Under The Knife 6/24/24

Un-Injected

It’s almost standard these days for any injury to be examined and then I get to write the phrase, “received a PRP injection. He’ll be re-examined in a week.” Elbows, shoulders, knees, sprains, and strains. The problem is, there’s very little evidence it works. More than a decade ago, Dr. James Andrews said at a conference that he did it because while he didn’t have the evidence, he sometimes saw good results and never saw a problem from the injection. Maybe it worked, maybe it didn’t, maybe it was placebo. There’s nothing really wrong with that statement.

But there’s growing evidence that it actually doesn’t work. One of the largest studies I’ve seen was just published, with a good sample size, great construction, and a very clear outcome. Yes, it’s not definitive, but that’s exceptionally rare in medical studies like this. (I read a lot of them.) Anytime something becomes a miracle cure, for everything from a torn ACL to regrowing hair, there’s a vast chance that something isn’t matching the hype.

This won’t necessarily stop PRP from being nearly automatic with most sports injuries, especially elbow injuries. With no evidence of harm and a very motivated patient and payor, throwing the kitchen sink at a problem is seldom questioned. With the small number of doctors in the space and the near-universal use, there’s no negatives to continuing. (Don’t underestimate the “rich payor” as a big part of this. We’ve seen this more and more in medicine as costs go up and rich people are willing to take on more and more cost for everything from cosmetic procedures to Ozempic.)

But it raises the question of improvement. Why are we using something that doesn’t show much effect, if any, instead of something that does. Finding something that does is hard, and often expensive and takes years. Better exists with ACLs and elbows, but surgeons continue to do older procedures that have longer recovery times because they’re established, practiced, and safe. Just not demonstrably better, as some new procedures are.

This has a cost. Ronald Acuna will miss six to nine months with his ACL. Let’s say we could push that down and lock it in at six by using a newer procedure. It doesn’t get him back for the playoffs, but it’s a shorter rehab, there’s great results, and it would have him with a near-normal off-season. Given his season after his first ACL, wouldn’t the Braves and Acuna want to give him a better opportunity to regain his movement, his confidence, and to get him back into his MVP-level preparations? This isn’t theoretical; this exists and was a known possibility for Acuna and any other ACLs that happen along the way, in any sport.

I’m not saying PRP is a scam and should be banned. There are positive studies as well, but most of them are observational, small sample, or use very specific high-dose protocols. There’s likely a place for PRP, but where should be up for debate. Remember that next time someone casually says “He’ll have a PRP injection and we’ll see how he progresses.”

For now, on to the injuries:

GIANCARLO STANTON, DH NYY (strained hamstring)

How you look at Giancarlo Stanton’s season thus far kind of depends on how you look at the game. His batting average and strikeouts offend the old-timers, his homers and the team’s record get noted by the casuals, while the stat crowd notes his low value and WAR. None of it is good, but the Yankees have been good enough to get past Stanton being a very expensive replacement level player with prodigious power.

Losing Stanton to a hamstring strain certainly isn’t good, but it’s not going to be hard to replace unless you lean in hard on disproved protection theories. The hamstring strain isn’t thought to be significant, but the Yankees have been a bit all over the place with announcements this year. (Leak check?) He’s likely to miss more than the minimum with this, even at the mildest and carrying it past the ASB for a moderate strain would be likely.

The replacement is likely to be pieces and parts, mostly Trent Grisham, but the significant opening is the DH. Using Aaron Judge there more might help him get a bit of rest, though his foot hasn’t been nearly the issue many expected. With the Yankees cruising, they may well use the time to try and figure out their best configuration for the playoffs, which may not include Stanton even though he’s functionally locked in to the Bronx until 2027.

MAX SCHERZER, SP TEX (strained back/inflamed forearm)

It’s not the route anyone expected to take after off-season back surgery. The thumb/forearm issue made the rapid comeback a bit slower, but Max Scherzer is still ahead of the expected schedule, though it was always a bit conservative. There’s been some speculation that the Rangers pushed Scherzer through, trying to get his value in since they don’t have a long term commitment to him. I doubt Scherzer would allow it and there’s no reason for the Rangers to risk anything given their expectations, even while playing under that level.

Scherzer was solid in his debut. He lived around 93, a tick down from where he averaged last year, and he didn’t let the adrenaline overtake him, a good sign. All his pitches worked against a solid enough Royals team, including a first inning S/M/K on Bobby Witt Jr. At 57 pitches, it’s a reasonable limit given where he was, though I’d been told his limit was higher. My guess is they saw something and adjusted down or just said get him out.

How Scherzer recovers is going to be the key now. With this rotation, more than most, fitting it together is almost as important as keeping it healthy. I’ll be watching to make sure he hits his between-starts work and whether the Rangers keep Dane Dunning back as a shadow since they’re technically on the ‘same day’. The thumb/forearm issue is far more the worry than the back at this stage.

With Scherzer back, Jacob deGrom on the horizon, and the sheer number of injuries they had in the first half, the Rangers should be a very different team in the second half. They’ve stayed close enough that if they can keep the players healthy once back and not just rotate people through the IL, there’s a chance to get back to the playoffs.