UTK 8/21/20

Free Friday: Paxton, Molina, Strasburg, and Cupshots

It’s been a long week of injuries for MLB and they don’t seem to be slowing down. Injuries are up and we’re seeing odd patterns and clusters, outbreaks and season-enders. Here’s a look at some of the biggest injuries and the things you need to know about them. You get this information near-daily if you’re a subscriber to Under The Knife, plus starting next week, you’ll get my football columns on Thursday and Sunday. All for just five bucks a month. Right now, let’s get to the injuries:

James Paxton SP NYY (strained forearm)

It looks like it’s another forearm injury for baseball. As James Paxton walked off the field, he could be seen pointing and perhaps rubbing on the distal side of the elbow, precisely where we’ve seen a lot of injuries this season and as yet, there’s no clear reason why we’re seeing this versus the more normal Tommy John-type ligament injuries. Paxton will have an MRI on Friday that will give more guidance, but it’s hard to imagine that this won’t push him to the IL.

The Yankees have been hit by a lot of injuries and around the league, there’s some poking and prodding at a medical staff that was turned over to keep from having precisely these kinds of issues. While the Yankees are always high profile, I’m not sure that in this short, weird season, that we’ve seen any sort of sign that the Yankees are experiencing more injuries than anyone else. Lose Paxton, Judge, and Stanton in the same week and yes, it will appear that way and it certainly doesn’t help fill out the lineup card.

The worry here is that Paxton - who has had shoulder and back problems in his career - is on a similar path to Justin Verlander. We’ve seen that it’s taken Verlander almost a month just to be throwing again and his return is unclear. If Paxton is on a similar schedule, the Yankees won’t get him back until just before the end of the season. The MRI should give us more info today, so be watching for any sign that this goes beyond the flexor, that the UCL is intact, and that

Yordan Alvarez DH HOU (strained knee)

Last time out, I discussed why the situation with Yordan Alvarez seemed weird. I was wrong in thinking that he was dealing with a degenerative situation, but as the situation is clarified, it becomes even more confusing. Alvarez is headed for surgery with a patellar tendon strain, one I’m told is significant and for surgery, it would have to be.

The patellar tendon is the thick tendon that underlays the kneecap (patella) and is a thick, strong structure. For there to be a tear there usually takes significant trauma and is very visible on MRI. Like, very.

Let’s go beyond this and take a look at how the repair happens, as demonstrated by Chris Ahmad, the Yankees team doctor:

WARNING: this one’s not the easiest to watch.

Sorry, I can’t change the keyframes so for you squeamish people, hope lunch is good. The fact is that the Astros had to have known Alvarez had this issue and that someone decided that he could try and play through it. It didn’t work, potentially getting worse in a very short period of time, pushing him to a surgery that will have him back by a normal spring training, but just barely.

Something’s missing here. The Astros medical staff doesn’t miss things like this - no MLB medical staff does, especially with the signs Alvarez was exhibiting. I’ll continue to try to figure it out, but Alvarez is done for the season. He’ll have every chance to come back in the future and this kind of surgery shouldn’t affect his ability to do the things he does. At worst, he’ll be a full time DH, but he was on that track already.

Kirby Yates RP SDP (bone chips, elbow)

After a very encouraging (relatively) report that Kirby Yates has bone chips in his pitching elbow, Bob Nightengale had a report that Yates is done for the season. None of my sources could tell me what changed, if anything. Yates was headed for a second opinion with Texas doctor Keith Meister, but that exam did not happen in person yet.

I’m not saying Nightengale is wrong here, but not all of this lines up. Bone chips change, but they are a simple operation and one that even in this shortened season shouldn’t cost more than a couple weeks. Big decisions like this aren’t made with an appointment upcoming, so I’ll say that absent further information, Yates’s status is in a holding pattern here. I can say that what I wrote yesterday still feels true based on my conversations today. (Quick reminder that subscribers can always go to undertheknife.substack.com and read all the back issues. Non-subscribers can only read free articles.)

As of Friday, there’s no additional clarity on Yates’ situation. It is unknown whether Yates has made the scheduled visit to Dr. Meister.

Bo Bichette SS JAY (sprained knee)

One of my favorite phrases is “as you read here yesterday.” So, as you read here Monday, Bo Bichette’s knee injury is to one of the collateral ligaments - in this case, the lateral collateral (LCL), which is on the outside of the knee. Let’s go to the video for the anatomy lesson:

Most of you don’t need to do that manual test, but you can see why I was sure the Blue Jays had a very good idea what was going on here. Yes, it’s really that simple.

For Bichette, the Grade I sprain means it won’t need surgery and that it shouldn’t take that long to heal up. The real issue is going to be function. Will Bichette need to have some sort of bracing to protect it, or will he be stable enough to go out and do the kind of high stress, no-think lateral moves that a shortstop has to make? The medical staff and Bichette will test things out over the next week or so, but this should not have short or long term consequences.

One of the keys is that Bichette has no meniscus involvement. The LCL will heal and the leg is stable enough for most function right now. It’s those high stress lateral moves that could happen that he’ll have to be protected from. Could they shift him to DH for a bit? Perhaps, but even that shouldn’t be long term. The Jays got a bit lucky here, but luck is often created by hard work.

Stephen Strasburg SP WAS (inflamed wrist)

Carpal tunnel is a very common condition for a lot of people. It’s probably best known in those who type a lot, though any sort of repetitive activity with the arms and hands can lead to it. Activities like jackhammering can cause it and in severe cases, surgery is required. It’s not a difficult surgery - it’s basically opening up a ‘tunnel’ for the nerves t run through without being pinched - but it is very fine, given the size and amount of structures.

Where it’s not common is pitchers, but that doesn’t help Stephen Strasburg. He’s dealt with this issue for much of the summer. It cost him his first scheduled start and after just a few times back out, he started having symptoms again. He has the classic ones, numbness and finger weakness, which as you can imagine is quite the problem for a pitcher.

There’s a lot of conservative therapies for carpal tunnel, including rest, so don’t think Strasburg is heading right to surgery. With any surgery, you have to time them backwards. This is easy for pitchers since you start with Opening Day, work in how much time they’ll need to ramp up, and then calculate in the normal rehab time from whatever procedure. Most will quote about six weeks for recovery from carpal tunnel surgery, but that’s mostly made up of middle-aged data entry clerks. It’s still safe to say that the Nats could hold off on surgery for quite a while to see if they can avoid it altogether.

The next question is whether Strasburg is done for the year. I don’t think it’s there just yet, even with the comments from Davey Martinez indicating that they’ll be very conservative with him. The medical staff could find something quickly that resolves this, so I think they’ll keep working in hopes he could return. That said, the Nats will plan as if he won’t return or that his return will be well off in the distance of a weird season. The Nats will also watch the standings to see how they’ll play this, even with expanded playoffs.

Yadier Molina C STL (illness)

Yadier Molina is back in workouts and reports out of St. Louis have him pushing to get back on the field. This is no surprise and is extremely on brand for Molina. My question is whether this is a situation where his reputation and team standing will outweigh good sense in getting him back on the field.

This isn’t a situation like pitchers where workload management is key, but it’s not completely dissimilar. I’m sure Molina and the other affected Cardinals didn’t just shut things down, but they also had to change what they did and it’s fair to expect there was some level of reconditioning on top of the “out of tune” that happens when baseball players don’t baseball for a bit.

Molina’s longevity and durability are a bit of a double-edged sword here. He should know his own body and the medical staff should know what to look for to declare him ready to go, but again, his position makes it harder for him to not just write his own name in the lineup, as he’s done in the past.

What are the dangers? The simplest is that he would be at more risk for burst injuries, muscle soreness or strains, and there’s some evidence that shows there’s a bit of an increased risk for “catcher injuries” - foul tips, bruises, etc - in the immediate weeks following a longer term absence. It’s less for shorter stays, which amounts to an on-field IL stint. It’s the off-field downtime which is unusual and makes it more difficult to analyze exactly what to expect.

The positive is, we should know very soon. Molina began working at the alt site on Tuesday and could be back as soon as this week, though most reports say that Molina’s return is more likely to happen this weekend, pending game action and the results of those workouts.

This seems like a good place to note that the St. Louis beat writers have done an amazing job covering what is a very difficult situation. They’ve not only been able to give information despite no access, but they’ve shown that trust and relationships matter far more than standard access. (I’m still in favor of standard access, mind you.) The beats deserve credit for their work, both writing and in endless interviews, plus a lot of social media handholding for a very vocal fan base.

UPDATE - with Matt Wieters headed to the IL himself, Molina was really forced back into the lineup. Molina was pushing anyway, but the Wieters injury made it impossible for the Cards to pull back on the reins. We’ll definitely have to see how this goes now that Molina is back and active, and without a great backup option. I’m curious to see if the Cards will rest Molina more in this first week.

Quick (New) Cuts:

Cory Knebel hits the IL with a hamstring strain. The Brewers will be careful to make sure he heals well and doesn’t alter his mechanics, as he’s not too far out from his Tommy John rehab and return … Gleyber Torres took a bad step coming out of the box and now, he’ll be in a tube. Torres is having an MRI for what the Yankees seem to think is a significant hamstring strain. He could miss a month, if confirmed in today’s imaging … Very bad news for Brendan McKay. The surgery he had on his shoulder was for a significant labrum tear. It’s not the 1 in 40 return it was when I first wrote about it in 2004, but it’s still an injury no pitcher wants … Mitch Garver has what the Twins are calling a “low grade intracoastal strain.” With his hard swing and being a catcher, they’re playing it safe and ILing him, though sources tell me they think he’ll be ready at the minimum … It’s unclear how Byron Buxton hurt his shoulder, but the inflammation is enough that he can’t play CF. The Twins will place him on the IL … Elvis Andrus heads to the IL to rest a strained muscle in his lower back. Hard to say if this is a burst injury, but the Rangers are getting to the root cause here and hopefully clears up the situation. It’s a quirky replacement, as how many times has a guy who came up as a catcher (Isiah Kiner-Falefa) started at shortstop in a later game? Where’s Joe Sheehan when you need him? … Willie Calhoun, who’s not the pure speed player some think he is, will be out three weeks with a hamstring strain, according to multiple reports. That would indicate a Grade II strain … Thoughts and prayers, Jose Alvarez.