Braves take risk with injured veterans
Can Wagner, Hudson, Glaus, Saito hold up after recent surgeries?
The Atlanta Braves have a lot to be excited about heading into 2010, including a hot young hitter named Jason Heyward. Like any team, their success hinges on the health of their players. Since the Braves added a few folks who are coming off injury, it appears their moves involved some calculated risk. Naturally they expect the reward to outweigh that risk.
Here's a look at four Braves players, three of them new to the team this year, whose injury concerns are a topic at spring training.
Billy Wagner: The Braves signed the veteran closer to a one-year, $7 million deal in December and are depending on him to be their ninth-inning guy. The decision not only to add him to their staff but also to rely on him in such a major role indicates they have confidence in his health. But should they?
Wagner is not only a, shall we say, mature pitcher at age 38, he is also not long removed from Tommy John surgery on his left (throwing) elbow. Wagner's Tommy John surgery, or ulnar collateral ligament reconstruction, took place in September 2008 and was made even more complex in that he simultaneously underwent repair of the flexor/pronator tendon. According to ESPN.com's Jayson Stark, Wagner indicated that along with the tendon repair and ligament reconstruction, he had bone chips removed and that the ulnar nerve was also addressed. Four things happening at once sounds like a big deal, so we break it down, piece by piece.
Bone chips are often a by-product of stress on the elbow. Sometimes throwers -- like Johan Santana this past year -- have procedures just to remove bony fragments while the ligament remains intact. In the event that the ligament fails, as was the case with Wagner, any loose fragments would be removed during the course of repair, so that component of the procedure is not unusual.
When a player speaks about having something done with the ulnar nerve, he is typically referring to an ulnar nerve transposition. Basically, the procedure moves the ulnar nerve from its normal position just behind the bony prominence on the inner elbow (the "funny bone" area) to the ventral (or front) surface of the forearm. The nerve can become irritated when there is a lot of stress on the medial side of the elbow, as is often the case with throwers, leading to numbness and tingling into the fourth and fifth fingers. In some cases the nerve subluxes, or slips in and out of its groove along the elbow, again leading to numbness, tingling and even pain. Some surgeons prefer not to move the nerve unless it is specifically causing a problem pre-operatively; others do it as a matter of course when they do the surgery.
The rationale for transposition is that the nerve now travels a shorter distance with one fewer "kink" along its pathway. In other words, instead of traveling around the elbow and back into the forearm where the nerve is essentially placed on stretch every time the elbow flexes or bends, the transposed nerve travels a relatively straight line along the arm and down into the forearm. The result is that the nerve is put on slack (meaning less stress and tension) every time the elbow flexes or bends. Some prefer not to move the nerve because of concerns about scar tissue binding around it over time. If a player is having issues with the nerve at the time of ligament reconstruction, it will likely be transposed as part of the surgical procedure.
The addition of flexor-pronator repair to a UCL reconstruction means the surgery is more extensive than if there was no need to repair the tendon. The tendon anchors the flexor-pronator muscle group (responsible for flexing the wrist and rotating the forearm downward) to the bone, right in the vicinity of the UCL. While the addition of the second surgical component doesn't change the overall rehab picture much, it does slow the process slightly, as there is a desire from the medical side to be a bit less aggressive. The success rate of Tommy John surgery averages around 85-90 percent, a very high number compared to returning from other injuries that require surgery. One surgeon I spoke with suggested that the addition of a flexor-pronator repair simultaneously might lower that success rate to a percentage in the high 70s.
The more surgery an athlete requires, the bigger the question mark when it comes to his return. Recovery from Tommy John surgery is fairly predictable, but a combination procedure in an older thrower significantly decreases that predictability.
Here's what really worked in Wagner's favor when it came to the Braves' willingness to take a chance on him. Not only did Wagner complete a fairly uneventful rehab and recovery -- in fact, he was doing so well that he had to be held back a bit as a precaution -- he has already demonstrated that he can pitch successfully. Wagner returned late last year to pitch in 17 games. More important, he pitched well and did not experience any problems. That last fact singlehandedly overrides some of the risk posed by Wagner's age and complex surgery.
It seems that the Braves have made a good calculation of risk versus reward, and it could pay off nicely. Wagner says that his arm feels great and that he's landed with a team he's wanted to be with and a manager he's wanted to play with for some time. If the rest of him holds up, he should be in good shape.
Tim Hudson: Like Wagner, Hudson alleviated concerns about the health of his surgically repaired elbow by returning for several solid outings in late 2009. Hudson was returning from Tommy John surgery and had been off the mound since the middle of 2008. It is not uncommon to see pitchers struggle with command when they first return from this injury, not because of the injury or surgical repair, but in response to being away from the game for so long. Pitching is such a complex combination of coordinated movements and timing that the body has much to relearn after a year away from competition.
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The good news for any pitcher returning from this surgery is that the success rate is very high. Unlike attempting to return from a shoulder labral or rotator cuff repair, which has far less consistent results, recovery from this elbow ligament reconstruction is generally more predictable. One of the reasons is that during this procedure, the damaged tissue is replaced by a tendon from another part of the body, most often from the forearm, meaning the athlete gets an entirely "new" support on the inner side of the elbow. This ligament replacement has a rejuvenated shelf life, and as long as care is taken to progress the rehab gradually so as to allow all the tissue around it to heal well, there should be no major setbacks.
At 34 years old, Hudson still has some throwing years left in him and his three-year contract with the Braves indicates they believe that to be the case as well. Although Hudson was challenged by oblique injuries several years ago, that had not been a problem for him recently. One could argue that a bonus of the extensive time off after Tommy John surgery is that it allows the entire body a reprieve from the demands of pitching, with a gradual return that focuses on proper form and mechanics. It won't be long before we see how that plays out for Hudson, but if the end of last season is an indicator, the Braves have reason to be optimistic.
Troy Glaus: Glaus is another interesting addition to the Braves' roster, coming off an injury-riddled year of his own. The biggest issue for the 33-year-old last year was a persistent shoulder injury. As he described it, several MRI arthrograms (in which dye is injected into the joint to help visualize it) of his ailing shoulder showed no structural damage, yet conservative rehab failed to alleviate the stabbing pain he would experience every time he brought his arm forward to throw. Ultimately surgery was decided upon to take a closer look and per Glaus, his surgeon, Dr. Lewis Yocum discovered a subscapularis tear and addressed it.
The subscapularis is one of the four muscles of the rotator cuff and functions as an internal rotator as well as a stabilizer to the shoulder. Subscapularis tears can be hard to detect clinically because there are so many other strong internal rotators in the shoulder that can compensate for a deficit in that muscle. In the absence of direct visual evidence of a tear (and not every injury is visible on MRI), it's easy to understand why this may have been challenging to diagnose.
After surgery, Glaus was slow to recover (and he sustained another injury shortly after he returned last fall), but he believes that despite the frustration of the unwanted extended time off, he has a far better appreciation for what the particular needs are for his body to stay healthy. He described an offseason of workouts "without any limitations," focusing on more "dynamic" workouts (for example, incorporating lunges with lateral movements) and increased repetitions with lower weights. Listening to him, I was impressed by the mature outlook of an athlete in the second phase of his career; he has been through a number of injuries and learned from them. When speaking about his transition to first base, Glaus added that he knows he will need to learn the nuances of the position but that he already knows the particular demands for his arm. "I don't need to throw 90 miles per hour, but I do need to throw at multiple angles." Consequently he focuses on the exercises that target his particular needs.
Glaus sees himself as healthy now with the plantar fasciitis issues of 2008 behind him, along with the shoulder and everything else for that matter. The time off because of injury last year may have actually given his body some much-needed rest. Nonetheless, his history of soft-tissue injuries is noteworthy and makes him appear to be more at risk for some similar episode. It certainly seems that Glaus has taken all the steps possible to try to ensure his health across the season. Now he and the Braves are counting on those measures paying off.
Takashi Saito: Many likely remember that Saito suffered a sprain of the UCL on his right (throwing) elbow in 2008, an injury significant enough to sideline him for two months. What might be overlooked is that Saito was the first Dodger recipient of a PRP (platelet-rich-plasma) injection to address his UCL sprain. That course of treatment, along with a solid rehab plan, may well be the reason he was sidelined for only two months. Consider that Saito, now 40 years old, was well advanced in his pitching career and that a ligament reconstruction might have meant the end of the road. If he could pitch successfully following a course of rehab, however, he might be able to extend that career a few more years. And it appears that he has done just that.
The cloud over Saito's 2008 injury did indeed have a silver lining in that he suffered an acute sprain. Unlike a chronic ligament injury where a player experiences progressively increasing pain over time, Saito threw a pitch, felt a sharp pain in his elbow when a portion of the ligament tore and was immediately unable to throw again. Acute injuries are better suited to a trial of PRP injection, a procedure whereby blood is withdrawn from the athlete, centrifuged to separate out the platelet components and serum that is then injected into the injured region. Platelets contain growth factors that help speed the body's natural healing processes, and since they are already present in the patient's own blood, there is nothing artificial or additive about the procedure. Following a three-week rest period to allow the tissue to heal, a pain-free Saito gradually resumed throwing and was able to return to action within eight weeks. Compare that timetable to what would have been a minimum year-long absence -- maybe even retirement -- had he required Tommy John surgery.
Although Saito joined the Boston Red Sox for the 2009 season, he remained essentially injury-free. While the Red Sox could certainly be credited with using Saito wisely so as to avoid overstressing his elbow, the fact remains that he survived the season without a setback and performed well enough to convince the Braves that he deserved a shot.
So are the Braves worry-free? Not by a long shot. After all, Saito's elbow has logged many miles at this point. There are many other structures within that elbow that have yielded to wear and tear at this stage. Saito no doubt has some arthritic changes in the joint and there really is no way of knowing just how healthy that ulnar collateral ligament is. Small changes in the function of the elbow can translate to huge drop-offs in performance. That said, Saito has shown that he still has something left in the tank as long as his elbow -- along with the rest of his 40-year-old frame -- cooperates.
Stephania Bell is a physical therapist who is a Board Certified Orthopedic Clinical Specialist and a Certified Strength and Conditioning Specialist. She is a clinician, author and teacher with extensive experience in the area of orthopedic manual therapy and sports medicine.
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