Commentary

Sox right to be cautious with Beckett

Updated: March 12, 2008, 11:15 AM ET
By Stephania Bell | ESPN.com

The Red Sox do not want to start off the 2008 season without their ace, but they might have to do just that. Josh Beckett, who had some soreness in his back throughout the prior week, began experiencing back spasms March 8 after he lost his footing on the mound during warm-ups, according an ESPN.com report.

Apparently the mound had been in use earlier in the day, perhaps rendering it a little softer than usual, and Beckett's landing (left) foot slid as the ground beneath gave way during his release. A little slip or loss of balance and the body tries to correct itself, using every available muscle to do so. When the muscles seize up, the result is pain and stiffness; anyone who has experienced a muscle spasm knows that while it can take just a split second to bring on, it can take days, even weeks, to resolve.

Although Beckett reportedly felt much better the next day, he said two days later that he felt significantly worse, a pattern not uncommon with any episode of low back pain. ESPN.com reported that Beckett was having trouble being in any one position for too long and felt the need to keep moving, also not unusual for individuals suffering from an acute episode of low back pain.

Josh Beckett
AP Photo/Charles KrupaJosh Beckett finished second in the American League Cy Young voting in 2007.
So what exactly is the diagnosis? Beckett said his injury is a "strained muscle or pulled muscle or whatever you want to call it" while the club is officially calling it "discomfort." The MRI of Beckett's back was negative, and a disc injury has been ruled out.

The spasms themselves reflect a protective guarding or splinting by the muscles, but the trick is figuring out why the muscles are in spasm and addressing the source. There are so many pain-generating structures within the spine that it is often difficult to localize a problem. Joints, ligaments, discs and even the muscles themselves can suffer direct insult that can trigger pain. This pain often results in protective muscle spasms, which are the body's way of preventing unnecessary movement to avoid further injury to the area.

Although the MRI was negative, this alone does not eliminate any particular structure, particularly a disc, from being a source of pain. Numerous studies have shown that individuals can have severe pain without significant findings on imaging (such as MRI). Likewise, individuals with numerous findings on MRI can exist relatively pain-free.

There are a number of theories as to how this all works, but one of the key features is inflammation. Even minor inflammation can trigger a significant pain response, yet it may not correspond with any physical finding. That is why diagnoses are rarely based on imaging alone. The patient's history and the clinical examination play a critical role in determining the source of a problem, with imaging serving to enhance that process. This would suggest, then that, based on a clinical exam, the Red Sox medical staff determined Beckett's problem to be predominantly muscular.

It is worth noting, however, that a minor disc injury -- one too small to be noted on imaging -- could result in enough inflammation to trigger similar pain and spasms. In fact, this is how such problems often begin. Rarely is there a one-time blowout of a disc; it is usually a progressive episodic problem. Although there are no guarantees, the best chance of preventing this from escalating during the season is ensuring adequate rest and recovery for Beckett right now, even if it takes a few weeks.

In the end, from a treatment perspective, the course of action is fairly straightforward: rest, rehab and focus on core strengthening activities combined with total body flexibility while reintroducing throwing. Beckett appears unlikely to make the trip to Japan, not only because he may not be ready for a start, but because the duration of the flight could be enough to exacerbate his condition. (Peter Gammons reported that the main reason Beckett would travel, should he decide to do so, would be to continue treatment with the Red Sox medical staff.) In fact, Beckett is not likely to pitch until April, since he has yet to pitch in a game. The Red Sox want to protect the long-term health of their ace across the season, a reasonable possibility if he recovers well here. Just don't expect to see him in the beginning.

Stephania Bell is a physical therapist who is a board certified orthopedic clinical specialist and a certified strength and conditioning specialist. She is the injury analyst for ESPN.com Fantasy.