UTK 7/29/20

Second Opinions, Flexor Freakout, and more

Reader John V asked me a great question via email: “Normally a player like Justin Verlander would be on the first plane to Birmingham to see Dr. Andrews. That’s obviously not happening this year, so are they stuck with team doctors or how does it work?”

The answer is that Drs. Andrews, ElAttrache, Dugas, Kremchek, Altchek, Meister, and the handful of others that are normally consulted on arm injuries have adjusted like the rest of us. Even in normal times, a lot of the consulting was done on the phone. MRIs can be wired over, medical files can be reviewed, and everything short of an actual physical exam can be done. Even then, the doctor can ask for manual testing to be done while he watches via FaceTime or Zoom.

Where things change is the actual surgery. Players and doctors took some heat for doing Tommy John surgeries during the initial stages of the pandemic, despite doing them in places where “elective surgery” was legal and available. A lot is going to depend on location - Florida is still a massive hot spot, as is Texas, California, and Alabama. Would that push someone to New York (Altchek) or Cincinnati (Kremchek)? Doubtful, unless that was already their preference. We haven’t yet seen a team/player/agent bring a doctor to the patient, which would be very unusual but has been discussed.

Right now, a player who needed Tommy John surgery is likely to lose all of 2021 to the rehab as is, which makes the timing of the surgery a bit flexible. In talking with the people around the league, any situation that didn’t require immediate surgery would likely be delayed at least a few weeks to see if the situation changes. The rest is pretty standard, if adjusted like everything else in the world

Thanks again for the question and if you have one, I welcome your emails. One of my hopes is to publish answers here in the column, like this, so we can spread some knowledge. Now, on to the injuries:

Miles Mikolas SP STL (strained forearm)

Houston, we have a problem. St. Louis too. All around the league, we’re seeing one injury more than others and well above the norm we would see at any point in a season. That flexor strains in all their varieties are outpacing Tommy John surgery is odd, to say the least. There’s simply no explanation for it and I’ve spoken with doctors, pitching coaches, and more over the last couple days. We didn’t see this in the spring, we didn’t even see it much in Summer Camp, but suddenly, flexor strains are everything.

First, let’s discuss what it is. The above video gives a bit on the anatomy and the causation. It doesn’t give any indication of why we’re seeing an outbreak - pardon the term - of these strains. There’s theories, but that’s all the are at this point, but to my mind, none are worth detailing because none feel correct.

Miles Mikolas’ strain is significant enough that he’ll need surgery. His season is done and the recovery and rehab could take him into next season, depending on how significant the surgery has to be. Players do come back from this kind of surgery well, including Tommy Hunter and David Robertson.

For surgery, it has to be a really significant strain, something that’s not going to heal on it’s own, so it remains a last resort kind of surgery and therefore somewhat rare. Once we get a better idea of how much work had to be done, we’ll have a better idea on when Mikolas should be back. For now, Daniel Ponce de Leon will take the slot in the very thin and very risky Cards rotation.

Stephen Strasburg SP WAS (nerve impingement)

The nerve impingement in Stephen Strasburg’s arm seems to be getting better. He’s been able to throw and reports are that he has less tingling in his hand. The issue is the root cause - is something merely impinged, as in a carpal tunnel situation, or is something further up his arm inflamed, causing the nerve pinch? The worst case scenario is that this is like Peyton Manning, an issue coming from his spine, but that would be easy to find via imaging, so I have to think the Nats have ruled that one out by now.

If you think of the nerves in the arm like small, fragile ropes, you wouldn’t be wrong. They run down with a certain length to a certain spot, but if it gets ‘grabbed’ at a spot higher up, it gets moved or pinched. That’s bad and interferes with the function, causing pain or numbness. Think about when you sleep on your arm funny and wake up with it tingling. That’s a very simplified version of what’s going on here. The key is to figure out the cause and stop it as much as possible. Inflammation is the easiest to deal with, but none of them are good in the short term.

Corey Kluber P TEX (strained shoulder)

It might be a sign of the world we’re living in that Corey Kluber is leaving the Rangers to do his rehab where he does his offseason work. Eric Cressey is a top physical trainer and sports expert, so much so that the Yankees hired him to take care of his athletes. Yes, he can work with others, including his longtime trainee, Kluber. Kluber’s strained shoulder is going to take at least a month to heal up, but he’s going to be in Massachusetts working to make sure that time is used efficiently.

Is this just a preference or can Cressey do more for Kluber than a team can do? I don’t know, especially with all the great staff and tech additions the Rangers have made. What I know is that Cressey is more than qualified and that Kluber is comfortable there. That’s worth something. If he can rebalance and rework himself after this teres strain, Kluber can still be valuable for the Rangers and give them some more data to determine whether to bring him back next season.

Kyle Crick RP PIT (strained shoulder)

Velocity is one of the defining qualities for modern pitchers. Yes, you can succeed as Kyle Hendricks, but unless you have plus-plus and very consistent command down there at 90, you’re going to get killed. 96 and up? Studies have shown over and over that there’s a linear difficulty to hitting pitches.

The downside is that not many people can hold together at those kind of velocities. What’s the highest “safe” velocity? No one knows, though it should be knowable just from the Statcast databases. Kyle Crick’s been 96 and up since his conversion to relief and he was expected to be the high leverage short guy for the Pirates pen. He pushed to the IL quickly with a generic “strained shoulder.” The team sources aren’t leaking out what’s strained, so it’s difficult to give any time line here. But it’s not good.

Andrelton Simmons SS LAA (sprained ankle)

I heard someone call Andrelton Simmons a “fast healer.” I’m not sure where that came from, since he’s been relatively healthy. I wonder if the internal brace thumb surgery he had - same as Mike Trout - that got him back quickly got mistaken for fast healing.

Regardless, Simmons has a significant enough ankle sprain to hit the IL. David Fletcher will shift over for the position, but he (and most everyone else in the league) is a defensive downgrade. There’s some rumor due to the mechanism that Simmons doesn’t have a true ankle sprain, but just watch this video from MLB and you can clearly see him crank that ankle over on first base. I can’t tell if he stepped on the first baseman at all, but regardless, it’s going to be a week or so before we see him again, though these kinds of sprains tend to heal pretty cleanly. So much of Simmons game relies on his feet and ability to make quick lateral moves, so it could be a bit longer, quick healer or not.

Quick Cuts:

Clayton Kershaw could be back on the mound as soon as Friday. His throwing session on Tuesday went well. Expect a workload limit to keep this first outing on the short side … Juan Soto got his second negative test and is cleared to return. Expect him in the lineup asap … Both Travis d’Arnaud and Tyler Flowers are making progress after they were held out with “illness symptoms,” per one Braves source. Yes, they’re being very careful with words … Dario Agrazal isn’t a big name, but add another name to the list of early season flexor strains. See above for my take on this … Strained lat? Yes, another lesser seen shoulder-area strain, this one to Mike Montgomery. There’s no timetable on his return after a disastrous first outing … Kris Bryant has a bruised elbow so got a day, maybe another, off while it heals. The Cubs do not think this is serious … Nate Pearson debuts today and yes, I’m excited to see this.