Trading Barbs.

Mike Lowell and Rob Bradford are total BFFs. So, it would make sense that when Lowell decided to make his side of the "Great Thumb Controversy" known he went right to Bradford. Sounding slightly bitter, defensive and like he's giving a deposition, Mikey says:

“I was in constant contact with the training staff and I told them at the two-week (mark) I didn’t feel a difference with my thumb and at the four-week mark it was the same thing and then at the seven-week mark Mike Reinold flew down to Miami to check it out and that’s when they decided to put me in the splint and keep it immobilized for a month. That’s when the thinking was that it might be something more than it was originally thought to be. The first day of the winter meetings was when I was ordered to get an MRI."

I don't really understand what the point of this was as I'm sure it doesn't help things with the front office if they do end up stuck with each other. Mike certainly doesn't seem too happy with them.

Thumbs Down.

Mike Lowell seems to have the worst luck when it comes to injuries. Damage to the radial collateral ligament of the thumb, while not unheard of, is rare.

It's a short little ligament that originates at the styloid process of the radius (the little point of bone on the end of the radius) and connects to the scaphoid bone in the wrist (the lower of the two wrist bones in the picture) and the trapezium (the other wrist bone in the picture). You should be able to easily feel it in your own wrist. It's in the space between the end of the radius and the metacarpal of the thumb. The purpose of the RCL is to stabilize the wrist and to limit how far the hand will move in the direction of the pinkie finger. If you hold your right hand straight out in front of you with the wrist flat and try to move just your hand to the right, it won't go very far because of the RCL. Mikey Lowell's probably moves alarmingly further because his RCL is torn.

As to why nobody bothered to get this checked out sooner: The prescribed treatment for the injury is to splint the thumb for four or five weeks in the hope that it will heal itself before attempting surgery; so they very well may have done this. The surgery itself is fairly simple, depending on the quality of the ligament. You open up the hand and reattach the ligament. In severe cases the ligament may be too damaged to use and you'd have to do a tendon graft. Then you reset the bones and pin the joint in place.

Recovery is probably three or four weeks until you take the pin out and then an additional three weeks or so until the ligament is healed. I'd say it would probably be the beginning of March before he'd be ready to get back into the swing of things.

The Shoulder Bone's Connected to the Collar Bone (Hopefully).

J. D. Drew has a reputation for being a wimp but an acromioclavicular joint sprain is not a walk in the park and the fact that he could play through such an injury (even with cortisone shots) is impressive--not very smart but still impressive.

The scapula is very much a three dimensional bone and, as such, is difficult to describe; there's a sort of crook (the coracoid process) that goes all the way toward the front of the body and can be felt as a bony bump just under the clavicle and there's the scapular spine that sticks out in the other direction (away from the body) and extends above and beyond the flat part of the scapula.

But the scapula as Africa is a good visual, as it's shaped sort of like Africa. On the left scapula, the glenoid fossa (the socket part of the ball-and-socket joint) would be near Morocco. If you started digging in northern Mali, then you'd be the right area for the coracoid process. But the main feature that we're concerned about is the scapular spine. If it was an African mountain range, then it would start in the Sudan and cut across the continent in a northwesterly direction. At the end of the spine, the bone sort of flattens out and forms a roof above the glenoid process. That section of bone is called the acromion process. The bone you can feel on the back of you shoulder is the acromion process.

The humerus is connected to the rest of the body at the glenoid fossa of the scapula. The scapula's attachment point to the rest of the body is at the clavicle or the acromioclavicular joint (AC joint). It's the scapula's only point of articulation. In the anatomical map, the Middle East doesn't exist.

The shoulder joint is flimsy. Between the two bones (the acromion process and the clavicle) there is a cartilaginous disc. The bones are held in place by the muscular structure--the anterior deltoid in the front and the trapezius muscle in the back--and by ligaments strapping the thing together. The important ligaments (for our purposes) are the acromioclavicular ligament (which connects the acromion process and the clavicle) and the coracoclavicular ligament (which attaches the clavicle to the coracoid process). They form a sort of triangle that stabilizes the joint. But it's not a perfect system and it's relatively easy (through direct impact on the shoulder usually by falling) to irritate the ligaments.

A sprain to the AC joint could be as simple as a stretched acromioclavicular ligament (Grade I) to completely tearing that ligament and the coracoclavicular ligament (Grade III)--this injury leaves the scapula (and, therefore, the humerus) unattached to the main skeleton. (There are three more severe grades of injury but they have to do with how far out of place the clavicle ends up.)

JD sprained his AC joint at the beginning of last season. Because they treated it with a cortisone shot (to reduce the swelling) and a couple of days off, one can assume that it wasn't a severe strain. The pain didn't go away and he got another cortisone shot in September. Obviously, the pain still hasn't gone away as he had surgery on the shoulder last Thursday.

Because AC joint surgery is major surgery (it involves either cutting off the end of the clavicle or, alternately, screwing it in place) and no one seems to think that this is a big deal, chances are this surgery was more of a cleaning than a fixing. Occasionally, patients with Grade II injuries (the acromioclavicular ligament ruptures but the coracoclavicular ligament is only sprained) will experience fraying and tearing of the cartilage between the acromion process and the clavicle. And it develops into an impingement. So they go in arthroscopically and smooth it out the best they can. Recovery from the procedure is maybe eight weeks.

Hips Don't Lie.*

Since I'm still keyed up, let's talk hips and hip effusions.

An effusion is build up of excess fluid in a body cavity. When they drained Mike Lowell's hip joint, they took out 15cc of synovial fluid. The average amount of fluid in a hip should be around 5cc. If 5cc is a little more than a teaspoon (and it is), then 15cc is nearly a tablespoon plus a teaspoon--which seems pretty excessive.

The problem with excess fluid is that it increases the pressure on the joint. And in some cases can cause the bones to become slightly displaced. When bones are out of place, it causes pain and limits the functionality of the joint. Just the act of draining the joint and relieving that pressure, is probably what led to Mikey felt better today.

The more interesting question is what is causing the buildup of fluid in his hip. Although they do occur in adults, hip effusions are more often a kiddo problem; specifically, boys aged 2 to 10. The most common causes would be synovitis (an inflamed synovial membrane), septic arthritis (an infection of a joint), and osteomyelitis (a bone infection). Other cause could be trauma, osteoarthritis, or gout/psuedogout.


*When this song was popular I had a clever friend who quipped "I've just about had it up to here with Shakira and her honest hips." Made me laugh; still does.

3000 Miles or 68 Games.

Mike Lowell will be making his way back to Boston to get an injection of Synvisc in his balky hip on Monday.

Most of the movable joints in the body (hip included) are synovial joints. Synovial joints differ from fibrous joints and cartilaginous joints in how the bones are held together; fibrous joints are held together by fibrous connective tissue and the bones shouldn't be able to move (the bones of the skull are good examples), cartilaginous joints are held together by cartilage and move only a little (where the first rib connects to the sternum is a good example), and synovial joints are two bones that are strapped together by ligaments with some space in between.

Inside a synovial joint the bones are covered with cartilage to lessen the impact of them knocking together during movement. The cavity between the bones is also lined with a membrane, conveniently called the synovial membrane. This membrane secretes synovial fluid into the empty space.

Synovial fluid has a high viscosity and a consistency similar to that of raw albumen. (When you separate a joint--like a knuckle--little bubbles will form in the fluid and when you close the joint the bubbles will pop, creating a satisfactory cracking sound.) Its purpose is to lubricate the joint and reduce friction as the cartilaginous ends of the bones slide across each other. It may also help to nourish the cartilage.

The treatment they're prescribing for Mikey is usually given to patients suffering from osteoarthritis in the knee. It is, essentially, synovial fluid replacement therapy. Hyaluronate (Synvisc being the brand name) injection is similar in concept to an oil change. They inject the treatment into the joint and it protects the cartilage in much the same way that motor oil protects an engine. Hyaluronan (what it's made of) has also been shown to have anti-inflammatory properties, which may help to protect against further damage.

Its effectiveness in patients with osteoarthritic knees is questionable. Some patients have seen no improvement and others have seen a reduction in knee pain for up to six months. But there doesn't seem to be any harm in giving it a shot.

The Sex Injury.

I suppose that most things are possible but it seems unlikely.

Dustin Pedroia was pulled from yesterday's game after re-aggravating a strain in his left groin. As amusing as it might be a groin strain doesn't refer to the reproductive system but rather to a bundle of six adductor muscles in the inner thigh. The muscles are: the pectineus (light blue), the adductor brevis (yellow), the adductor longus (green), the adductor magnus (purple), the gracilis (red), and the obturator externus (dark blue). The main function of the muscle group is to move the leg inward; they also function to help rotate the hip.

A muscle strain can be as minor as just stretching a muscle too far to tearing the muscle fibers to tearing the muscle completely. The only way to treat the injured muscle is rest and then work specifically to strengthen the muscles. If Pedroia plans to return in the next few days, chances are that he didn't tear the muscle.

Shows What I Know.

Seemingly mere moments after I decided to declare that the surgery to remove Jed Lowrie's styloid process was the least likely avenue for the club to pursue, they go ahead and remove his styloid process. I suppose that's what I get for offering medical opinions that I am unqualified to give. In an effort to heed the clear warning to keep my trap shut, I will resist saying that six weeks until he is able to swing a bat seems extremely optimistic.

Calling Jeff Bailey.

Rocco Baldelli's left hamstring has been bothering him for the past week but he felt capable of playing right field and getting into the lineup today. In his second at bat, he hit a ball to the warning track and found his way to third base on Nick Markakis' error. But when the fourth inning started, Chris Carter found himself in right field and Rocco, potentially, on the DL.

Meanwhile down on the farm, Jeff Bailey had been playing left field for Pawtucket when he was pulled from the game. Apparently, ready to be sent up to Boston to take Rocco's spot.

There has been no official announcement, Francona says that will have to wait until tomorrow.

Ouch.

(Ignore the arrow. At the top of the other bone is a broken styloid process.)

So the word on Jed Lowrie's wrist is that he's fractured the styloid process of his left ulna. It's likely that this is the same bone he broke last season (nondisplaced fractures of the wrist are almost always of the ulnar styloid.)

The styloid process is a little spike of bone attached to the head of the ulna. You can feel it if you feel up your wrist. The bump on your wrist is the head of the ulna, if you start at the top of the ulnar head and move laterally toward the outside of the wrist and dig in a little, there's a little triangle of bone-that's the ulnar styloid process. It's function is to have a place for the ulnar collateral ligament to attach. If it's broken(besides being painful), the wrist becomes unstable.

There are three options for him:

The first would be to get cortisone shots to reduce inflammation, rest it, and hope that the bone reknits itself. If he goes with that plan, they'd be looking at three to six weeks in a splint.

The second option would be a closed reduction of the fracture. In that case, they'd wire or screw the process back onto the ulnar head. Recovery from that would take at least a couple of months. His wrist would look like this:

The last, and least likely option, would be to open his wrist up and take out the bone the completely. The problem, if they were to pursue that option, would be finding a new home for the connective tissuses that relie on that structure. If they did that, he'd be done for the year. In addition, you couldn't be absolutely certain that the wrist would still function in a way that would allow him to play baseball. Of course, it might go the other way and stucturally changing his wrist might improve his ability to play the game ala Rookie of the Year.

Not having seen his x-rays, I'd guess that if they think he can be healed by rest, they bone isn't displaced enough to warrant the surgery.

This Boot is Made for Walking.

Kevin Youkilis has left the WBC and returned to Fort Myers with a case of Achilles tendinitis. He enjoyed his time on Team USA and was quick to point out that the tournament wasn't responsible for his injury:

“I didn’t get hurt playing in the WBC. I could probably go out right now and probably play if need be. But it’s not in my best interests right now. I need time to recuperate. If I don’t stay in this boot for three days, this will linger the whole season for me. This is something I had to do. I had to come home. It’s not easy for me to walk away from playing baseball — ever. Especially with Team USA. But this is something that was in the best interests of the Red Sox and the best interests of myself. This year is about playing for the Boston Red Sox and winning a championship.”

This is true. Tendinitis is a repetitive stress injury (micro-tears in the tendon) and it wouldn't have a sudden onset from a single event. Have him clomp around in the boot for a couple of days, with the ankle immobilized to reduce pulling on the tendon, and he should be fine.

Pains.

(More gory version here--Don't say I didn't warn you.)

Poor Julio. He was having a really nice spring. He was hitting, showing a little power, not bobbling the ball and he was having success with throwing. And now he's got the setback of a torn meniscus.

The knee is the meeting of the femur and the tibia, with the patella acting as bodyguard. If you look at the distal end of the femur, it has a cleft appearance with two large bumps and a valley in between. The proximal surface of the tibia, on the other hand, is relatively flat. The menisci are two semi-circles of cartilage that are attached to the tibia and act as a barrier between the two bones. They sort of mimic the shape of the femur as each meniscus cups around one of the femur's bumps.

The knee is a hinge joint and while it does have a tiny bit of give, it's meant to open and close--and that's it. There isn't a lot of room for error in a knee. If you twist it, it's likely to cause damage to the meniscus in the form of a tear. Problems arise when the bits of cartilage slip into the space and block the knee from functioning.

His recovery from arthroscopy would depend on the severity of the tear and in which direction the cartilage was torn but the best case scenario would be around a month.

Aches.

Dustin Pedroia was sent home from the World Baseball Classic yesterday with a strained left abdominal muscle. They have also put the kibosh on him returning to Team USA, saying:

"Red Sox Medical Director Dr. Tom Gill examined Dustin Pedroia this evening in Fort Myers, FL. Pedroia was diagnosed with a minor strain in his lower left abdominal region. While he will be held out from activity for a couple of days, it is not expected that he will miss significant time. Pedroia will rejoin Red Sox spring training camp on Sunday and is no longer participating in the World Baseball Classic."

That Didn't Take Long.

(Click to make bigger and to be able to read the labels.)

Mark Kotsay's back is not in good shape. He first went on the DL with a strained back in May of 2003 and missed sixteen games. He missed sixteen games of the 2005 season with back problems. He missed nineteen games in 2006 with back spasms. He started 2007 on the DL after having surgery on a herniated disc. He came back in June of that year but only lasted until mid-August when the pain came back and caused him to miss the rest of the season. He landed on the fifteen-day DL in May of last year and missed thirty-three games. So the news that his back has once again proved problematic shouldn't come as a surprise to anyone.

Back on January 29, Kotsay had endoscopic surgery to remove a displaced disc fragment from his back. When a disc herniates besides the nucleus pulposus leaking into the foramen and aggravating the spinal cord; bits of cartilage, apophyseal bone, and anulus can also enter and float around in the spinal cord's space. It's likely that one of these bits of anatomical litter was removed from his back.

His surgeon performs Micro-Endoscopic Discectomy (neat little animation of the procedure here by clicking on micro endoscopic disectomy.) A tiny slit in his back, make the hole slightly bigger by pushing the muscle to the side, insert a light and a tool, grab the errant fragments, and close him up.

Because the muscle isn't cut, the recovery from the procedure shouldn't be too bad. It can actually be performed under local anaesthesia, as an outpatient procedure. The idea that he might be ready to go by some time in April isn't too out there of an idea.

Can Somebody Please Call a Medic?

It seems that Terry Francona has been chewed on and spat out. From the Herald:

"Francona will undergo an arthroscopic procedure on his left knee today and tomorrow will get an injection for his ailing hip. Francona, who had his right knee replaced several years ago, is trying to postpone a left knee replacement for at least another year.

Meanwhile, Francona recently learned he’s suffering from a torn labrum in the hip, the same malady that ended Mike Lowell’s season and led to surgery last month.

Finally, Francona has yet another appointment Tuesday with a back specialist to determine surgery options."

Oof. A safe and speedy recovery (and a bit of good news healthwise) is in order.

My Mother Taught Me Well.

This photo of Mike Lowell rehabbing appeared on Bradford's 'EEI blog a few days ago. The first thing I noticed was not itty-bitty Mike Reinold's gigantic smile. Nor was it that Mike Lowell and I have very similar taste in socks. Nope. The first thing I noticed was the state of their walls. "Why are their walls so dirty?" I demanded of my computer. Seriously. You'd think that if they weren't going to clean them, they'd at least be able to afford a new coat of paint.

Four be the things I'd be better without: Love, curiosity, freckles, and doubt.

The title comes from the Dorothy Parker poem: Inventory.

As much as I proclaim myself to be sort of blase about the series loss, I find myself unable to fall asleep. And since Mike Lowell goes under the knife later today, let's talk surgery.

Arthroscopic surgery can be performed under local anaesthesia as an out-patient procedure. But not Mikey's. Given the complicated structural nature of the hip with it's deep musculature, and the involvement of the vascular and nervous systems, it's better to perform the surgery under general anaesthesia when you can more easily regulate those functions; i.e. paralyze him, lower his blood pressure, and slow his heart rate so he doesn't gush blood all over the place. And to control the gross-out factor. One must never underestimate the gross-out factor.

The first step of the procedure is to yank his femur out of his socket (which is not only extremely painful and will leave him with a very impressive bruise afterward, it's also decidedly horrible-looking during the surgery.) The joint is separated so that the surgeon has room to work. He then makes two or three tiny (a centimeter or two long) slits through the tissue. Through one of these slits, he'll insert an arthroscope (similar to a straw, it's a hollow rod with a light and a camera attached to it.) He'll use the other slits to insert his other instruments.

Once he's in, the first step will be to debride (clean out) the joint. While cartilage is a fabulous substance (essentially it's strands of the protein collagen woven around water), it does have it's faults. It's main issue: it doesn't have a blood supply. When it gets damaged it takes a long time for it to fix itself. Inside Mike's acetabulum there will likely be pieces of broken-off cartilage floating around and the labrum will probably be shredded. Once the surgeon has scraped out the damaged cartilage, he'll throw a couple of stitches into what remains of the healthy labrum.

The next issue to be dealt with would be the impingement. I'm not certain that this problem was made clear before (so he might not have an impingement) but since Mike was talking about bone spurs with 'EEI, it's probably a safe assumption to make. An impingement is caused by an osteophyte (literally: bone growth) but not by a bone spur, as such. Essentially, the bone of Mike's femoral head has a bump on it. The bump limits his range of motion and bangs into his labrum. They'll deal with that issue by shaving off the growth. And if there aren't any other problems, close him up and wake him up.

I was rummaging recently and I came across this video:





It's from the Southern California Orthopedic Institute (I found it here-they actually have a much clearer description of what's going on in Mike's hip than I was able to muster) and it's the first in a series of videos of an actual hip arthroscopy.

Seriously: Don't click the video if you don't really want to know. It's an actual surgery and isn't pretty. It might, in fact, be described as gruesome. The surgeon asked "Hey! Can I record your procedure and then throw it up on YouTube?" and his patient replied "Go for it." Fair warning.

Poor Mikey.

Mike Lowell has been playing with a partially torn right acetabular labrum since late June.

The hip is a ball-and-socket joint. The head of the femur is the ball and the acetabulum is the name for the socket. Acetabulum comes from the Latin for 'cup' and is, essentially, a shallow indentation in the pelvic bone. It's a feature of the bone designed to give the femur a place to rest and the hip joint a place to work it's magic.

But the socket has to be shallow. If the femur was really jammed into the joint, the range of motion would be lessened. But if it was too shallow, there would be little to hold it in place and it would be easier for the ball to slip out and dislocate the joint-which is extremely painful. That's where the labrum comes into play.

The labrum is a collar-like ring of cartilage that sits on top of the socket. It's function is to make the joint a little bit deeper and help prevent dislocation. When a labrum tears, it becomes harder for it to function usefully. It becomes easier for the joint to slide around (subluxation) or for it to become completely dislocated.

Since they used the word partially to describe his injury and since he still has the use of his right leg, one can probably assume that the labrum is still mostly attached. The pain he's experiencing is probably just subluxation of the joint. But from the look of the pain he's in, it's probably a significant tear (and not just bits of broken off cartilage floating around in the joint.)

The injury shouldn't get significantly worse if he keeps playing. But he'll likely need someone to go in with an arthroscope within a few days of the season ending to patch it up.

*The illustration is from Gray's Anatomy and because Gray's is old, it's labeled as the cotyloid ligament. Also, fair warning: google image searches for acetabular labrum are not for the faint of heart.

Nuts.

The news is not good for JD.

He's got a herniated disc. When a disc herniates, the nucleus pulposus in the center of the intervertabral disc squishes out through the anulus fibrosus. From there it can irritate the nearby nerves causing pain, weakness, and loss of motion.

The typical treatment for a herniated disc is to not do anything. For most patients, the disc will heal itself within a month. Pain pills and back strengthening exercises are all that's typically needed. In more extreme cases surgery is necessary. In the surgery they either take out the disc or bits of it. It wouldn't be the ideal solution for someone who needs to keep their back flexible.

Illustration from the Mayo Clinic.

You Just Can't Keep a Good Pitcher Down.

According to Tony Massorotti David Aardsma has been placed on the DL with a strained right groin and has been replaced by Justin Masterson. Masterson had success against the Angels during his start in April-it'll be interesting to see how he's transitioned to relieving and if he can continue to be successful. Speedy recovery to Aardsma, though.

So, Uh, When it Rains? It Pours.

So Coco started off the second inning of tonight's game by picking a fight with the Rays pitcher. After being hit by the second pitch he saw, Coco charged the mound. Watching Coco it seemed pretty clear that he probably spent some time in the gym with his dad (why you would throw a punch at someone who's father had been a boxer is beyond me. I suppose he might not have known.)

Shields threw a weirdo, over-the-top, lazy, probably pretty ineffective (had it landed) punch, which Coco bobbed-I'm going to guess that Shields doesn't have all that much experience throwing a punch, especially given the fact that he used his pitching hand. Coco answered with an ill-placed roundhouse that seemed to clip Shields' shoulder. The catcher (Navarro) tackled him and then a couple of extraneous Rays jumped on top (Crawford, Gomes, and Iwamura) and started pummeling him.

To hear Coco tell it, however, they were fighting like "little girls", scratching at him and pulling his hair. From his post-game interview, he seemed to find the whole thing very amusing; which leads me to believe that he's been in some real fights in his time. He's always struck me as more deserving of the "scrappy" descriptor than Pedroia, anyway. Every time he comes up to bat he looks like a five-year-old ruffian. If you take away his toys, he's going to come at you fists flying; even if you put your hand on his forehead to keep him back, he'll keep trying to land a punch.

In all likelihood, he's looking at a ten-game suspension. As much as I love Coco, it wouldn't have been too horrible. But then the fourth inning happened.

In the fourth inning, Ellsbury made a beautiful diving catch to get the first out. Unfortunately, in the process of doing so he seemed to roll his wrist over. They did x-rays to determine that nothing was broken. It was announced as a sprained wrist but all that means is that it hurts like a sonofabitch but nothing appeared to be structurally wrong with it. They intend to do more testing tomorrow to figure out what exactly is wrong.

And then the weirdest thing happened between the fourth and the fifth innings. In the dugout, Manny took a swipe at Youk. Youkilis seemed absolutely utterly, confused by the whole incident. No indication from anyone what it was about, with Francona only saying in his presser that it had been taken care of. Indeed, when Manny came out of the game in the seventh, he and Youkilis shared a fist-bump.

The last unpleasant moment of the evening came in the seventh inning. Manny was the first to bat in the Sox half of the inning and watched most of the pitches thrown at him sail by. After one of those pitches sailed by, he shook out his right leg and Francona came jogging over. They left him in the game until he had drawn a walk but perhaps his hamstring is worse than they've let on. Anyway, Cash ran for Manny and really looked adorably perplexed that he was being asked to DH.