SB Nation User Blog: silent_bob

Carpenter, Mulder, Clement: A Medical Perspective

silent_bob — Sat, 19 Apr 2008 00:07:26 -0000

So far so good. The 2008 version of our beloved was supposed to “weather the storm,” “stay in it,” “hang on” until the starting pitcher calvary comes. Sixteen games in, six games over .500? Grravy.

Question is, are the guys we’re waiting for actually worth the wait? Matt Clement’s shoulder is STILL less than 100%. We shouldn’t be surprised, really. Matt’s throwing shoulder needed major reconstruction; including repairing the rotator cuff and tacking the labrum (the cartilage ring around the shoulder socket) back down. Pitchers usually aren’t the same after labrum repairs. In addition, Clement in the past has relied heavily on a sinker and slider. Both pitches place a large amount of torque around the shoulder and elbow joints.

We all know what Mark Mulder is trying to overcome. Nobody, not ZIPS, not Bill James, not Chone, likes his chances. Medically speaking, neither do I. I question why he didn’t feel pain while pitching with a torn rotator cuff in 2006. I question why his rotator cuff did not heal after his first surgery. I question why he again pitched without pain despite the failed repair. And yes, I finally admit, I question the medical/training staff’s rehabilitation techniques. If Mark’s shoulder didn’t give him negative feedback (i.e. pain) when he had a TORN ROTATOR CUFF, how can anyone reasonably expect him to find the mechanics that made him so effective in Oakland? So he’s now making rehab starts and we haven’t heard a negative “arm slot” comment yet. Will Mark Muldoo make a triumphant return? I just don’t see it. Prove me wrong, Mark. I beg you.

Now, on to Chris Carpenter. This guy seems to be a medical marvel; recovering from multiple shoulder and elbow surgeries prior to winning a Cy Young. He’s no spring chicken, however, at 32 years old. Tommy John surgery, as far as the public is concerned, is a career rejuvenator. The list of big-name pitchers who have successfully returned to form is long and distinguished (enter your own Top Gun quote here). My question: is the surgery as good as advertised? I did some digging to find outcomes research. Before getting to that, to give VEB readers a better understanding of what these pitchers are up against, I thought I’d shed some light on what goes on during the course of rehab.

Rehabilitation guidelines correlate with stages of healing. Tendons and ligaments generally take 6-8 weeks to heal. In most cases of TJS, a tendon from the forearm, the palmaris longus (sometimes they use a hamstring tendon or piece of the achilles), is cut out and looped between the two elbow bones in a figure-8 pattern to replace the torn ligament. The tendon takes at least the 6-8 weeks to heal and essentially turn into a ligament. Strengthening exercises for the shoulder, elbow, and wrist are progressed as appropriate during this 6-8 week window. Subsequent milestones are as follows:

Advanced Strengthening Phase (Weeks 9-13)

- In this phase, the athlete progresses with all strengthening exercises, begins power exercises (plyometrics), and resumes golf/swimming activities.

- Goals:

Increase strength, power, endurance
Maintain full elbow range of motion
Prepare athlete for gradual return to functional activities
Prepare athlete to begin to throw

Phase IV-Return to Activity Phase (Weeks 14-26)

- Goals:

Continue to increase strength, power, and endurance of upper extremity musculature.
Prepare athlete for full functional return.

- This is generally where the throwing program begins. A sample program goes something like this:

Step	Distance	Throwing Schedule	Min./Session	Special Instructions
1	30-50 ft	30-50 feet	10 to 15	Easy tossing, no wind-up
2	50-60 ft	2-3 days/week	10 to 15	Easy tossing, no wind-up
3	30 ft	alternate days	10 to 15	Lob ball
4	40-50 ft	2-3 days/week	15 to 20	Lob ball with easy wind-up
5	60 ft	2-3 days/week	20 to 25	Lob ball with occasional straight throw at 1/2 speed
6	100 ft	2-3 days/week	20 to 25	Lob ball with occasional straight throw at 1/2 speed
7	150 ft	12-day cycle	20 to 25	Throw 150 feet on 5-6 bounces
				12-day cycle: Throw 2 days, rest one (repeat 4 times)
8	150 ft	12-day cycle	30 to 35	Gradually increase to 150 feet and then decrease
9	60.5 ft	12-day cycle	30 to 35	Mixed with some long throws, 3/4 speed-full speed
10	60.5 ft	12-day cycle	30	Throw batting practice, 3/4 speed-full speed
11	60.5 ft	12-day cycle	25 to 30	Emphasize technique & accuracy, 3/4 speed-full speed
12	60.5 ft	12-day cycle	30 to 35	Gradually increase throwing time, 7/8 speed-full speed
13	60.5 ft	2 days/week	60 to 120	Game simulation including breaks between innings

According to most reputable sources, successfully completing this plan may be accomplished quicker than two weeks per step, but it is not recommended. Optimal results are attained when the recovery is not hurried.

Back to the outcomes research. A study out of the University of Pennsylvania investigated whether Tommy John Surgery (TJS) is actually as successful as it seems to be. To investigate the surgery outcomes, researchers compared 68 pitchers who had thrown in at least one major league game before requiring the surgery to a group of 112 randomly selected pitchers who never had this surgery (the "controls").

The results?

56 of the players, or 50%, were back on the mound by 18.5 months after surgery, with no change in their performance.
Of 68 Major League Baseball pitchers who underwent the surgery between 1998 and 2003, most (82 percent) returned to play with no change in average earned run average or walks or hits per innings pitched.

Good news, right? We have a better than 4 in 5 chance of getting our ace back, as good as new. But when?

According to this study, the AVERAGE rehab timetable for major league pitchers is 18.5 months. Using that as a guide, I sought out major league starters who returned to start in the big leagues in less than 18.5 after ligament replacement surgery.

Without further ado, the list, starting with the most recent cases I could find, their age when they had surgery, and their numbers in the last full season prior to the injury compared with their immediate results upon return:

Brandon Backe (28): DOS 9/7/06 DOR: 9/4/07

IP - K/9 - BB/9 - ERA+ - WHIP

2005 5.2 5.8 4.0 89 1.46

2007 5.2 3.5 3.5 117 1.33

-Backe made five rehab starts at AAA. He then said this prior to his 1st start back: "I'm not totally over it, I'm not totally healthy. Next year I should be at 100 percent and good to go. It's kind of a show of hard work making it back this soon.'' Backe started 5 games in 2007, on regular rest.

Randy Wolf (29): DOS 7/1/05 DOR 7/30/06

IP - K/9 - BB/9 - ERA+ - WHIP

2004 6.0 5.9 2.4 105 1.32

2006 4.7 3.5 3.5 84 1.69

AJ Burnett (26): DOS 4/29/03 DOR 6/3/04

IP - K/9 - BB/9 - ERA+ - WHIP

2002 6.2 8.9 4.0 122 1.19

2004 6.0 8.5 2.9 117 1.33

John Lieber (32) DOS 8/8/02 DOR: ST 2004

-Lieber rehabbed through the end of August 2003. He made three minor league starts and was not recalled in September. The Yankees made a baseball decision not to pitch him out of the bullpen, even though he was available to do so. In 2004, he threw 176 innings with an ERA+ of 104.

Pat Hentgen (32) DOS 5/01 DOR: 9/8/02

IP - K/9 - BB/9 - ERA+ - WHIP

2000 5.2 4.1 5.5 99 1.19

2002 4.5 4.1 2.9 55 1.33

*Paul Byrd returned to starting after 13 months post-TJS, but he was buying HGH in that time period.*

In many cases, starting pitchers returned to pitch as relievers 12-14 months after surgery. Some notables:

Ryan Dempster (26): DOS 8/4/03 DOR 8/1/04
Matt Morris (24): DOS 4/13/99 DOR 5/30/00
John Smoltz (32): DOS 3/00 DOR 5/17/01

So what conclusions can we draw from this?

Most starting pitchers don't successfully return to starting prior the 18.5-month point.
The outliers (SP's who have returned to starting immediately at 12-14 months post-TJS) were younger than 30.
Most documented success stories of early return involve gradual transition to the MLB bullpen then back to a starter.

Chris Carpenter turns 33 in April. He underwent TJS on July 24, 2007. He has a history of shoulder and elbow surgeries on the same throwing arm. My conservative estimate, based on this research, is a return in 14 months, or late September 2008, probably coming out of the bullpen. I don’t like his prospects as a starter in 2008.

With today's news, who do you say is the new GM?

silent_bob — Mon, 22 Oct 2007 19:44:18 -0000

I really think it's down to Mo vs. Antonetti. I'm not a betting man, but my money would be on Mo. Nevertheless, DeWitt is doing this HIS way. I'm interested in which GM you PREDICT will be running the show.

Personally, I want Antonetti as our GM and it's encouraging that DeWitt has waited to at least interview the guy. I hope he's seriously considered.

Poll

Now that Tony's back, which GM is "in the Cards"?

Antonetti - SABR-loving Cards fans' prayers are answered.

109 votes

Woodfork

7 votes

Mozeliak - Tony's familiar with him, he's already signing TLR players - the writing's on the wall.

58 votes

174 votes | Poll has closed

Our future GM?

silent_bob — Mon, 08 Oct 2007 22:09:43 -0000

Here's a great read from 2003 about Chris Antonetti, the Indians' assistant GM and stat-freak.

" Helping to separate head from heart, and gut instinct from statistical reality, is the role of the Indians' confidential computer database, DiamondView. Consider it a kind of truth machine, whose function is to temper, or even override, subjective measurements with objective ones.

Antonetti, the Tribe's best analytical mind, oversees DiamondView's use in team decisions such as the Thome negotiations. The database is believed to be among the most sophisticated in baseball. The Indians are so protective of it, they copyrighted it."

Here's the link to the story.

I don't know if we'll interview this guy, but he would probably get along with Luhnow, don't you think?

What to do with the outfield?

silent_bob — Fri, 10 Aug 2007 17:51:24 -0000

Alright, now that Slick Rick is up for the rest of 2007, with my mad math skillz, I count SIX outfielders on the active roster. Now I know that 75% of VeB would like to trade JuanE for a bag of balls. And I might be with you there, if the other team takes all of his salary.

But lets just say this doesn't happen and this team continues to play within striking distance in the Central. Fellow Birdos, answer me this:
-Who do you play where against lefties? Against righties?
-Is Edmonds a platoon player now?
-Do you sit Juan against righties? Why?
-Does Ankiel play every day or platoon?
-Is left field now a Duncan/Ludwick platoon?

Whaddya think?

Wanna go to the game July 4?

silent_bob — Tue, 03 Jul 2007 20:31:12 -0000

I have 2 LaRussa plan tix, section 335 row 2. Let me know if you're interested. I'm asking $20 or best offer for both.

Not try to solicit on this site, but I cannot go to the game and I really don't want to completely eat these tickets.

You can reply here or email me at b.weissert@gmail.com.

Go Cards!

More VEB Love

silent_bob — Sat, 02 Jun 2007 13:08:39 -0000

Larry and everyone else - you do a phenomenal job here of breaking the game down. The community's consensus about Reyes vs. Duncan, 4 seamer vs. 2 seamer gets lost on many everyday Cardinal fans. But when guys like Bernie use some of Larry's analysis in a column (he doesn't give credit, however), it makes me realize how cutting-edge this blog is. Take a look at Bernie's Bits:

"I'm conflicted on the demotion of Anthony Reyes. No. 1, Cardinals pitching coach Dave Duncan has a proven philosophy (pitch down in the zone, get ground balls) and Reyes stubbornly resists it. On the other hand, not all pitchers are alike. Not all can fit into a particular mold. Reyes makes a lot of hitters swing and miss and appear overmatched when he throws that four-seam fastball up in the zone. Either way, it looks like the Cardinals have a trading chip."

Just thought I'd take a moment to express my appreciation.

Keep up the good work boys.

Oh, and by the way - if anyone has questions about injuries or rehab, just throw up a diary. Giving out free information is the least I can do, considering how much I get out of this site every day.

What happens when we assume...

silent_bob — Tue, 01 May 2007 21:28:02 -0000

You all know the rest. I really wish that everyone who is casting stones please take a step back. All this speculating, conclusion-jumping, and finger-pointing really makes me ill. I tried reading through the comments after Larry's excellent post - but I couldn't.

Look, people... I know that we search for meaning in such times. But we have to also realize that this Cardinal team is grieving. Tony is grieving. Hell, most of US are grieving. And that's OK. If Josh Hancock was drinking and driving - well, so what? It does not take away from anything he did while he was on this earth.

As Larry stated earlier:

"it's beginning to look as if hancock was driving drunk. should that prove to be the case, there will need to be a reckoning; but that, too, should wait until the man has been buried. there is no hurry to do anything right now --- to play good baseball, to catch the brewers, or to proclaim the moral of the story. just get through the day."

Please. Give it some time.

RIP Josh.

Carp's MRI Results

silent_bob — Mon, 09 Apr 2007 21:48:52 -0000

Update [2007-4-11 11:47:0 by SilentBob]: Paletta weighs in. Per Matthew Leach: Dr. George Paletta, the Cardinals' head team physician, clarified Chris Carpenter's diagnosis on Tuesday and professed optimism about the right-hander's rehabilitation from a right elbow injury. The Cardinals issued a brief release on Monday describing Carpenter's condition as "moderate arthritis and a mild impingement" in his elbow. Paletta explained that the impingement resulted from bone spurs in Carpenter's elbow, and said that the impingement is a more significant issue than the arthritis. "They are working in tandem," Paletta said by cell phone from St. Louis, "but I think the more significant problem is the spurs -- that's what's really causing impingement in the back of his elbow." Check Liam's links below for details. [end update] Carp's elbow is essentially fine, but this could be a drawn-out process - Rest/rehab/NSAIDs/rehab starts, etc. They aren't just going to go and cut on his elbow because of some arthritis. Surgery will be the last choice.

Will Carroll RE: Carpenter

silent_bob — Fri, 06 Apr 2007 20:36:43 -0000

Free article on BP:

"The panic seems to have passed in St. Louis, as Chris Carpenter was cleared to begin working towards his next start. The Cardinals have juggled their rotation to cover the start he'll miss this weekend, with the plan being to slot him back in on Tuesday. Most of the descriptions of what's going on with Carpenter, including this one from Matthew Leach, have the anti-inflammatories getting the range of motion back in Carpenter's arm. The symptoms match up well with bone chips, so the worst-case scenario is a recurrence of this type of situation that necessitates surgery. Carpenter has had bone chips removed from this elbow before, so a recurrence is almost expected. The team is doing a bit of ostriching on this in not taking an MRI, but in part that could be because they have a solid diagnosis and plan. Other pitchers, such as Kelvim Escobar and Johan Santana, have come back from this type of problem quickly, and Escobar is probably the best comp here."

http://www.baseballprospectus.com/article.php?articleid=6072

The bone chip analysis does seem to fit in Carp's, in my medical opinion as well. Bone chips occur when stress on the inside of the elbow causes impaction of top of the ulna (lower arm bone)onto the the bottom of the humerus (upper arm bone) at the joint surface, possibly scraping some bone/cartilage away. This cartilage/bone stuff can float around in the joint and occasionally get stuck, causing swelling.

As long as its not the UCL (Tommy John ligament), I'm completely unalarmed. Problem is, Carp could end up needing his elbow scoped out sometime this season, which would likely shelf him for 4-6 weeks.

Carp's bullpen session and next 2 outings will be crucial, IMHO.

I'm sick of the negativity about this offseason...

silent_bob — Fri, 05 Jan 2007 04:44:10 -0000

What is with the continued drubbing of the ownership? Most of us who read/post on this site will probably agree with what I have to write, but I know there are many out there who just can't get enough of ripping the Cards, even after we just won it all.

I know our rotation doesn't look good now, but who here doesn't trust Walt's judgement?

I don't think that all these fans projecting gloom and doom in '07 have a long term memory, however, seeing as we have won the NL pennant 2 of 3 years and have also won a World Series title.

Hopefully with our organization making the commitment to youth, we can continue to develop quality young arms and we can make free agent splashes when they are worth the risk! We did so with Schmidt and it didn't work out. So what? He didn't want to play in StL. Fine by me. Have a nice career. There will be others, next year, and the year after, who will want to play here because it's a great place to play.

This organization has a plan. And a pretty incredible track record, considering our market/payroll, etc.

What team has won the most games over the past 5 years?

TEAM WINS AVG PAYROLL RANK
NYY 582 1
STL 575 10
ATL 571 8
OAK 571 24
BOS 548 2

This organization knows what they are doing. The Cards will be fine.