Under The Knife 4/16/21

Free Friday: Big news, big returns, and big shifts

The big news in these parts is that I’ve signed to do a new book. I’ll have more details on it soon, but I’m excited about it. It’s not going to change anything you see here and I’m hoping that I’ll be able to figure out a way to make it an addition to your subscription or at least a discount. I’m already at work on it and a series of podcasts that go alongside it. I’m already doing a lot of interviews with people who will be quoted in the book, so I figured that’s another value add, though a bit outside the scope of UTK.

Anyway, as always, Free Friday is a recap of the week’s injuries for those that are not paid subscribers. Paying five bucks a month gets you this earlier, where it can better help your fantasy team, re-set your betting models, or just help you understand the game of baseball a little better through the lens of sports medicine and sports science. While it is a recap, I add new information and updates, so even if you read it when it came out, you can scan it again for UPDATES and the new info as well. Let’s get to it:

JD Martinez DH BOS (COVID symptoms)
Lourdes Gurriel OF JAY (COVID symptoms)

The COVID IL is one of those things I hope will be a fading memory soon, but at this stage, we’re seeing some use of it that feels unanticipated. In both cases it feels appropriate if unplanned, but there’s also some loopholes here that would need closing if this or something similar sticks around in the future. There’s always been a bit of play in the standard Injured List, but the requirements to go on it do exist and are followed. There’s no “shadow IL” like there is in the minors.

For JD Martinez, he went on the COVID IL as required last week after exhibiting symptoms, reported as the sniffles and a slight fever. He passed multiple tests and was reinstated immediately and went boom on his return with three homers in the game. I’d say he’s just fine now.

Gurriel is a more interesting case. He was placed on the COVID IL after having some symptoms post-vaccination. This is common and seems a good use of the COVID IL, especially since he’s in such close proximity to other players that likely aren’t all vaccinated. We still know very little about transmission, so the Jays used this to allow Gurriel some time and simply pulled a player from the taxi squad as intended. Gurriel was reinstated on Monday and should return to his normal role with the Jays.

I’m wondering if someone will look back at these 20 or 50 years from now and see “COVID” and think about it like we do with “Spanish Flu” — we know it existed, but very little detail, let alone the disruption it was once in each century. How will we tell people why there were no fans in the stands or why masks suddenly appeared in dugouts?

UPDATE: The Astros had a number of these cases during the week. Teams are spacing out player vaccinations due to these mild but substantive side effects. I’m also told that there’s absolutely no predicting it. A team physician told me that one of the players he saw with mild symptoms after the vaccine had already tested positive for COVID last year, while one of the most severe reactions he’d seen was in a young, healthy player. The unpredictability is problematic, but the biggest issue most brought up was vaccine hesitancy. Players are not required to be vaccinated and it seems to be player leadership that determines things. If the team’s star decides to get vaccinated, most follow, and vice versa.

Johnny Cueto SP SFG (strained lat)

Latissimus dorsi (“Lat”) strains have been on the rise for about a decade and function as a bridge inside the kinetic chain, from the arm and shoulder down to the back. It’s that big a muscle and kind of functions as a bit of both. Johnny Cueto is the latest to strain this muscle and as a Grade I or minor strain, he doesn’t have a big defect (tear) in the muscle. That’s good, but the muscle itself is slow to heal and susceptible to re-injury early on, so the timing on this is likely weeks, if not a month.

The bigger question is why this happened. Cueto is not an overpowering pitcher but his quirky, inconsistent motion might be putting more stress on the back of his shoulder through deceleration. The lat is part of that process, trying to keep the arm and shoulder attached as it goes from 100 to 0 in a very short space and time. Logan Webb is the likely replacement, but we’ll have to see how quickly Cueto can get back to some form of throwing to see how long he’s likely out.

Drew Smyly SP ATL (inflamed elbow)

Drew Smyly is the third rotation guy to go down for the Braves early this season. That’s not good, but Smyly’s forearm inflammation is the first to be purely a pitching injury. While we don’t know the exact location or cause, this kind of injury tends to involve the flexor, which can often be associated with overstressing the elbow. While it stuns many to think we don’t know what causes pitching elbow injuries, the fact is we don’t. It’s all theory. The most widely held of those is that the UCL is in part protected by the flexor muscles which act as a kind of brake or shock absorber. In many cases, those break down ahead of a UCL injury.

That’s not to say that’s what’s going on with Smyly. We simply don’t have enough information to know exactly what’s happening in his left arm. Smyly’s been bad through his first two starts, so it’s possible this is part of the reason. The Braves staff will have a lot more info after an MRI, so we should know soon if this is going to be a long stint on the IL for Smyly. If so, the Braves may have to do more than just call up Kyle Wright to bolster what was expected to be a strong rotation.

Fernando Tatis Jr SS SDP (shoulder subluxation)

Remember about a week ago when everyone was writing obituaries for Fernando Tatis Jr? His shoulder subluxation didn’t kill him, but you wouldn’t have thought so from some of the hot takes. Add in the daggers for the big contract the Padres had just signed their star shortstop to and you’d never think the next sentence would come: Tatis is likely to return this week, with a near-minimum stay on the DL.

The Padres are keeping what they’re doing with Tatis very closely held, with only a few people privy to it, so I won’t pretend I know everything that’s going on. It’s a significant start to a strengthening program as well as trying to formulate a maintenance plan to keep him going after his return. Both of those are works in progress because they’ll have to be adjusted to how Tatis responds. If one thing doesn’t work, they’ll move to the next, narrowing down the treatments and modalities to find the best and most plausible. That’s not an easy task, but it will actually be aided by him going into games.

Tatis’ shoulder is not out of the woods. He escaped significant internal damage, but a recurrence is possible and with that comes the risk of not being so lucky the next time. The downside here is that we see an immediate recurrence with more damage, or that Tatis isn’t able to be maintained and needs surgical intervention to repair any damage and tighten up the shoulder to keep this from being a recurrent problem.

The big worry is a big swing, but I can’t see the Padres telling Tatis to cut it down and become a slappy hitter. That’s not his game and certainly not what they’re paying him for, and remember, he initially hurt the shoulder on a throw, so the swing isn’t the only worry. They’ll likely say don’t swing so hard, dive so much, and so on, but baseball is such an instinctual game that’s hard.

This is a situation where I’d think a team would rush to find an expert and bring in someone, especially someone an injured player had worked with previously, to help with the process and the maintenance. The Padres have $300 million plus in Tatis, but they seem unlikely to spend money to bring in a specialist or even an extra Athletic Trainer to focus on Tatis despite his value and the rest of the team’s needs and injury issues. We’ll see how this goes and should get the early returns on Tatis later this week.

UPDATE: Tatis is expected to be activated on Friday after another batting practice went well. Tatis is feeling no problem with the shoulder on swings and sources tell me he’s not holding back. There’s still no official word that Tatis is planning off-season surgery, but he’s checked in with the usual suspects in terms of surgery. He has to be rostered in all formats and while recurrence risk is there, the reward is still pretty big.

James Paxton SP SEA (sprained elbow/strained forearm)

James Paxton’s season lasted 24 pitches. Paxton was placed on the IL after leaving in the first inning of his first start in obvious pain, but the injury was called a forearm strain. That kind of flexor strain isn’t good, but it obviously wasn’t the whole story. A second opinion led to a recommendation of Tommy John surgery, which would indicate a significant sprain of the UCL.

What we don’t know is who did the second opinion and if the team - likely the first opinion - agrees with this. This kind of thing is common and while some teams have rules about this, such as requiring a third opinion for a “tiebreaker”, they’re always a bit fuzzy. It comes down to how much the second doctor is trusted — if it’s an Andrews or ElAttrache, that’s tough to argue — and how much the team doctor wants to hold to his opinion. In the end, the decision is always the player’s, as it is for any medical decision.

We’ll see where this goes, but this one doesn’t look like it’s headed for a happy ending. Paxton did look good, showing he was back to his mid-90’s fastball in those 24 pitches. Maybe there was more in there. With a one year deal, I wouldn’t be surprised if the Mariners - already on the hook for his rehab - don’t sign him to another deal for ‘22 that might allow them to get something out of him yet.

UPDATE: Paxton had a another opinion come in and Tommy John was recommended for his sprained UCL. A source tells me that the tear is about half (50 percent) which is well above the normal threshold of a third. The surgery is not yet set, but the expectation is that Paxton will have the surgery, though the source tells me Paxton did ask whether he’d need the surgery and rehab if he retired. That’s a pretty standard question, so I wouldn’t read too much into it.

Tim Anderson SS CWS (strained hamstring)

The issue with Tim Anderson is less the hamstring strain itself, which has cleared up after a Grade I strain, but with the whole concept of recurrent injuries. For a speed player like Anderson, a hamstring injury brings up the idea that he will have a series of them and that it will erode his dominant skill. While there are examples of players adjusting to a changed skill set, there’s many more examples of players that have kept their skills by focusing on that area and making sure that they don’t get in the state where the injury occurred.

That’s going to be the focus in the longer term for Anderson and the White Sox. Some strains are simply overexertion, likely combined with some other stressors like dehydration or body chemistry. There’s a lot to the idea of recurrence risk, but the reality is mixed and so individualized that I feel like I’ve overplayed it here and in the past once I look at the data. Especially with hamstrings, the state of the art in terms of strengthening, gaining mobility, and even the rehab has advanced significantly, especially with the simple Nordic series of exercises and the variants that have developed more recently.

I think Anderson should be fine when eligible to return Thursday, at least in the short term. I don’t expect he’ll immediately go stealing bases, but his burst speed is more important for defense and stretching singles into doubles. He’s someone I think can clearly help the Sox at the top of their lineup and most fantasy rosters, as well as provide an immediate impact for the Sox in terms of run creation and prevention.

UPDATE: Anderson returned Thursday and looked good, scoring a run on a single and looking very comfortable (and fast) as he ran in. I continue to think Anderson will be fine and that the recurrence risk is likely overestimated by many.

Max Fried SP ATL (strained hamstring)
Mike Soroka SP ATL (Achilles repair/rehab)

Max Fried is case #1,001 in universal DH evidence. Fried injured his hamstring legging out a double - so he can hit, but the running part was the problem. This happens and is merely unlucky, but the Braves are in a more interesting position and I think both sides of this will affect how the team deals with this.

With Fried likely down past the minimum and perhaps as long as six weeks, the easy fix would be to slot in Mike Soroka, who’s been held back after Achilles repair despite showing all the skills, but he’s still not throwing after experiencing shoulder issues.

Will Fried’s injury - which is exactly the type of thing that the Braves worried might happen to Soroka’s Achilles on return - affect their willingness to bring Soroka back? The team has other options, but at some point, they’re going to have to bring Soroka back with those risks, as well as Fried once he’s back.

All pitchers and indeed all players have this kind of risk. It gets noticed more when it’s someone like Fried, especially with all the DH discussion, but the injury itself is as standard as it gets. The MRI he’s undergoing on Wednesday will tell us how severe and will give the Braves more information on how long they’ll be without Fried. With Soroka out, the team has players like Sean Newcomb who could shift to the rotation or maybe they’ll debut Jared Shuster, last year’s pick out of the Wake Forest pitching factory.

UPDATE: Fried was placed on the IL and the strain is considered minor, but will give Fried the chance to hit the reset button and lock in his mechanics. Soroka does not have a schedule for when he’ll return to throwing, with a source saying that the shoulder is still sore and a bit inflamed at the site of the strain.

Quick Cuts:

KeBryan Hayes has been swinging in the cages and could be activated this weekend after his wrist showed it can handle back to back days of hard swings … Cody Bellinger is very unlikely to be activated from the IL for the San Diego series. His calf is still problematic, especially in some dynamic positions … The Twins are specific in saying that Byron Buxton is dealing with tightness in his hamstring versus a strain. Taking them at their word, Buxton should be back shortly, but this hamstring is one that will need constant monitoring in the short and longer terms … Kevin Kiermeier has had great results during his rehab from a quad strain. He could be activated this weekend, weeks ahead of expectations … Nomar Mazara hits the IL with an abdominal strain that happened on a hard swing. His stay will be around the minimum … Joakim Soria will throw a pen over the weekend and could return to the pen next week if all goes well … Cavan Biggio escaped a fracture after being hit on the hand while at bat. It still hurts so we’ll see how much, if any, time he misses … Currently, the NBA is seeing an unprecedented number of injuries. The easy explanation is the pandemic, but while that’s involved, there’s more to it. I do wonder if the relatively normal off-season for baseball will help it avoid an uptick, though early data shows a lot of leg and core injuries.