Cole Hamels: Short- and Long-Term Effects of Shoulder Tendinitis for Pitcher

True story: One of the first Baseball Prospectus events I ever did was at a Giordano’s in Chicago back in 2003. It was Rany Jazayerli, Nate Silver and myself. (What ever became of those guys anyway?) During the Q&A, someone asked a question about a young Phillies prospect. Rany, then the resident prospect guru, gave his opinion, but because of his pre-draft medical issues, I was asked my opinion on Cole Hamels.

“A left-handed Mark Prior,” was my reply. At the time, in Chicago, that was one heck of a compliment.

Prior went on to have a nice year in ’03, but a fluke injury took him down. Hamels, on the other hand, went on to become one of the best lefty pitchers in baseball over the last decade. Now, Hamels is having a minor shoulder problem of his own.

Hamels reported to spring training and promptly told reporters, per the Associated Press (via Yahoo! Sports), he was a week behind schedule. During the offseason, Hamels suffered through a bout of tendinitis in his shoulder. This is not uncommon for pitchers, and the standard of care is normally to take a look, make sure that there’s nothing more wrong with the shoulder and then to use rest to allow the inflammation to calm down.

There’s no evidence that Hamels needed anything more serious than rest and likely some anti-inflammatories to clear it up. At this point, Hamels does not appear to be injured, just behind schedule.

Pitchers are usually on very strict schedules for offseason throwing and the buildup to the season. Spring training allows pitchers to “stretch out” their arms over several starts, increasing their stamina to be ready for April, not mid-February. That traditional schedule is the reason pitchers and catchers report early.

Remember that Hamels is perhaps the best example of a modern Tom House pitcher. The former Rangers pitching coach now consults with many, especially young pitchers, and in this era, few have been more touted than Prior and Hamels. Hamels’ fluid mechanics and linearity have allowed him to overcome a heavy workload during his pre- and post-age-25 seasons. 

Hamels is hardly the only pitcher to encounter offseason issues. Jeremy Hellickson had elbow surgery, and many others—lower-profile pitchers—will find themselves behind schedule in days or weeks. While the pitching motion itself is not unnatural, it’s the repetitive nature of the position that puts serious demands on the various joints, muscles and connective tissue. 

The question now is whether Hamels is actually a week or so behind schedule. We’ll know quickly as spring training gets under way. If Hamels does miss his first scheduled start or is an inning or so behind his teammates—including new Phillie A.J. Burnett—we’ll know that head athletic trainer Scott Sheridan and his staff have things under control. If it’s more, Ryne Sandberg has his first challenge as manager. 

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Roy Halladay Shoulder: Best-Case, Worst-Case Scenarios for Phillies Pitcher

Roy Halladay struggled throughout the 2013 season. His arm slot has changed, likely because he was trying to find a comfortable way to get the ball to the plate. That change is common and signals damage inside the shoulder, which is exactly what was found upon imaging.

Halladay will now have arthroscopic surgery to correct a frayed labrum and rotator cuff, as well as clean up bone spurs or debris inside the shoulder.

While damage to the labrum and cuff can be devastating, Halladay and his doctor, Neal ElAttrache of the Kerlan-Jobe Clinic, feel confident that the damage is minor. The biceps, labrum and rotator cuff often work in concert, leading Dr. Stephen O’Brien to call the area the “biceps-labrum complex.”

Minor fraying is an indication that the area has been stressed over time, but has not given out completely. The location of the fraying would be instructive, but as of now, there’s been no comment on this. The likely areas are in the back of the shoulder, where pain from both types of injuries tends to be felt. 

There is a bit of a chicken-and-egg issue here since the damage is thought to be minor. Did Halladay change his arm slot because of the BLC damage, or did the BLC get damaged because new muscle areas and patterns were created by the arm slot? With fraying, there is less indication of a traumatic event and more one of wear and tear. 

Halladay has been well-used, but seldom has shown any sign of overwork. Comparing Halladay’s workload to other pitchers of this era makes it look that way, but comparing him to players of even the last generation doesn’t appear to indicate any real abuse.

Halladay’s workload in comparison to Roger Clemens is light. Neither was a max-effort pitcher and had great success over the course of a decade. Notably, Clemens came back from shoulder surgery on almost precisely this issue, though his came at the dawn of his career rather than the twilight. 

Halladay’s biomechanics were very stable coming into this year. His delivery was rebuilt in 2000 by Mel Queen, a bold move by the Blue Jays that paid off handsomely.

Halladay’s delivery is unusual, largely the result of Queen dropping his arm slot to a sidearm and increasing the lateral motion created naturally by the mechanics rather than additional spin.

Yes, Halladay is a sidearmer; look at the picture to the right and note that without the tilt of his shoulders, the acromial line—an imaginary line from elbow to elbow, through the shoulders—is almost perfectly flat, while the pitching forearm also stays relatively flat at the point of release. This is not uncommon, though few are as pronounced as Halladay.

During the 2013 season, Halladay often dropped his pitching elbow further. The technique takes pressure off the shoulder.

Try this at home: Put your arm out to a pitcher’s “90-90“, where the pitching arm is extended into the shape of an L. The upper arm is parallel to the floor and extended at a 90-degree angle. The forearm is bent at 90 degrees, putting the forearm parallel to the body.

If you pull the arm back slightly, you will feel some tension at the back of your shoulder. Drop the elbow towards the floor slightly and you will feel that pressure release. However, the shoulder joint itself is now in a much less advantageous position and throwing from this position can cause some issues. 

As Halladay heads to surgery next week, what are the best-case and worst-case scenarios for what happens? Let’s take a look:

 

Best-Case

The best-case is also the expected case. Dr. ElAttrache expects to go into the shoulder arthroscopically and be able to clean up the damage without performing any significant repairs. With the scope, the surgeon can shave down the fraying, remove the bone spurs and other assorted debris and leave Halladay with smooth, healing surfaces. 

Halladay will almost immediately begin to rehab and could be throwing as soon as six to eight weeks afterward. His rehab should move quickly as the shoulder strengthens and is freed up by the repairs. The strength and stamina will have to be built up through a throwing program. Halladay will be able to move quickly if things inside the shoulder aren’t causing pressure or discomfort.

Once Halladay begins to throw, watch for his elbow location in his delivery. If the surgery works, it should be assumed that the elbow will come back up to the normal slot and that the Phillies will see increased control and velocity from Halladay. 

In the best case, Halladay will have no physical setbacks in the rehab process, will show quick comfort in his throwing program and will have to rebuild stamina in order to return, a relatively simple process that Halladay has done many times before. 

 

Worst-Case

The worst-case scenario is that once Dr. ElAttrache gets inside the shoulder, he finds more significant damage. While MRI and other advanced imaging techniques give a good view inside the joint, it is not perfect. There is a reasonable chance that there is more advanced tearing of one or both damaged structures that would necessitate a more significant repair.

Rather than just cleaning things up, the surgeon may have to repair the structures using some combination of fixation (anchors) and repair (stitches), as well as debridement. If there is significant impingement or osseous changes, a simple removal of bone spurs may need to be changed into a resection, where a portion of the bone is shaved or cut off. 

Even if things go well, Halladay may not be able to return this season. While the three-month return will be difficult, seeing Halladay back on a mound this season is quite possible. It would also be normal to see this extend well past the three-month period. Dr. Keith Meister tells his patients that even with a minor repair, the shoulder will need a year or more to return to normal.

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Philadelphia Phillies Team Health Report: 2013 Injury Risk for Every Starter

Will Carroll has produced an annual Team Health Report for each MLB team for 12 years. The report gives risk ratings for every player in the expected starting lineup and starting rotation, plus two relievers. A proprietary formula sets a baseline according to a player’s age and position. It is adjusted by 12 factors, including injury history, team history and expected workload.

This risk rating is classified into three tiers—red (high risk), yellow (medium risk) and green (lower risk). It should be used as a guideline and is about probability, not prediction. To learn more about how the Team Health Reports are devised, click on this article. 

2012 Rank: 26th of 30 teams in DL days and dollars lost

Biggest Injury: Chase Utley, $8.1 million lost value

Head Athletic Trainer: Scott Sheridan

The Phillies got old quick. Injuries will do that to a team as much as the calendar.

Injuries to Ryan Howard, Chase Utley and Roy Halladay highlighted the problem, but it was more deep-seated than that, and this offseason really didn’t help. Instead of getting younger, the team seems to be taking an incremental approach and hoping that Scott Sheridan and his staff can hold them together for one more run with this group.

That’s not the worst idea. Sheridan and his staff won a Martin-Monahan Award a couple years back, just as their run at the top of the NL East started. Injury stats are often forward indicators, as they were for the Rays and Brewers, but is it also a forward indicator of a decline? The data sure seems to say yes to that.

What’s less clear is whether that decline can be halted or even slowed.

This is a team that is flat-out risky. Aside from those “big three” injuries, all of whom must come back to full production for this team to have a chance at .500, let alone a title, there’s risk up and down the lineup and there was more brought in. If everything goes right, they could contend, but the Nationals and Braves have made huge leaps in talent, not incremental changes.

This could be the last year of what Ruben Amaro and ownership see as a success window. Charlie Manuel is close to riding off into the sunset and handing over the reins to Ryne Sandberg. Utley and Howard could be near the end as well, especially if they continue to have physical problems. The rest could be quickly torn down for prospects, though likely not to the core like the Marlins did. 

The season, then, hinges on the medical staff. If they can get this team back into the upper third of injury stats, there’s a chance that the Phillies play into October. If they stay at the back half, they’ll likely be in the same place of the standings.

Click ahead for the Phillies. Here are links for all the teams’ reports.

AL East	Baltimore	Boston	New York	Tampa Bay	Toronto
AL Central	Chicago	Cleveland	Detroit	Kansas City	Minnesota
AL West	Houston	L.A.	Oakland	Seattle	Texas
NL East	Atlanta	Miami	New York	Philadelphia	Washington
NL Central	Chicago	Cincinnati	Milwaukee	Pittsburgh	St. Louis
NL West	Arizona	Colorado	L.A.	San Diego	S.F.

 

Will Carroll is the Lead Writer for Sports Medicine at Bleacher Report. He has written about sports injuries and related topics for 12 years. His column is called “the industry standard” by Hall of Famer Peter Gammons.  

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