Markakis initially injured himself last September while stealing 2nd base when his belt buckle dug into his pelvic area and caused him immediate pain. This injury was re-aggravated while diving for a catch in right field on the last game of the year, causing him the inability to remain in the game. After the season was over Markakis had an MRI and was diagnosed with a bone bruise and instructed to rest. After adequate rest time, and no change in his symptoms, another MRI was perform and muscle tears in his rectus abdominus (Athletic Pubalgia ) were diagnosed, and recently surgically repaired.

Baltimore Orioles - Nick Markakis

Earlier in the 2011 season Washington Nationals third baseman, Ryan Zimmerman, underwent a similar surgery to repair torn muscles in his abdominals. Zimmerman didn’t have a specific injury to his abdominals, however continued to have persistent abdominal pain that progressed and was eventually diagnosed as Athletic Pubalgia.  Although he was told 6 weeks, it was nearly 12 weeks before Ryan Zimmerman was back in action for the Nationals.

Although Athletic Pubaligia, is often called a “sports hernia” it is not a hernia. The term “sports hernia” is sort of an umbrella term that refers to any tear of muscle, tendon or ligament in the lower abdomen or groin. These tears can occur with quick sudden changes in direction, forced hip movement with the foot planted, or with forceful exertion of the abdominal muscles. It is commonly found in athletes who participate in sports that involve repetitive twisting and turning such as football, baseball, soccer, ice hockey, rugby and tennis. It can cause abdominal/groin pain, increased pain with sprinting or twisting, pain with coughing or sneezing, pain during and after activity and minimal pain at rest.

Muscles and Tendons Involved in Athletic Pubalgia

There are several muscles of the abdomen and groin that attack to the pelvic bones and serve to stabilize the joint during twisting motions. In the picture to the left you can see the rectus abdominus (your six pack muscles ) attach to the bone of your pelvis, as well as your External Obliques, the hip flexor and groin muscles. You can see that with repetitive swinging, tremendous amount of stress will be placed on this structures and eventually micro tears and tears can occur. It has been theorized that an athlete may be prone to this injury if muscle imbalances are present with strong adductor (groin) muscles and weak abdominal muscles. The strong going muscles can create a pull that can overpower the abdominals and make these muscles prone to tears.

The surgery to repair these torn muscles is similar to reconstruction of the knee. The surgeon with re-attach the muscles down to the bone using sutures that will provide stability. After the surgery, the athlete can expect to be walking the same day, however will be limited in lifting and baseball activities for up to 6 weeks. The most important part of rehabilitation for Nick Markakis, as well as anybody else, is to address the imbalances that contribute to this injury. If those imbalances are not addressed in rehabilitation he may continue to have pain and possibly re-tears in the future. This could be the reason it took Ryan Zimmerman longer than expected to return. Markakis will be focusing on stabilizing with his abdominals (rectus, obliques and transverse ) more, and firing his going muscles less.  My guess is Markakis will be at 100% be the second week of the regular season, should everything go as planned in rehab.

Thats all for now. Hope that makes sense.

Football playoffs means baseball season is right around the corner. GO NINERS.

Blessings,

HOUSE

References

Sueki, Derrick, and Jacklyn Brechter. Orthopedic Rehabilitation Clinical Advisor. Maryland Heights, MO: Mosby Elsevier, 2010. Print.

“MLB News | MLB.com: News.” The Official Site of Major League Baseball | MLB.com: Homepage. Web. 08 Jan. 2012. <http://mlb.mlb.com/news&gt;.

Home Page. Web. 08 Jan. 2012. <http://coreperformancephysicians.com/&gt;.

Vicente Padilla: Radial Nerve Injury

This is a rare occasion.

Yes, its true I’m going to talk about a Dodger, but only because I find his injury so interesting and something worth talking about. Padilla is a right handed pitcher that has been a starter / long reliever in the majors for over ten years. He has bounced around several teams in that time and also had a battle with injuries over his twelve year career.

His most recent bout of injury has intrigued me. In April of last year (I know this because I’m an uber nerd that keeps track of this kind of stuff), Padilla started complaining of forearm tightness and soreness in his pitching arm. Not an uncommon complaint of pitchers, however the tightness was enough that the Dodgers had to place Padilla on the DL and he was diagnosed with radial nerve irritation. He came back, but struggled with tightness and weakness the entire year, and only started 16 games for the Dodgers (good news for the Giants though… and Aaron Rowand)

This radial nerve irritation kept him sidelined into spring training this year, and in February he had a surgical release of the nerve. By April, he came back to replace the struggling Jonathan Broxton (he’s going to be a whole different blog….) as the dodgers closer, pitched a few games, and then was placed BACK on the DL again MAY 14th  with more “radial nerve irritation.”

The radial nerve passing through the Supinator muscle (Ss being the superficial and Sd being the deep heads of the muscle).

Just to give you a quick anatomy break down, the radial nerve runs through the deep muscles of the forearm, and splits right at the elbow into a deep branch (PIN) and superficial branch (SR). This is the most common site of nerve entrapment because the nerve has to run directly through the Supinator muscle. When the supinator gets inflamed, or overused with repetitive movements, it can compress on the deep branch of the radial nerve and cause severe pain and weakness in the forearm.

I guess the next question would then be; why or how does the Supinator muscle get inflammed? Well, supination of the forearm is the motion that brings your palm up towards you (like you are asking for soup is how I remember it), whereas pronation makes your palm face down. This is important because when pitchers throw a breaking ball (slider, curve, cutter…) his hand is supinated when the ball is released. The opposite would be true for a change up, where the ball would be released with the hand pronated. So he could have caused irritation in that supinator muscle by over throwing breaking balls. Possible. However, a lot of pitchers throw a lot of breaking balls and yet this is not a common injury. The other cause for a muscle getting overused, is the weakness of other muscles, causing one particular muscle to do the work, which is probably more likely his case.

The common treatment for pitchers is for a surgeon to make a small incision, find the place where the nerve has been getting entrapped, and simply make more room for that nerve so it isn’t being compressed. This is what they did with Padilla in February. Now, his nerve has been compressed for some time now (at least since last April), so its no surprise that even after surgery he continues to have problems with it, and had to go back on the DL. However, if he doesn’t address the cause of why this happened to begin with, he will continue to aggravate it no matter how much room they give that nerve.

Hope that makes sense.

By the way…..congrats to FC BARCELONA on the Champions League Title. Someday I will marry David Villa…just saying.

House