Commentary

Baseball Injuries 101: Sprains, strains and other pains

Updated: February 21, 2008, 5:18 PM ET
By Stephania Bell | ESPN.com

You have to learn to take the good with the bad in life -- and sports.

Spring sports goodness comes in the form of the afternoon sun, fresh-cut grass and the crack of a bat, all signaling the coming of baseball. Spring also guarantees the less-pleasant arrival of taxes, allergies, and in the world of sports, injuries. Some players are coming back from injury, others get hurt during spring play, but either way, you must account for the injury effects as you prepare for your drafts.

You will have an edge in fantasy gaming when you can assess how concerned you should be about a particular injury to a particular athlete before your competition can. Hitters and pitchers are completely different creatures, and for the most part, so are their injuries. That's why I'm here: To help you prepare for this year's fantasy baseball season by creating a primer of some of the key injuries you will see in baseball injury reports.

Hitters

Hitter injuries tend to run the gamut of infinite possibilities. Anything is possible because most of them are unpredictable. For instance, Yankees first baseman Doug Mientkiewicz broke his wrist last season in a nasty collision at first base, and Milton Bradley tore his right ACL when manager Bud Black restrained him from umpire Mike Winters during an argument. Nonetheless, there still are a few consistent ailments that tend to crop up with hitters, either as a result of baserunning, fielding, sliding or batting.

The muscle strain

Also referred to as a "pull," "tweak," "twinge" or "tear," the oft-reported muscle strain is the ultimate definition of boring when it comes to baseball injuries, but it is so commonplace that we would be remiss if we did not address it. The most commonly strained muscles for hitters tend to be the hamstrings (large muscles on the back of the thigh) and the quadriceps (large muscles on the front of the thigh) because these are the power muscles used during explosive running. Baseball is a game of frequent stops and starts and rapid acceleration and deceleration, which demands power from these muscle groups. Other muscles hitters tend to strain are the calf (lower leg) and oblique abdominals. The calf muscles aid in push-off and deceleration and typically get injured while running, while the obliques, the muscles that help rotate the trunk, are most often injured during power swings. One of the easiest ways to strain a muscle is to demand this explosive type of activity when the muscle is cold or tight. I have often thought that warming up on a stationary bike in the dugout prior to entering the on-deck circle would go a long way to decreasing the home plate to first base hamstring strain, but I'm not sure we will see that implemented anytime soon.

Strains are assigned a grade of I (mild), II (moderate) or III (severe), and a strict timetable for return to play with any grade is impossible to nail down. Teams rarely reveal the extent of an athlete's muscle injury, which often can't be precisely determined anyway (except in the case of a complete tear). But there are some guidelines to follow in case more information is given.

A mild strain is often not even noted as a formal injury but might be as simple as a player feeling the leg "tighten up." A Grade I strain suggests there is either no or minimal visible damage to the muscle fibers, but there is microtrauma, which can result in pain and inflammation. The athlete might miss up to two weeks, or he may not miss any time at all. A Grade II strain suggests definitive damage to the muscle itself and has the widest range of deficit and time lost. A Grade III strain reflects a complete tear of the muscle (there might be a few fibers that remain intact, but for all intents and purposes, the muscle has been disrupted). This severe injury typically results in surgical repair for a major muscle group like the quads or hamstrings, as was the case for Indians outfielder David Dellucci, who tore his left hamstring from the bone in 2007.

Roco Baldelli
Icon SMIWhen you think of muscle strains, you think of Rocco Baldelli.
The above definitions reflect the acute or sudden muscle strain, but there also are muscle injuries that can repeat over time and become chronic. Chronic strains can be extremely debilitating and potentially career-threatening; just ask Rocco Baldelli, who has been bothered by chronic hamstring injuries to both legs.

There are many theories as to why athletes suffer muscle strains, often pointing to multiple variables as opposed to just one. One thing to consider for your fantasy draft, though: Is a player you are considering prone to repetitive muscle strains (such as Baldelli)? Or has he experienced a recent string of multiple muscle strains to different body regions (like Eric Chavez), which might suggest that he is wearing down physically, especially if his baseball age is advanced? How fit is the athlete? Better conditioning appears to be one factor in maintaining better overall health. Treatment primarily consists of rest, with the key being adequate time to allow proper healing. Modalities such as ultrasound, light therapy and electric stimulation can all be used to help influence tissue healing, and exercise is used to help restore the muscle's strength and flexibility as healing permits. Even when a fantasy owner is dying to get a player back in his lineup, it is important to keep in mind that the risk of returning an athlete too soon after a muscle strain is reinjury, which might ultimately result in a worse outlook than the one associated with the original injury.

Meniscus tears

In 2007, we witnessed several players struggle through meniscal injuries, including David Ortiz, who did his best to push through pain as he hobbled around the bases during the World Series. The meniscus is a fibrocartilage disc, of which there are two, inside the knee joint. One sits on the inner aspect (medial), and one is on the outer portion (lateral). The discs help provide some cushion between the two bones, the tibia and femur, that form the joint, and they actually serve to increase joint stability. When a meniscus develops even a minor tear, it can behave like a hangnail, "catching" in the joint as the knee tries to go through various motions. This catching can cause the knee to lock up, preventing normal range of motion, and it can be painful, making it virtually impossible to pivot (such as when a player swings a bat), run or slide, all of which, incidentally, can be the same things that can lead to a tear in the first place.

Many minor meniscal tears are addressed via arthroscopic surgery, in which the offending flap is removed. Once the flap is removed, the athlete can return to the sport, usually within four to six weeks. But there might be future consequences, depending on the size and location of the tear. Larger tears are more problematic because the knee loses a bigger piece of its cushion. If the location of the tear is at a point where there is extensive joint pressure, the absence of a portion of the meniscus results in bone-on-bone contact, which ultimately can lead to wearing of the protective cartilage and associated inflammation (arthritis). Occasionally a meniscus tear will be repaired via stitches if that seems like a viable option, but the rehab period for a repair is much longer (several months) than for a removal. The repair advantage? The athlete keeps the protective cushion inside the knee joint. So why isn't that done every time? Because the meniscus itself does not have a great blood supply, which means tears tend not to heal well, hence the reluctance to repair it.

Players will typically have this type of injury surgically addressed, and most often it will be a partial removal (meniscectomy) instead of a repair. Depending on the timing of the injury and the degree of disability, however, the team and player might opt to defer the procedure until the season ends (like in Ortiz's case). So what can you expect from an athlete who is playing despite a meniscal injury? As a fantasy owner, you can expect the athlete to be up and down with it, and you will have to contend with unpredictability. The injury can affect a hitter's swing (because it limits his ability to pivot), his speed (especially rounding bases), and it will impact his base-stealing ability (hurts speed and ability to slide, especially feet first).

Hand/wrist injuries

There are too many possible variations in this category to elaborate on all of them, but suffice it to say that typically these injuries are the result of the hand making contact with something it shouldn't. An errant pitch, collision with another player and a dive to the ground all can result in a finger or wrist sprain (ligament injury), a fracture (broken bone) or dislocation (a bone slips out of the joint). The severity of the injury will determine whether treatment is as simple as "buddy taping" two fingers together or as complicated as surgery. Time missed can range from as little as a few days for a sprain to months if a bone, ligament or tendon is badly damaged. A primary concern for hitters after such an injury is their ability to grip the bat. Can they bend the finger or hand enough to control the bat? Can they maintain their grip throughout the range of their swing (which dictates power)?

Ryan Zimmerman
Mitchell Layton/Getty ImagesFantasy owners have no reason to worry about Ryan Zimmerman.
Broken bones in the wrist affect hitters similarly. These days we hear more about hamate fractures in hitters, often in the non-dominant hand. The hamate bone has a hook-like projection that sits very near the surface of the palm, and it can develop a crack as a result of contact with the bat or shearing of the tendons that pass over it. Athletes often don't recognize an initial specific injury but begin to complain of pain and swelling in the area at which point imaging, usually a CT scan, uncovers the problem. Treatment might involve surgery to remove the broken piece, and it typically takes a couple of months to recover. Once fully healed, the good news is that this should not be a recurring problem (meaning Nationals third baseman Ryan Zimmerman should be in good shape for 2008). Other wrist and forearm fractures vary in terms of severity, depending on the location and the complexity of the fracture. Most simple fractures take roughly six weeks to heal, however, so if a member of your fantasy team succumbs to one, you can count on at least that window of time.

Pitchers

The injuries that affect those players who throw for a living tend to be much more similar, and any baseball fan can probably rattle off a list of common pitching ailments, much like the standard lunch menu at the company cafeteria. Rotator cuff tendinitis, elbow tendinitis and medial elbow ligament disruption requiring the dreaded Tommy John reconstruction are a few of the most familiar. Although back, hip and knee injuries can and do occur, the primary nemesis for a thrower is any injury that compromises the million-dollar (or multimillion-dollar) arm.

Elbow tendinitis

This injury label is generic, simply meaning inflammation of some tendon around the elbow. For throwers, the most commonly affected tendons are those located on the medial or inner aspect of the elbow. It is here where the tendons of the wrist flexors (which bend the wrist down toward the ground) and the forearm pronators (which rotate the forearm from a palm-up to a palm-down position) attach, hence the term flexor-pronator group. The flexor-pronator muscles provide protection to the elbow joint by countering the torque produced during pitching, so lingering problems here can put the elbow at risk. Treatment begins with rest, while also addressing pain and swelling, followed by soft-tissue work and strengthening. Time lost will depend on the severity of the episode, but you can usually count on a couple of weeks at the minimum. If managed well, this can be a "one and done" type of scenario. As an example of just that, Mariners closer J.J. Putz developed a flexor-pronator strain during spring training but was available to pitch by the start of the regular season and held up well through the remainder of 2007.

Rotator cuff tendinitis

The terms "tendinitis," "inflammation" and "strain" are often used in combination with the words "rotator cuff" to describe any problem affecting this muscle group or the tendons that anchor them to the arm bone or humerus. The rotator cuff is a group of four muscles (supraspinatus, infraspinatus, subscapularis and teres minor) that combine strength and finesse to coordinate the motion of the shoulder. This muscle group represents the pitcher's bread and butter; its most significant functions are to help stabilize the arm in the socket and decelerate the arm from the violent motion of pitching. The forces are so great at the shoulder when throwing that the rotator cuff must work extremely hard during every pitch. The effectiveness of the rotator cuff muscles is further dependent on the muscles that control movement of the scapula, or shoulder blade, and these muscles are often surprisingly weak in pitchers.

When throwers develop rotator cuff problems, and almost all of them certainly will at some point in their careers, initial treatment usually begins with a "shutdown" period, meaning no throwing, so that the shoulder can completely rest. The time period varies, depending on the seriousness of the injury and other treatment to help decrease pain, and inflammation happens concurrently. As the shoulder improves, strengthening exercises are initiated, not only for the rotator cuff but also for the scapular muscles. If that goes well, the athlete is progressed to a staged throwing program. If the athlete successfully completes each stage of the throwing program, then he moves on to bullpens, simulated games and usually even rehab starts until the team, in conjunction with the medical staff, determines that he is ready to resume game-situation pitching.

Jason Schmidt
Rob Leiter/MLB Photos via Getty ImagesJason Schmidt's shoulder surgeries makes him a risky draft pick.
After offseason rest, this condition often settles enough for the athlete to return in the spring without a hitch. The fantasy owner who sees this crop up midseason, however, has a sense of dread, and deservedly so, because it can become a recurring theme throughout the season (read: multiple trips to the DL), and the timetable for return has a wide variability, ranging from the pitcher missing everything from a few weeks to the rest of the season. In the worst-case scenario, there might be a tear in the rotator cuff that ultimately requires surgery (think Dodgers starting pitcher Jason Schmidt, who underwent his second shoulder surgery in 2007). Return after rotator cuff repair is not a sure thing, so a fantasy owner should hope for an athlete's recovery after conservative treatment. Any pitcher coming off rotator cuff repair is a risk in a fantasy draft, and although it can turn out well (such as Pedro Martinez in 2007), the risk likely outweighs the reward in the early stages of the athlete's return.

Labral tears

Injury to the labrum of a pitcher's shoulder is not something a fantasy owner wants to hear. But guess what? You will hear it, and frequently. Labral tears are just part of the territory that accompanies being a major league pitcher; it's just a question of degree and disability. In other words, if you were to look through a surgical scope at the inside of a thrower's shoulder, including those who had no reported injury symptoms, you would find damage to the labrum more often than not. The fascinating thing is that some pitchers manage to throw and throw well despite the presence of significant tissue damage. Other pitchers have a relatively minor injury but are completely incapacitated. The reason for this is unclear. It is not necessarily a question of pain tolerance; rather it appears to be a much more complicated mechanical picture.

The labrum is a ring of cartilage that surrounds the glenoid or the "socket" portion of the shoulder joint and actually serves to enhance shoulder joint stability. When torn, the labrum can catch, causing the shoulder to be painful and potentially feel unstable. The biceps tendon has an attachment to the labrum, so if the biceps is involved, it can lead to problems at the labrum. The labrum undergoes great strain where it attaches to the biceps at the extremes of motion, such as when the shoulder is at its fully cocked position before ball delivery and at the end of ball release (during follow-through). Since a pitcher repeats that motion time and again, not only during a game but also during warm-ups, bullpen sessions and any other throwing, the labrum is constantly subject to stress. Surgical repair might be the eventual treatment in a thrower who does not respond to a period of rest and conservative rehabilitation, and the recovery is lengthy. Pitchers do return from labral repair, but their timetable to return and their effectiveness when they do return is quite variable. Fantasy owners who draft a pitcher coming off an offseason labral surgery should recognize that there is a risk involved until the athlete shows that he has indeed regained his form.

"Dead arm"

We often hear about this phenomenon associated with pitchers, but what is it really? Generally speaking, this term is associated with arm fatigue from overuse. It tends to crop up during spring training, when throwers resume a more intense schedule after the offseason. This also can affect young pitchers who get moved up to the majors midseason. The adjustment to the level of competition, as well as the strain of an increased workload, can take a toll on the young pitcher's arm. It is not completely understood, but the interesting feature is that the symptoms are predominantly weakness, not pain. Weakness means the pitcher simply can't deliver the ball the way he intends, and as a result becomes ineffective. There is also some notion that the condition is associated with instability in the shoulder, which is not uncommon for throwers since their shoulders are inherently "looser" in order to allow them to do what they do. Combine decreased joint stability with fatigue of the muscles that help support that joint, and you have an ineffective arm.

Treatment is very simple: rest. The thrower is shut down, usually for a period of at least two weeks, to let the arm recover, and is then gradually introduced to throwing again. Unlike most other injuries, the dead-arm syndrome does not appear to have any long-term injury implications in and of itself, so it does not spell doomsday for fantasy owners. It might, however, signal that a thrower needs to increase his overall strength for long-term protection of his shoulder.

Ulnar collateral ligament (UCL) reconstruction (Tommy John surgery)

By now, this procedure has become so commonplace among pitchers that it commonly is referred to by its nickname, Tommy John, who was the first major league pitcher to undergo this operation. The actual ligament that is damaged, which then needs to be reconstructed, is the ulnar (medial) collateral ligament, which reinforces the inner aspect of the elbow and runs from the end of the humerus (arm bone) to the ulna (inner forearm bone). When this ligament is damaged, the pitcher loses command of his pitches and typically has pain directly over the area of the ligament. Additionally, the elbow joint can be less stable, although this is not a defining feature of the condition. The surgical procedure involves taking a tendon from elsewhere in the body (most often one of the forearm tendons) and weaving it through drill holes in the two bones where the ligament normally attaches, thereby reinforcing the inner aspect of the joint. The rehabilitation process is long, typically spanning one year from surgery to pitching again.

The timing of the surgery might influence the timing of the return as well. For instance, Twins hurler Francisco Liriano had his surgery in November 2006 and will return in spring training of 2008, giving him an extra few months of rehabilitation and game preparation. The fact that throwers must take so much time off to allow proper healing from surgery and gradually return to throwing affords them the opportunity to address other areas of concern. Even with a primary elbow injury, many throwers have shoulder concerns as well. The lengthy rehab time allows throwers to strengthen the muscles of the shoulder, fine-tune the muscles of the core and generally get in better baseball shape.

This total body rehab might be a big reason throwers feel they can throw harder after such a surgery. Their delivery might be aided by the fact that their body is in better shape, placing less demand on the arm itself. Although pitchers can come back with a solid performance in the first year, statistics seem to reflect a two-year timetable is most ideal for a return to form. This might be because a year away from throwing means the pitcher needs to rediscover the "finesse" portion of his game again. Strength comes first, command and control come later.

Chris Carpenter
Marc Serota/Getty ImagesChris Carpenter is just one of many top pitchers to have "TJ surgery."
Overall, the statistics reflect a pitcher can have a successful return if he's willing to dedicate the time and effort required to have a good outcome. The motion of throwing a baseball will continue to place unnatural demands on the shoulder and elbow, and this surgery will continue to have a place in the sport. Like the aforementioned shoulder surgeries, it is an option of last resort for a pitcher who simply can't continue to perform because of the elbow. Pitchers typically will go through two cycles of rest and rehabilitation before ending up on the operating table, so fantasy owners should keep that in mind if one of their pitchers develops a case of disabling elbow pain. The part that is hard to predict when a pitcher goes out with elbow pain is whether it will be a single episode that he will overcome (such as Felix Hernandez's last season) or it is the beginning of a disabling cascade (Cardinals ace Chris Carpenter never could make it back after Opening Day, eventually having the surgery in July). It is worth noting that even a single episode of serious elbow pain raises red flags that the thrower might be headed for further elbow breakdown. Unfortunately, that could happen within the season, or months to years later.

Certainly there are plenty of other injuries that will make themselves apparent over the course of a season, but these seem to be the ones we hear about over and over again. The challenge for fantasy owners is that rarely do injuries fit a neat timetable, and rarely does the same injury behave the same way in two different athletes. A little knowledge can go a long way, though, in helping the fantasy owner set a lineup or make a trade. With that in mind, we wish you the best of luck and a healthy roster in 2008. Play ball!