Shoulder Injuries Are Serious Business
Braves starer Mike Minor (36) Will visit Dr. Andrews next week to find out why he’s experiencing shoulder tightness again. Daniel Shirey-USA TODAY Sports
News this week that Mike Minor would miss Sunday’s start and is now set to visit Doctor Andrews poured cold water on what we all hoped would be a rapid return to form for the Braves lefty. At this point no one is suggesting that Minor’s shoulder is anything other than sore and tight due to overuse again this spring. It is however worth revisiting why shoulders are so problematic.
Shouldering The Burden
The worst thing about a should injury is that it isn’t an elbow. While elbow injuries are the most dramatic and widely discussed, there is a repair with a high success rate. That’s not so with shoulder injuries.
Shoulder injury remains the most common recurring problem for pitchers. Fourteen months ago I wrote an in depth look at shoulder injuries and rather than recount the detail in that post I recommend that as background for this update. The multitude of things that can go wrong and how those thing affect the player make severity of such injuries harder to diagnose, take Jason Schmidt’s case for example.
You may remember that Schmidt was one of the most sought after free agent pitchers following the 2006 season. After moving to the Giants in 2002 he averaged 201 innings and 200 strikeouts a year while posting a 3.35 ERA (3.28 FIP) and a 127 ERA+ over five seasons. He signed with the Dodgers and made just six starts posting a 6.31 ERA; understandable when your fastball sits between 82 and 85.
According to an article for ESPN by Jerry Crasnick Schmidt was mystified. He told Crasnick, “I thought the radar gun was broken.” He wasn’t nearly as mystified as the doctors who according to Crasnick, “. . .were stunned that Schmidt could even reach home plate with his pitches.
The damage included a torn labrum, frayed biceps tendon and inflammation of the bursa, a fluid-filled sac that reduces friction in the shoulder.” Schmidt’s shoulder didn’t quit over night; there was no single event that caused this. Every pitcher has an injured shoulder, it’s the nature of the job and Schmidt’s shoulder finally said “I quit.”
To help understand what happens, I recommend a post called baseball Players and their Shoulder injuries, Doctors Champ L. Baker Jr and Andrew W. Ayers. Here are a couple of excerpts that provide some insight.
“. . . the shoulder ball (humeral head) fits loosely in the socket (glenoid) and is unrestricted, much like a golf ball on a tee. The farther one is able to bring the arm back into abduction (raised away from the side of the body) and external rotation, the faster the ball will go when released. . .
That sounds like the job description of a pitcher and what most strive to do. There’s a downside to maximizing they velocity however.
“. . . (that movement) also forces a reliance on relatively weak soft-tissue structures to maintain shoulder stability. These . . .feel the greatest stress during the throwing motion and are, therefore, the most frequently injured . . .”
Let’s simplify that.
The movement of the shoulder is described (in the Crasnik piece and many others) as similar to taking a piece of hemp rope and pulling it back and forth across the corner of a table. Every movement causes the rope to fray and heat up. In the shoulder that’s inflammation of the rotator cuff or tendonitis.
Everyone’s rotator cuff frays, but pitchers – and quarterbacks, those who throw the javelin and others using the motion often – are likely to see the tendonitis recur and eventually see the cuff will tear.
Repetitive high stress movement may also cause damage to the labrum – stabilizing cartilage surrounding the shoulder socket and makes the shoulder joint loose. There are divergent opinions on whether it’s damage to the labrum or extra stress on the ligaments that cause loosening of the joint. Whatever its cause, the shoulder joint is never going to be tight again.
In other words, if your shoulder has become an issue it will always be an issue. Exercise may mitigate it, your body may be able to adapt and allow you to continue in spite of it, but the shoulder will always be weaker.
Been There Done That
Since 2010 the league’s seen 213 different pitchers placed on the DL in 296 total shoulder related listings. Every year three to five pitchers make two visits or more. During the same time period 194 different pitchers were placed on the DL in 271 total listings for elbow related issues.
In 2014 a total of 47 pitchers hit the DL for some kind of shoulder injury and four of those made two visits within the year.
Being Young Helps . . . but just a little
Since all pitchers are carrying injured shoulders they get used to an aches and pains along with occasional stiffness and soreness. They are also competitors who want the ball and – being guys – are reluctant to give in to a little pain and hate the idea of going to the team doc.
Rangers’ team physician Dr. Keith Meister says they’ll come when they are in pain but, “. . .one man’s soreness is another man’s pain.” Players also know that unlike TJ surgery which has a 90+% successful return rate, there is no fix to a shoulder with anywhere near that success rate. Of the 31 pitchers who’ve had shoulder surgery since 2009 11 are active, 9 are out of baseball, 8 are in the minors and 3 have retired. Some have retired rather than have surgery as well.
Disabled list data compiled from Baseball Heat maps and Pro Sports Transactions.
So worry and/or pessimism about Minor’s shoulder issue is justified but it isn’t all gloom and doom. If a pitcher is astute enough to recognize that what he’s feeling isn’t a normal ache early on, there are things that can be done to pull back from the edge.
Treatment
The first thing is of course pitcher should stop throwing and hitters should stop swinging the bat. Pain is nature’s way tell you to rest. Resting the shoulder – along with medications that reduce inflammation – helps the it return to something resembling normal . If the inflammation is severe enough, injections can help speed the process up. Continuing to stress the shoulder before it has had enough time to recover will make things worse.
An MRI can give some insight into the level of damage; a contrast MRI provides the best current method of looking for soft tissue damage. Teams will sometimes hesitate to order the contrast MRI because of the extra recovery time needed due to the use of dye. We saw this when Brian McCann’s shoulder was falling apart in 2012.
We’ll just clean it out
Cleaning out a shoulder sounds simple enough but it is a surgery albeit limited access surgery. A clean out doesn’t actually fix anything. Instead they go in and remove floating debris; bits of rotator cuff that have worn off and are now hanging around causing inflammation. They may also scrape bits off the cuff that are about to become floaters – it’s called debriding.
The body resents anything poking around inside of it even if the intention is good, so recovery isn’t instantaneous. Before they go in the surgeon explains that if he sees a bone spur or something else that requires repair he’s going to go ahead and do that because even the best MRI can’t see what’s really going on.
Jul 22, 2014; Atlanta, GA, USA; Atlanta Braves starting pitcher Mike Minor (36). Mandatory Credit: Kevin Liles-USA TODAY Sports
What about Minor
Initial reports this spring had Minor back in form and impressing Fredi Gonzalez. Two weeks later he’s scratched from his start because his shoulder is tight. So, what’s going on? Let’s let Minor tell us.
In multiple interviews Minor said the same things. These quotes are from a piece by Mark Bowman.
“I’m not concerned because it’s kind of the same thing as last year,” Minor said. “We had MRIs and they all came back negative [last year]. I guess I just want to know why [my shoulder] keeps getting inflamed.”
Spin machine translation: I thought all of this was behind me and it’s the same thing as last year. I followed directions, did my exercises and didn’t over exert myself early like last year but it still hurts and I want to know why.
That’s smart, he remembers Tommy Hanson and wants a different outcome. He knows that if he continues to try and pitch through this it could go down hill quickly.
The post talks about him battling his way through last season including taking shots in the shoulder but continuing to pitch. Here’s what he said.
“It’s just going to get worse throughout the year,” Minor said. “So, I wanted to say something now, when it was getting tight and see if we can figure it out.”
Spin machine translation: It hurt all year even though it got worse but I stuck with it. That isn’t what I choose this year.
The post goes on to say that MRI’s after the season showed no structural damage and Minor isn’t worried about what Dr. Andrews might find. That’s probably true but according to the Johns Hopkins Orthopedic web site while MRI’s are best for soft tissue they aren’t absolute.
“. . .MRI’s are generally over-read by the radiologist . . . MRI’s are not the most accurate way to evaluate these structures in the shoulder. . .the reality is that MRI’s have significant limitations in helping to make the diagnosis of hidden or subtle instability.
Minor’s final quote means more than a casual reading reveals.”I could pitch and potentially, I don’t think anybody would even notice” Minor said. “So that’s why I’m saying that if I can throw and pitch, I don’t see there being anything drastically wrong.”
He thinks that he could fight his way through the year as he did last year; in pain . he just wants to be sure that continuing to pitch doesn’t result in a premature end to his career.
That’s A Wrap
Shoulder injuries are a fact of life. Unlike a torn UCL, every pitcher has shoulder damage when he starts his career and that damage will continue for the rest of his life. The trick is a conditioning program that makes such damage less likely and an awareness of your body’s limitations and knowing the difference between acceptable pain and pain that needs immediate attention.
I know some disagree but I believe Minor has the talent and ability to be a number two on most staff’s and a one on many. Finding out that he pitched through more pain than anyone let on last season confirms he’s tough mentally as well as smart intellectually. Speaking up now was a wise move for both his career and the Braves. I still believe the Braves will trade him at some point and the the best return he must be pitching so well it hurts to let him go. With that in mind, if he has to take April and May off that’s fine with me as long as he comes back strong and show’s his talent on the mound every fifth day.