Umpires were escorted off the field under armed guard after fans became enraged over a controversial balk call, but no one was arrested and hostilities were no worse than common catcalls and booing, San Francisco Police told MLB News Online after the Giants 3-2 loss to Colorado on Tuesday.
Giants manager Bruce Bochy had been ejected for arguing a disputed 7th inning balk called by plate umpire Gary Darling after Giants catcher Bengie Molina stood up and requested time. Darling granted time but then called the balk when Giants starter Tim Lincecum stopped his motion, but then threw to the plate.
The balk allowed the winning run to score from third base as fans loudly expressed their displeasure and Bochy ran onto the field to harangue Darling for more than three minutes until finally being ejected.
"Essentially, the umpire ordered the Giants manager off the field; that's all," San Francisco Police Spokesman Dewayne Tully explained. "It was just a lot of booing."
The police escort was "routine," Tully said, noting that some of the team's security is provided by off-duty uniformed San Francisco police. "There was no police action of any sort."
Wednesday, April 30, 2008
Tuesday, April 29, 2008
Phillies to Consider Ray King, Steve Kline
In need of a bullpen lefty, the Phillies will await a status report on former Nationals reliever Ray King -- who is expected to become a free agent -- before deciding between him, former Giants lefty Steve Kline and other candidates.
King, 34, was sent by the Nationals to Triple A Columbus late last week, but turned down the assignment, thus voiding his contract. He had a 5.61 ERA in limited play this year, following up a 4.67 mark in 67 appearances last year.
Kline, 35, a Philadelphia area native, was cut by the Giants after spring camp and signed to a minor league contract by the Phillies, but so far has struggled against Triple A bats at Charlotte.
King, 34, was sent by the Nationals to Triple A Columbus late last week, but turned down the assignment, thus voiding his contract. He had a 5.61 ERA in limited play this year, following up a 4.67 mark in 67 appearances last year.
Kline, 35, a Philadelphia area native, was cut by the Giants after spring camp and signed to a minor league contract by the Phillies, but so far has struggled against Triple A bats at Charlotte.
Cubs Seek Boost from Phillies Castoff
Mindful of a lack of depth in the outfield, the Chicago Cubs reportedly have opened talks to sign 28-year-old outfield prospect Valentino Pascucci, who led the International League with 34 homers last year.
Pascucci -- a native of the Los Angeles area -- last played at the major league level in March, when the Phillies demoted him from spring camp to the minors, only to release the 6-foot-6, 260-pound slugger altogether after he struggled to make contact in a limited trial.
Pascucci last appeared in the major leagues with the Montreal Expos in 2004, who took him in the 15th round of the 1996 draft. Though he was a major contributor last year for Triple A Albuquerque in the Marlins system, his bat has been supplanted there by former Angels prospect Dallas McPherson, who is hitting nearly .300 and is approaching double digit homers in the early going.
McPherson is a natural corner infielder, but Albuquerque is giving him a tryout in the outfield.
With star outfielder Rafael Soriano out with chronic leg injuries, the Cubs have been forced to bolster the outfield with infielder Mark DeRosa, have recalled Matt Murton and signed light-hitting Blue Jays castoff Reed Johnson.
If Pascucci signs with the Cubs, expect him to be assigned to Triple A Des Moines.
Pascucci -- a native of the Los Angeles area -- last played at the major league level in March, when the Phillies demoted him from spring camp to the minors, only to release the 6-foot-6, 260-pound slugger altogether after he struggled to make contact in a limited trial.
Pascucci last appeared in the major leagues with the Montreal Expos in 2004, who took him in the 15th round of the 1996 draft. Though he was a major contributor last year for Triple A Albuquerque in the Marlins system, his bat has been supplanted there by former Angels prospect Dallas McPherson, who is hitting nearly .300 and is approaching double digit homers in the early going.
McPherson is a natural corner infielder, but Albuquerque is giving him a tryout in the outfield.
With star outfielder Rafael Soriano out with chronic leg injuries, the Cubs have been forced to bolster the outfield with infielder Mark DeRosa, have recalled Matt Murton and signed light-hitting Blue Jays castoff Reed Johnson.
If Pascucci signs with the Cubs, expect him to be assigned to Triple A Des Moines.
Sunday, April 27, 2008
Troy Glaus Undergoes Eye Treatment
Cardinals third baseman Troy Glaus has undergone a battery of skin tests and other examinations to evaluate the effectiveness of antihistamines and other remedies aimed at counteracting airborne allergens that have affected his vision due to common allergic rhinitis or conjunctivitis while playing in St. Louis.
While the specific offender has not been isolated, Glaus is being tested for reactions to a number of pollens common to the Central Mississippi Valley, including grasses, weeds and trees. Mites, dust and dander at his home is also suspect.
Though causes of Glaus' watering eyes are likely present not only in St. Louis but elsewhere, a preponderance of poplars, cedars, ragweed or other irritants in the old Busch Stadium area -- combined with prevailing winds and other atmospheric conditions -- have prevented Glaus keeping his eyes clear only during home games, particularly day games.
Look for the treatments to be effective within two or three days, if not sooner, and for Glaus' return to the lineup without impediment.
While the specific offender has not been isolated, Glaus is being tested for reactions to a number of pollens common to the Central Mississippi Valley, including grasses, weeds and trees. Mites, dust and dander at his home is also suspect.
Though causes of Glaus' watering eyes are likely present not only in St. Louis but elsewhere, a preponderance of poplars, cedars, ragweed or other irritants in the old Busch Stadium area -- combined with prevailing winds and other atmospheric conditions -- have prevented Glaus keeping his eyes clear only during home games, particularly day games.
Look for the treatments to be effective within two or three days, if not sooner, and for Glaus' return to the lineup without impediment.
Rick Ankiel Moved in Batting Order
Slumping Cardinals outfielder Rick Ankiel's troubles are serious enough that manager Tony LaRussa dropped him from the middle of the batting order to the No. 2 spot, where at least he stands a chance of moving a runner when he meekly grounds out to second base.
Even a blind squirrel occasionally finds a nut.
Ankiel -- last year's feel-good story as the former hard-throwing pitcher who made himself over as a position player -- has seen his batting average plummet 40 points in six weeks to .247, leaving LaRussa with a huge hole in the lineup where he desperately needed an RBI threat to prevent the opposition from pitching around superstar slugger Albert Pujols.
Though the season is still very young, critics had warned against what was perceived as a plausible depth problem for the Cardinals, seeing little help available should the team falter due to productivity lapses such as that being experienced by Ankiel, to say nothing of the probability of injuries.
Secondary outfielders Ryan Ludwick and Skip Schumaker are hitting well -- though not with power -- but are more ideally suited to be mixed and matched against various right-handed and left-handed pitchers.
The prime candidate to replace Ankiel -- should his outstanding productivity from last year turn out to be a short lived aberration -- is Colby Rasmus, but Rasmus is barely hitting his weight even after more than 100 plate appearances for at Triple A Memphis.
Expect the Cardinals to keep rapidly advancing Joe Mather, who has taken a shining to International League pitching. Mather is hitting .348 with a .739 slugging average in a brief trial after coming over to Memphis from Double A.
Even a blind squirrel occasionally finds a nut.
Ankiel -- last year's feel-good story as the former hard-throwing pitcher who made himself over as a position player -- has seen his batting average plummet 40 points in six weeks to .247, leaving LaRussa with a huge hole in the lineup where he desperately needed an RBI threat to prevent the opposition from pitching around superstar slugger Albert Pujols.
Though the season is still very young, critics had warned against what was perceived as a plausible depth problem for the Cardinals, seeing little help available should the team falter due to productivity lapses such as that being experienced by Ankiel, to say nothing of the probability of injuries.
Secondary outfielders Ryan Ludwick and Skip Schumaker are hitting well -- though not with power -- but are more ideally suited to be mixed and matched against various right-handed and left-handed pitchers.
The prime candidate to replace Ankiel -- should his outstanding productivity from last year turn out to be a short lived aberration -- is Colby Rasmus, but Rasmus is barely hitting his weight even after more than 100 plate appearances for at Triple A Memphis.
Expect the Cardinals to keep rapidly advancing Joe Mather, who has taken a shining to International League pitching. Mather is hitting .348 with a .739 slugging average in a brief trial after coming over to Memphis from Double A.
Gary Sheffield: Return to DL or Retire?
The Detroit Tigers medical staff revealed that perennial quick-bat/quick-bat Gary Sheffield had two cortisone injections in both his shoulders earlier this week to help alleviate pain. He had a second injection in his right shoulder on Wednesday in an effort to help the healing process, according to baseball injury analyst Rick Wilton.
If the latest injection does not provide relief, perhaps he will get a third or face a trip to the disabled list. In any event, Sheffield's outlook does not appear good.
It's uncommon for a player to receive two injections in such short time period, intimating that Sheffield's shoulder discomfort and limited range of motion of the right shoulder is more serious initially assumed. There is some hearsay intimated in the Detroit area that he is considering retirement.
If one cortisone injection is good, and two are better, why not three, or four, or six? Like prunes for constipation, "two may not be enough, six may be too many" as the Hailey's MO commercial tagline used to go.
Cortisone is a popular word for a wide variety of injectable corticosteroids (e.g., triamcinolone, dexamethasone, betamethasone, methylprednisolone), anti-inflammatory medications that, when delivered by needle from a steady hand into the correct pinpoint area of the body, when clinically indicated, has the benefit of ostensibly producing maximum drug effect over a small concentrated area, avoiding adverse systemic effects.
To get the same effect systemically, taking the medication orally, one would have to ingest large doses of the same drugs, risking a wide variety of systemic effects.
Systemic corticosteroids cause weight gain. They elevate the blood sugar. They thin the bones, cause gastrointestinal bleeding, produced cataracts, atrophy the skin, and, in some people, result in florid psychosis. But injectable corticosteroids are not risk free and are no panacea for what ails you.
Because of the lack of well-controlled outcome studies, the multitude of target organs, and the complex interactions in the body, little is actually known about the exact mechanism of action of corticosteroids in each of the many disease states and conditions for which they are presently used. Even less is known for treatment of sports injuries because of the lack of accepted and reviewed studies. Corticosteroids have either a direct or an indirect effect on the metabolism of most tissues in the body. Their high lipid solubility allows their effect to occur systemically. This effect is mediated by the ability of corticosteroids to bind to appropriate receptors in cell nuclei and to initiate messenger ribonucleic acid translation.
During administration of a corticosteroid, it is found in all cells in the body, but effects are induced only in those cells that have its receptor. Corticosteroids usually reach a maximal effect at about 4 to 6 hours when administered orally and intravenously. Intra-articular administration, such as that applied to Sheffield's shoulder, yields an immediate maximal response with varying durations.
As illuminated by DeLee: DeLee and Drez's Orthopaedic Sports Medicine, Second Edition, one well-known mechanism is the role of cortico-steroids as anti-inflammatory agents. The inhibitory action of corticosteroids on inflammatory mediators is similar to that of NSAIDs (nonsteroidal anti-inflammatory drugs, e.g., ibuprofen). The site of action is one step before cyclooxygenase and lipoxygenase. Phospholipase A2 is responsible for the release of arachidonic acid from phospholipids. Corticosteroids inhibit this release by inhibiting phospholipase A2. The synthesis of prostaglandin, leukotriene, and thromboxane is inhibited by the administration of corticosteroids. Because of this blanket inhibition, corticosteroids are much more effective at decreasing inflammation than NSAIDs are. With this increased short-term efficacy, however, the corticosteroids cause more adverse effects.
Corticosteroids influence immunologically mediated disease states. Most notable is the ability to produce monocytopenia, lymphocytopenia, and neutrophilic leukocytosis. Two broad categories of effects on white blood cells are alterations in cell function and changes in their trafficking through the circulatory system. Transient cell movement occurs in lymphocytes and monocytes as the corticosteroids induce their redistribution out of the circulation and into their respective lymphoid compartments. 'T' lymphocytes are preferentially depleted over other lymphocytes. Cell function can be compromised in three ways: (1) depletion of a cell type can occur; (2) accessory cells are suppressed; and (3) direct suppression of the functional capacity of the cell occurs. Translation? The body's immune system is rendered incompetent resulting in an inability to respond to stress and disease.
Of the two means of delivery of corticosteroids—oral administration and local injection—sports injuries are mostly treated with local injections. Although they are excellent anti-inflammatory agents, oral corticosteroids do not have a proven efficacy for sports injuries because of the systemic effects and risks when they are used frequently. Two studies of intra-articular corticosteroid injections showed a decrease in the migration of labeled neutrophils (white blood cells) to inflamed joints. The exact mechanisms are unknown, but it is speculated that corticosteroids block the action of macrophage-inhibiting factor, which accounts for reduced vascular permeability, cell adhesion, and migration. Synovial membranes were also found to decrease secretion of interleukin-1 after the administration of corticosteroids. All this medical gobbly-gook and gibberish is not good (read: bad).
Orthopaedic surgeons frequently use intra-articular and extra-articular applications of injectable corticosteroids in an effort to treat both acute and chronic inflammatory conditions and pain related to sports injuries. Treatment foci have included cartilage, bursae, ligaments, and tendons. Additional targets are nerves and the joints in rheumatoid and osteo arthritis.
Intra-articular injections of corticosteroids are most commonly used in arthritis treatment, both inflammatory and noninflammatory (degenerative) types. The injections decrease both inflammation and concomitant swelling, which decreases pain and increases joint mobility. Specific results are based on the degree of weight-bearing that the joint withstands.
The larger weight-bearing joints, like the hip and the knee, do not react as well in the long term to corticosteroid injections because pain is usually derived from gravitational forces sustained by the joint in osteoarthritis. The injections do, however, provide some short-term relief in these conditions. The application sites for corticosteroid injections in ligaments are questionable but most commonly are the collateral ligaments of the elbow, the extra-articular ligaments of the knee, and the ligaments of the ankle. Actual injection is applied around the ligament and not directly into it.
Corticosteroid injections are used for their anti-inflammatory properties to reduce pain, to decrease recovery time, and to allow earlier mobilization. The inherent composition of ligaments poses a problem, considering that approximately 70 to 80 percent of their dry weight is composed of collagen, and corticosteroids are known to inhibit collagen synthesis.
Long-term studies have shown that there is no appreciable difference in treatment efficacy with or without injections. Short-term use decreases pain but does not sustain pain relief and in fact could cause weakening of the ligament and possible rupture. Again, there is no consensus on corticosteroid injection in ligaments, but it is usually not recommended.
Tendon injuries, including tenosynovitis and tendinitis, are common ailments that plague athletes and warrant corticosteroid treatment. The most common form is tendinitis, with inflammation usually occurring at the insertion site to bone. Tenosynovitis is inflammation of the fatty tissue or synovium between the tendon and the tendon sheath called the paratenon. Risk of tendon rupture after corticosteroid injections locally makes such use significantly less desirable.
The subacromial, greater trochanteric, olecranon, prepatellar, and retrocalcaneal bursae are common sites of corticosteroid treatment. Results depend on the site of application. Trochanteric and olecranon bursitis both respond well to injections. Injections into retrocalcaneal (Achilles tendon) and prepatellar (patellar tendon) bursae have had less promising efficacy and have been associated with tendon rupture. Nerve compression syndromes (e.g., carpal tunnel syndrome) and stenosing tenosynovitis (e.g., de Quervain's disease and trigger fingers) are also treated with injectable corticosteroids, usually after a trial of NSAIDs has failed.
The efficacy and the application of each corticosteroid preparation have been differentiated only by the solubility of each preparation in water. The more soluble the preparation, the shorter half-life the drug maintains; thus, for more chronic conditions, water-insoluble corticosteroids are more applicable for treatment. In addition, because of proximity to another potential source of inflammation and pain, like the patellar tendon and the prepatellar bursa, it is sometimes difficult to know which tissue is being treated. This is a problem intrinsic to injection therapy. In contrast, when corticosteroids are injected directly and accurately into an anatomic structure and complete pain elimination results, the diagnostic usefulness of local injection of corticosteroid preparations is clear.
Although corticosteroid injections are widely used by physicians, a consensus on applications, techniques, and dosages has not been reached. Most physicians rely on past experience as a guide. Much more investigation is needed in this area. The primary contraindication to corticosteroid injections is local infection of the area of concern. In such an instance, it is necessary to avoid direct inoculation of the affected joint and to allow the innate immune response to initiate clearance of the bacteria.
Because corticosteroids have an inhibitory effect on leukocyte function and the normal healing response, their use can be a problem in the presence of early or established infection. Other contraindications include true hypersensitivity to corticosteroids, existence of a joint prosthesis, and hemorrhagic diathesis.
Direct injection into a tendon or a ligament should always be avoided owing to the risk of tendon rupture. Poorly compliant patients should not receive corticosteroids because they have an inherent propensity to fail to follow any portions of a treatment plan. In the case of corticosteroids, rest is just as important as rehabilitation. Joint instability, anticoagulation therapy, poorly controlled diabetes, and adjacent abraded skin are also reasons to avoid corticosteroid treatment.
Adverse effects include local and systemic manifestations. Initial findings supporting systemic absorption of locally administered corticosteroids included beneficial effects in distant joints, increased metabolites in the urine, and transient eosinopenia. The most serious of the potential side effects is that at higher doses, such as would occur during treatment of multiple joints at the same time, the corticosteroids can inhibit the hypothalamic-pituitary-adrenal axis. This suppression occurred anywhere from two to seven days after injection. The stress response to hypoglycemia was also suppressed for 48 hours.
Some of the local effects have been alluded to in the section on indications; namely, both ligament and tendon ruptures can occur despite peritenon placement of the medication. Arthropathy, another result of injection treatment, is related to the reduction or elimination of pain with subsequent increased activity at the joint. The clinical presentation improves subjectively, but the objective evaluation shows further progression of the disease. This is why compliance of the patient is important in the use of corticosteroid treatment.
Other effects are avascular necrosis at the site of injection and distant joints, infection, postinjection flare, hypersensitivity reactions, cutaneous atrophy at the site of injection, and calcification of the joint capsule. Rare cases of necrotizing fasciitis and visual hallucinations have also been documented.
One relatively new manifestation is osteoporosis, which has been found secondary to the use of corticosteroids. Corticosteroids have been found to increase osteoclastic activity and inhibit osteoblastic activity, thus decreasing bone mass. The only differences from normal osteoporosis that occurs with age are that it occurs faster and in all ages. Because injectable corticosteroids are not administered in a constant manner, as oral corticosteroids are, they have not yet been implicated as the cause of osteoporosis.
We project that the reach for potentent corticosteroid medications, and for additional medications, for Mr. Sheffield does not bode well for his longevity. In 2008, if he does return to duty, Sheffield will be reduced to pinch hitting and occasional DH roles. His remaining days in uniform are most definitely numbered.
If the latest injection does not provide relief, perhaps he will get a third or face a trip to the disabled list. In any event, Sheffield's outlook does not appear good.
It's uncommon for a player to receive two injections in such short time period, intimating that Sheffield's shoulder discomfort and limited range of motion of the right shoulder is more serious initially assumed. There is some hearsay intimated in the Detroit area that he is considering retirement.
If one cortisone injection is good, and two are better, why not three, or four, or six? Like prunes for constipation, "two may not be enough, six may be too many" as the Hailey's MO commercial tagline used to go.
Cortisone is a popular word for a wide variety of injectable corticosteroids (e.g., triamcinolone, dexamethasone, betamethasone, methylprednisolone), anti-inflammatory medications that, when delivered by needle from a steady hand into the correct pinpoint area of the body, when clinically indicated, has the benefit of ostensibly producing maximum drug effect over a small concentrated area, avoiding adverse systemic effects.
To get the same effect systemically, taking the medication orally, one would have to ingest large doses of the same drugs, risking a wide variety of systemic effects.
Systemic corticosteroids cause weight gain. They elevate the blood sugar. They thin the bones, cause gastrointestinal bleeding, produced cataracts, atrophy the skin, and, in some people, result in florid psychosis. But injectable corticosteroids are not risk free and are no panacea for what ails you.
Because of the lack of well-controlled outcome studies, the multitude of target organs, and the complex interactions in the body, little is actually known about the exact mechanism of action of corticosteroids in each of the many disease states and conditions for which they are presently used. Even less is known for treatment of sports injuries because of the lack of accepted and reviewed studies. Corticosteroids have either a direct or an indirect effect on the metabolism of most tissues in the body. Their high lipid solubility allows their effect to occur systemically. This effect is mediated by the ability of corticosteroids to bind to appropriate receptors in cell nuclei and to initiate messenger ribonucleic acid translation.
During administration of a corticosteroid, it is found in all cells in the body, but effects are induced only in those cells that have its receptor. Corticosteroids usually reach a maximal effect at about 4 to 6 hours when administered orally and intravenously. Intra-articular administration, such as that applied to Sheffield's shoulder, yields an immediate maximal response with varying durations.
As illuminated by DeLee: DeLee and Drez's Orthopaedic Sports Medicine, Second Edition, one well-known mechanism is the role of cortico-steroids as anti-inflammatory agents. The inhibitory action of corticosteroids on inflammatory mediators is similar to that of NSAIDs (nonsteroidal anti-inflammatory drugs, e.g., ibuprofen). The site of action is one step before cyclooxygenase and lipoxygenase. Phospholipase A2 is responsible for the release of arachidonic acid from phospholipids. Corticosteroids inhibit this release by inhibiting phospholipase A2. The synthesis of prostaglandin, leukotriene, and thromboxane is inhibited by the administration of corticosteroids. Because of this blanket inhibition, corticosteroids are much more effective at decreasing inflammation than NSAIDs are. With this increased short-term efficacy, however, the corticosteroids cause more adverse effects.
Corticosteroids influence immunologically mediated disease states. Most notable is the ability to produce monocytopenia, lymphocytopenia, and neutrophilic leukocytosis. Two broad categories of effects on white blood cells are alterations in cell function and changes in their trafficking through the circulatory system. Transient cell movement occurs in lymphocytes and monocytes as the corticosteroids induce their redistribution out of the circulation and into their respective lymphoid compartments. 'T' lymphocytes are preferentially depleted over other lymphocytes. Cell function can be compromised in three ways: (1) depletion of a cell type can occur; (2) accessory cells are suppressed; and (3) direct suppression of the functional capacity of the cell occurs. Translation? The body's immune system is rendered incompetent resulting in an inability to respond to stress and disease.
Of the two means of delivery of corticosteroids—oral administration and local injection—sports injuries are mostly treated with local injections. Although they are excellent anti-inflammatory agents, oral corticosteroids do not have a proven efficacy for sports injuries because of the systemic effects and risks when they are used frequently. Two studies of intra-articular corticosteroid injections showed a decrease in the migration of labeled neutrophils (white blood cells) to inflamed joints. The exact mechanisms are unknown, but it is speculated that corticosteroids block the action of macrophage-inhibiting factor, which accounts for reduced vascular permeability, cell adhesion, and migration. Synovial membranes were also found to decrease secretion of interleukin-1 after the administration of corticosteroids. All this medical gobbly-gook and gibberish is not good (read: bad).
Orthopaedic surgeons frequently use intra-articular and extra-articular applications of injectable corticosteroids in an effort to treat both acute and chronic inflammatory conditions and pain related to sports injuries. Treatment foci have included cartilage, bursae, ligaments, and tendons. Additional targets are nerves and the joints in rheumatoid and osteo arthritis.
Intra-articular injections of corticosteroids are most commonly used in arthritis treatment, both inflammatory and noninflammatory (degenerative) types. The injections decrease both inflammation and concomitant swelling, which decreases pain and increases joint mobility. Specific results are based on the degree of weight-bearing that the joint withstands.
The larger weight-bearing joints, like the hip and the knee, do not react as well in the long term to corticosteroid injections because pain is usually derived from gravitational forces sustained by the joint in osteoarthritis. The injections do, however, provide some short-term relief in these conditions. The application sites for corticosteroid injections in ligaments are questionable but most commonly are the collateral ligaments of the elbow, the extra-articular ligaments of the knee, and the ligaments of the ankle. Actual injection is applied around the ligament and not directly into it.
Corticosteroid injections are used for their anti-inflammatory properties to reduce pain, to decrease recovery time, and to allow earlier mobilization. The inherent composition of ligaments poses a problem, considering that approximately 70 to 80 percent of their dry weight is composed of collagen, and corticosteroids are known to inhibit collagen synthesis.
Long-term studies have shown that there is no appreciable difference in treatment efficacy with or without injections. Short-term use decreases pain but does not sustain pain relief and in fact could cause weakening of the ligament and possible rupture. Again, there is no consensus on corticosteroid injection in ligaments, but it is usually not recommended.
Tendon injuries, including tenosynovitis and tendinitis, are common ailments that plague athletes and warrant corticosteroid treatment. The most common form is tendinitis, with inflammation usually occurring at the insertion site to bone. Tenosynovitis is inflammation of the fatty tissue or synovium between the tendon and the tendon sheath called the paratenon. Risk of tendon rupture after corticosteroid injections locally makes such use significantly less desirable.
The subacromial, greater trochanteric, olecranon, prepatellar, and retrocalcaneal bursae are common sites of corticosteroid treatment. Results depend on the site of application. Trochanteric and olecranon bursitis both respond well to injections. Injections into retrocalcaneal (Achilles tendon) and prepatellar (patellar tendon) bursae have had less promising efficacy and have been associated with tendon rupture. Nerve compression syndromes (e.g., carpal tunnel syndrome) and stenosing tenosynovitis (e.g., de Quervain's disease and trigger fingers) are also treated with injectable corticosteroids, usually after a trial of NSAIDs has failed.
The efficacy and the application of each corticosteroid preparation have been differentiated only by the solubility of each preparation in water. The more soluble the preparation, the shorter half-life the drug maintains; thus, for more chronic conditions, water-insoluble corticosteroids are more applicable for treatment. In addition, because of proximity to another potential source of inflammation and pain, like the patellar tendon and the prepatellar bursa, it is sometimes difficult to know which tissue is being treated. This is a problem intrinsic to injection therapy. In contrast, when corticosteroids are injected directly and accurately into an anatomic structure and complete pain elimination results, the diagnostic usefulness of local injection of corticosteroid preparations is clear.
Although corticosteroid injections are widely used by physicians, a consensus on applications, techniques, and dosages has not been reached. Most physicians rely on past experience as a guide. Much more investigation is needed in this area. The primary contraindication to corticosteroid injections is local infection of the area of concern. In such an instance, it is necessary to avoid direct inoculation of the affected joint and to allow the innate immune response to initiate clearance of the bacteria.
Because corticosteroids have an inhibitory effect on leukocyte function and the normal healing response, their use can be a problem in the presence of early or established infection. Other contraindications include true hypersensitivity to corticosteroids, existence of a joint prosthesis, and hemorrhagic diathesis.
Direct injection into a tendon or a ligament should always be avoided owing to the risk of tendon rupture. Poorly compliant patients should not receive corticosteroids because they have an inherent propensity to fail to follow any portions of a treatment plan. In the case of corticosteroids, rest is just as important as rehabilitation. Joint instability, anticoagulation therapy, poorly controlled diabetes, and adjacent abraded skin are also reasons to avoid corticosteroid treatment.
Adverse effects include local and systemic manifestations. Initial findings supporting systemic absorption of locally administered corticosteroids included beneficial effects in distant joints, increased metabolites in the urine, and transient eosinopenia. The most serious of the potential side effects is that at higher doses, such as would occur during treatment of multiple joints at the same time, the corticosteroids can inhibit the hypothalamic-pituitary-adrenal axis. This suppression occurred anywhere from two to seven days after injection. The stress response to hypoglycemia was also suppressed for 48 hours.
Some of the local effects have been alluded to in the section on indications; namely, both ligament and tendon ruptures can occur despite peritenon placement of the medication. Arthropathy, another result of injection treatment, is related to the reduction or elimination of pain with subsequent increased activity at the joint. The clinical presentation improves subjectively, but the objective evaluation shows further progression of the disease. This is why compliance of the patient is important in the use of corticosteroid treatment.
Other effects are avascular necrosis at the site of injection and distant joints, infection, postinjection flare, hypersensitivity reactions, cutaneous atrophy at the site of injection, and calcification of the joint capsule. Rare cases of necrotizing fasciitis and visual hallucinations have also been documented.
One relatively new manifestation is osteoporosis, which has been found secondary to the use of corticosteroids. Corticosteroids have been found to increase osteoclastic activity and inhibit osteoblastic activity, thus decreasing bone mass. The only differences from normal osteoporosis that occurs with age are that it occurs faster and in all ages. Because injectable corticosteroids are not administered in a constant manner, as oral corticosteroids are, they have not yet been implicated as the cause of osteoporosis.
We project that the reach for potentent corticosteroid medications, and for additional medications, for Mr. Sheffield does not bode well for his longevity. In 2008, if he does return to duty, Sheffield will be reduced to pinch hitting and occasional DH roles. His remaining days in uniform are most definitely numbered.
Saturday, April 26, 2008
Mark Mulder Eyes Memphis Promotion
Injured Cardinals pitcher Mark Mulder -- having recovered discernible velocity on his fastball after just three minor league rehabilitation appearances -- is anticipating a promotion to Memphis and a probable return to St. Louis no later than mid-May.
Mulder struggled somewhat with command as he threw 49 of 84 pitches for strikes in a five-inning, 12-4 victory in his most recent outing for Double A Springfield at Tulsa. But he found he was able to exceed the 90 mph threshold with regularity as he struck out five batters while walking four.
Mulder garnered outs on seven infield grounders while giving up four runs on six hits. Increased velocity was the likely cause for Mulder's wildness in the first inning, when he allowed the first five batters to reach base.
It was the 30-year-old lefty's second appearance against the Drillers last week, having beaten them the previous Sunday when he threw six innings without giving up a run, though he relied mostly on breaking balls and other offspeed pitches in that appearance.
"I am 10 times happier with this outing that I was about my last one against these guys," Mulder was quoted as telling the Tulsa World. "I was wild, but my arm and my delivery worked so much better..."
Barring regression after coming back from rotator cuff surgery, Mulder likely should need no more than three appearances before returning to St. Louis, and could return sooner. Mulder is expected to make his next outing Friday, with an announcement being awaited Monday as to whether he will appear at Springfield or Memphis.
Mulder struggled somewhat with command as he threw 49 of 84 pitches for strikes in a five-inning, 12-4 victory in his most recent outing for Double A Springfield at Tulsa. But he found he was able to exceed the 90 mph threshold with regularity as he struck out five batters while walking four.
Mulder garnered outs on seven infield grounders while giving up four runs on six hits. Increased velocity was the likely cause for Mulder's wildness in the first inning, when he allowed the first five batters to reach base.
It was the 30-year-old lefty's second appearance against the Drillers last week, having beaten them the previous Sunday when he threw six innings without giving up a run, though he relied mostly on breaking balls and other offspeed pitches in that appearance.
"I am 10 times happier with this outing that I was about my last one against these guys," Mulder was quoted as telling the Tulsa World. "I was wild, but my arm and my delivery worked so much better..."
Barring regression after coming back from rotator cuff surgery, Mulder likely should need no more than three appearances before returning to St. Louis, and could return sooner. Mulder is expected to make his next outing Friday, with an announcement being awaited Monday as to whether he will appear at Springfield or Memphis.
Friday, April 25, 2008
Moises Alou's Problem Rooted in Pain
Outfielder Moises Alou is about to make his return to the Mets. He is recovering from surgical repair of a sports hernia. A what? A sports hernia occurs when there is a weakening of the muscles or tendons of the lower abdominal wall. This part of the abdomen is the same region where an inguinal hernia occurs, the inguinal canal. When an inguinal hernia occurs there is sufficient weakening of the abdominal wall to allow a pouch, the hernia, to be felt. In the case of a sports hernia, the problem is due to a weakening in the same abdominal wall muscles, but there is no palpable hernia.
The predominant complaint of athletes with a sports hernia is unilateral groin pain, though bilateral pain may also occur. The pain is usually noted during exercise, but if the patient continues to exercise with pain, it may occur during other activities. The onset is typically insidious, but in a third of cases the athlete may describe a sudden tearing sensation.
Insidious onset is often described by runners, while sudden onset is more common in ice hockey and soccer players. Athletes who present with an insidious onset often say their pain occurs at lower thresholds of activity as they continue to train or compete. The pain is most typically well localized to the conjoined tendon but may involve the inguinal canal laterally. A significant number of athletes describe pain in the abductor region and occasionally in the perineum or testicles.
The pain is most often unilateral but may be felt bilaterally. It is common for athletes to describe symptoms, unresponsive to conservative treatment, that have been present for a number of months. The pain increases with sudden movements, acceleration, twisting and turning, cutting, and kicking, and it may be provoked by coughing and sneezing.
By definition, a clinically detectable hernia is not present, so the physical findings of a sports hernia are often subtle. In an athlete who has stopped training or competing, the only physical sign might be a tender, dilated superficial inguinal ring on the affected side. Examination for this entity in males is done by inverting the scrotum with the little finger. Local tenderness over the conjoined tendon, pubic tubercle, and mid inguinal region is common and may be exacerbated by resisted sit-ups. A small cough impulse may be detected by an experienced physician but is not diagnostic. Physical exam results are often complicated by multiple pathologies, particularly adductor tendonopathy.
Ekberg, in a prospective, multidisciplinary evaluation, found that 19 of 21 athletes who had pain for longer than three months had two or more separate pathologies. The authors suggested that an adequate explanation of an athlete's symptoms might require several diagnoses. In addition, Lovell found that 27 percent of his study's 189 athletes who had chronic groin pain also had multiple pathologies; in those found to have a sports hernia, 26 percent had a secondary diagnosis. Identifying any coexisting pathologies is important in an effective management plan.
The inguinal canal, which carries the spermatic cord in males and the round ligament in females, is a passage about four centimeters long that runs obliquely downward and medially parallel to and just above the inguinal ligament. The anterior wall of the canal consists of the external oblique aponeurosis and the internal oblique muscle. The posterior wall is formed by the fascia transversalis, which is reinforced in its medial third by the conjoined tendon, the common tendon of insertion of the internal oblique and transversus, which attaches to the pubic crest and pectineal line. The superficial inguinal ring lies anterior to the strong conjoined tendon.
Disruption to the conjoined tendon is a feature of the operative findings presented by the majority of authors. Gilmore describes a disruption to the groin characterized by three surgical findings: 1) a torn external oblique aponeurosis causing dilatation of the superficial inguinal ring; 2) a torn conjoined tendon; and 3) a dehiscence between the torn conjoined tendon and the inguinal ligament, constituting the major injury.
Hackney found a weakening of the transversalis fascia with separation from the conjoined tendon in all of his 16 cases. Simonet, et al, found tears in the internal oblique muscles in the 10 elite ice hockey players studied. Malycha and Lovell describe an incipient direct inguinal hernia with an associated bulge in the posterior inguinal wall extending anteriorly in 80 percent of cases in their series of 50 athletes.
Yet another pathology is proposed by Williams and Foster, who present a less complex disruption involving a small tear in the external oblique aponeurosis at the site of emergence of the terminal branches of the anterior primary rami of the iliohypogastric nerve. These findings reflect a spectrum of injury to the inguinal canal in athletes who have persistent groin pain.
Other researchers suggest that these injuries occur because adductor action during sporting activity creates shearing forces across the pubic symphysis that can stress the posterior inguinal wall. Consequent repetitive stretching of, or a more intense sudden force to, the transversalis fascia and the internal oblique can lead to their separation from the inguinal ligament. This mechanism may also account for the common finding of coexisting osteitis pubis and adductor tenoperiostitis in these patients.
There are no diagnostic tests that can be used to detect a sports hernia. The diagnosis is made by the patient's history and physical examination. Radiographic investigations are important in diagnosing the sports hernia, principally to exclude coexisting pathologies with overlapping symptoms. Plain radiographs may demonstrate osteitis pubis, adductor tenoperiosteal lesions, symphyseal instability (demonstrated by flamingo views), hip osteoarthritis, and bone tumors.
A bone scan can be helpful in making a diagnosis of active osteitis pubis, tenoperiosteal lesions, and stress fractures. Two studies have suggested the usefulness of herniography in diagnosing a hernia in athletes with unexplained groin pain. Intraperitoneal injection of radio-opaque contrast followed by filling of the peritoneal sacs enables an assessment of the integrity of the posterior inguinal wall and inguinal canal.
Smedberg et al, described the sensitivity of herniography in detecting true direct and indirect herniation; however, hernia or weakness of the posterior inguinal wall was also found in half of the asymptomatic groin sides.
Fricker suggests that in these cases, given the natural history of the condition, bilateral repair may be appropriate. Such a view is controversial and needs further evaluation. Many authorities do not routinely use herniography in clinical practice because its effectiveness in detecting sports hernias has not been clearly demonstrated. In addition, clinicians generally do not favor its use because of its low specificity and potential morbidity. Finally, a negative herniographic result in the face of strong clinical suspicion should not be a contraindication to surgical exploration. Dynamic ultrasonography may be the best noninvasive method to demonstrate posterior wall defects.
But could the symptoms be due to something else? As has already been suggested, a range of musculoskeletal conditions may mimic the sports hernia, including osteitis pubis, adductor tendonopathy, stress fracture of the pubic rami, and ilioinguinal or obturator neuropathies. Osteitis pubis is characterized by local tenderness of the symphysis, and a bone scan typically shows increased uptake on the delayed views of either or both margins of the symphysis. Bone scanning will also confirm most diagnoses of pelvic or hip stress fracture. The pain seen with adductor pathology is usually localized to the area of injury and provoked by resisted adduction.
There are no treatments that have been shown to be effective for sports hernia other than surgery. That said, the initial treatment of a sports hernia is always conservative in hopes that the symptoms will resolve. Resting from activity, anti-inflammatory medications, ice treatments, and physical therapy can all be tried in an effort to alleviate the patient's symptoms.
If these measures do not relieve the symptoms of a sports hernia, surgery may be recommended to repair the weakened area of the abdominal wall. Because of the lack of objective findings on physical examination and the absence of a definitive diagnostic test for sports hernia, surgery is often considered only after a trial of nonoperative treatment. However, conservative treatment is rarely effective, while surgery appears to be beneficial.
In patients strongly suspected of having coexisting pathologies that contribute to functional disability or whose coexisting pathologies are not clearly diagnosed, a trial of conservative treatment is appropriate. In patients whose symptoms strongly suggest a sports hernia as the sole pathology, particularly in the professional athlete, surgery should be considered at an early stage.
In number of studies have shown between 65 percent and 90 percent of athletes are able to return to their activity after surgery for a sports hernia. Rehabilitation from surgery for a sports hernia usually takes about eight weeks. While the diagnosis and surgical repair of clinically detectable direct and indirect inguinal and femoral canal hernias are well described, the disruption seen in the sports hernia is less well understood. Familiarity with inguinal canal anatomy may clarify some of the pathophysiologic causes of the sports hernia. Awareness of typical patient history and physical examination findings and appropriate radiographic studies can help physicians select patients for surgery.
The predominant complaint of athletes with a sports hernia is unilateral groin pain, though bilateral pain may also occur. The pain is usually noted during exercise, but if the patient continues to exercise with pain, it may occur during other activities. The onset is typically insidious, but in a third of cases the athlete may describe a sudden tearing sensation.
Insidious onset is often described by runners, while sudden onset is more common in ice hockey and soccer players. Athletes who present with an insidious onset often say their pain occurs at lower thresholds of activity as they continue to train or compete. The pain is most typically well localized to the conjoined tendon but may involve the inguinal canal laterally. A significant number of athletes describe pain in the abductor region and occasionally in the perineum or testicles.
The pain is most often unilateral but may be felt bilaterally. It is common for athletes to describe symptoms, unresponsive to conservative treatment, that have been present for a number of months. The pain increases with sudden movements, acceleration, twisting and turning, cutting, and kicking, and it may be provoked by coughing and sneezing.
By definition, a clinically detectable hernia is not present, so the physical findings of a sports hernia are often subtle. In an athlete who has stopped training or competing, the only physical sign might be a tender, dilated superficial inguinal ring on the affected side. Examination for this entity in males is done by inverting the scrotum with the little finger. Local tenderness over the conjoined tendon, pubic tubercle, and mid inguinal region is common and may be exacerbated by resisted sit-ups. A small cough impulse may be detected by an experienced physician but is not diagnostic. Physical exam results are often complicated by multiple pathologies, particularly adductor tendonopathy.
Ekberg, in a prospective, multidisciplinary evaluation, found that 19 of 21 athletes who had pain for longer than three months had two or more separate pathologies. The authors suggested that an adequate explanation of an athlete's symptoms might require several diagnoses. In addition, Lovell found that 27 percent of his study's 189 athletes who had chronic groin pain also had multiple pathologies; in those found to have a sports hernia, 26 percent had a secondary diagnosis. Identifying any coexisting pathologies is important in an effective management plan.
The inguinal canal, which carries the spermatic cord in males and the round ligament in females, is a passage about four centimeters long that runs obliquely downward and medially parallel to and just above the inguinal ligament. The anterior wall of the canal consists of the external oblique aponeurosis and the internal oblique muscle. The posterior wall is formed by the fascia transversalis, which is reinforced in its medial third by the conjoined tendon, the common tendon of insertion of the internal oblique and transversus, which attaches to the pubic crest and pectineal line. The superficial inguinal ring lies anterior to the strong conjoined tendon.
Disruption to the conjoined tendon is a feature of the operative findings presented by the majority of authors. Gilmore describes a disruption to the groin characterized by three surgical findings: 1) a torn external oblique aponeurosis causing dilatation of the superficial inguinal ring; 2) a torn conjoined tendon; and 3) a dehiscence between the torn conjoined tendon and the inguinal ligament, constituting the major injury.
Hackney found a weakening of the transversalis fascia with separation from the conjoined tendon in all of his 16 cases. Simonet, et al, found tears in the internal oblique muscles in the 10 elite ice hockey players studied. Malycha and Lovell describe an incipient direct inguinal hernia with an associated bulge in the posterior inguinal wall extending anteriorly in 80 percent of cases in their series of 50 athletes.
Yet another pathology is proposed by Williams and Foster, who present a less complex disruption involving a small tear in the external oblique aponeurosis at the site of emergence of the terminal branches of the anterior primary rami of the iliohypogastric nerve. These findings reflect a spectrum of injury to the inguinal canal in athletes who have persistent groin pain.
Other researchers suggest that these injuries occur because adductor action during sporting activity creates shearing forces across the pubic symphysis that can stress the posterior inguinal wall. Consequent repetitive stretching of, or a more intense sudden force to, the transversalis fascia and the internal oblique can lead to their separation from the inguinal ligament. This mechanism may also account for the common finding of coexisting osteitis pubis and adductor tenoperiostitis in these patients.
There are no diagnostic tests that can be used to detect a sports hernia. The diagnosis is made by the patient's history and physical examination. Radiographic investigations are important in diagnosing the sports hernia, principally to exclude coexisting pathologies with overlapping symptoms. Plain radiographs may demonstrate osteitis pubis, adductor tenoperiosteal lesions, symphyseal instability (demonstrated by flamingo views), hip osteoarthritis, and bone tumors.
A bone scan can be helpful in making a diagnosis of active osteitis pubis, tenoperiosteal lesions, and stress fractures. Two studies have suggested the usefulness of herniography in diagnosing a hernia in athletes with unexplained groin pain. Intraperitoneal injection of radio-opaque contrast followed by filling of the peritoneal sacs enables an assessment of the integrity of the posterior inguinal wall and inguinal canal.
Smedberg et al, described the sensitivity of herniography in detecting true direct and indirect herniation; however, hernia or weakness of the posterior inguinal wall was also found in half of the asymptomatic groin sides.
Fricker suggests that in these cases, given the natural history of the condition, bilateral repair may be appropriate. Such a view is controversial and needs further evaluation. Many authorities do not routinely use herniography in clinical practice because its effectiveness in detecting sports hernias has not been clearly demonstrated. In addition, clinicians generally do not favor its use because of its low specificity and potential morbidity. Finally, a negative herniographic result in the face of strong clinical suspicion should not be a contraindication to surgical exploration. Dynamic ultrasonography may be the best noninvasive method to demonstrate posterior wall defects.
But could the symptoms be due to something else? As has already been suggested, a range of musculoskeletal conditions may mimic the sports hernia, including osteitis pubis, adductor tendonopathy, stress fracture of the pubic rami, and ilioinguinal or obturator neuropathies. Osteitis pubis is characterized by local tenderness of the symphysis, and a bone scan typically shows increased uptake on the delayed views of either or both margins of the symphysis. Bone scanning will also confirm most diagnoses of pelvic or hip stress fracture. The pain seen with adductor pathology is usually localized to the area of injury and provoked by resisted adduction.
There are no treatments that have been shown to be effective for sports hernia other than surgery. That said, the initial treatment of a sports hernia is always conservative in hopes that the symptoms will resolve. Resting from activity, anti-inflammatory medications, ice treatments, and physical therapy can all be tried in an effort to alleviate the patient's symptoms.
If these measures do not relieve the symptoms of a sports hernia, surgery may be recommended to repair the weakened area of the abdominal wall. Because of the lack of objective findings on physical examination and the absence of a definitive diagnostic test for sports hernia, surgery is often considered only after a trial of nonoperative treatment. However, conservative treatment is rarely effective, while surgery appears to be beneficial.
In patients strongly suspected of having coexisting pathologies that contribute to functional disability or whose coexisting pathologies are not clearly diagnosed, a trial of conservative treatment is appropriate. In patients whose symptoms strongly suggest a sports hernia as the sole pathology, particularly in the professional athlete, surgery should be considered at an early stage.
In number of studies have shown between 65 percent and 90 percent of athletes are able to return to their activity after surgery for a sports hernia. Rehabilitation from surgery for a sports hernia usually takes about eight weeks. While the diagnosis and surgical repair of clinically detectable direct and indirect inguinal and femoral canal hernias are well described, the disruption seen in the sports hernia is less well understood. Familiarity with inguinal canal anatomy may clarify some of the pathophysiologic causes of the sports hernia. Awareness of typical patient history and physical examination findings and appropriate radiographic studies can help physicians select patients for surgery.
Jimmy Rollins 'Fracture' Unfounded
Jeff Erickson, senior editor of Rotowire and the host of "The Rotowire Fantasy Baseball Show" on XM 175 (weekdays at noon ET) recently advanced the notion that Phillies MVP shortstop Jimmy Rollins' stint on the disabled list (ankle sprain) is worth investigating as to whether the injury is due to a fracture.
We don't know how this cockamamie rumor got started but we intend to put the brakes on it right now. Jimmy Rollins has a soft tissue injury of his ankle. He's working it, he's rehabbing, he is taking batting practice, and prior to being backdated on the DL, he pinch hit at least twice.
What may have happened is this: some Phillies medical brainiac -- despite an appropriate clinical examination and negative plain radiographs of the injured extremity -- decides, just to make sure, and just because Rollins is a multimillion-dollar MLB stud, blah, blah, blah -- that Rollins should undergo computerized tomography or magnetic resonance imaging ostensibly to illuminate occult fractures.
This is common practice in circles where expensive and medically unindicated tests are performed "just to be on the safe side." Every doctor's office and emergency room does it -- even to ordinary people -- because...well...they can. The subsequent fees help pay for the equipment and the doctor's kid's braces.
Anyway, it's important to recognize that the "gold standard" for diagnosing a fracture clinically is an appropriate medical history for mechanism of injury and examination of bony tenderness when a clinician pushes on the site (on the bone, not on the soft tissue).
Generally, an X-ray is then obtained to prove or rule-out bony injury. If the x-ray is negative, there is no fracture. But from time to time, a medical practitioner is convinced that the X-ray is wrong and goes on to more exotic (and expensive) imaging techniques (CT and/or MRI) and viola -- an "occult" fracture is realized.
Unfortunately -- arguably with select exceptions -- the nonplain film identified fracture outcome is exactly the same as if the fracture was never identified. Imagine, if every time somebody fell down resulting in an X-ray to rule-out fracture, and the X-ray was negative, all those people receiving a CT -- "just to be on the side" (and pay a few bills). Imagine the magnitude of that practice inflicted across the population. The unnecessary expense would probably rival the gross national product of Canada, and the superfluous radiation exposure would not do anyone any good either.
We are convinced that Rollins is fine, and he will be clubbing the ball and tearing up the base paths precisely three weeks from his original point of injury. You can bank on it.
We don't know how this cockamamie rumor got started but we intend to put the brakes on it right now. Jimmy Rollins has a soft tissue injury of his ankle. He's working it, he's rehabbing, he is taking batting practice, and prior to being backdated on the DL, he pinch hit at least twice.
What may have happened is this: some Phillies medical brainiac -- despite an appropriate clinical examination and negative plain radiographs of the injured extremity -- decides, just to make sure, and just because Rollins is a multimillion-dollar MLB stud, blah, blah, blah -- that Rollins should undergo computerized tomography or magnetic resonance imaging ostensibly to illuminate occult fractures.
This is common practice in circles where expensive and medically unindicated tests are performed "just to be on the safe side." Every doctor's office and emergency room does it -- even to ordinary people -- because...well...they can. The subsequent fees help pay for the equipment and the doctor's kid's braces.
Anyway, it's important to recognize that the "gold standard" for diagnosing a fracture clinically is an appropriate medical history for mechanism of injury and examination of bony tenderness when a clinician pushes on the site (on the bone, not on the soft tissue).
Generally, an X-ray is then obtained to prove or rule-out bony injury. If the x-ray is negative, there is no fracture. But from time to time, a medical practitioner is convinced that the X-ray is wrong and goes on to more exotic (and expensive) imaging techniques (CT and/or MRI) and viola -- an "occult" fracture is realized.
Unfortunately -- arguably with select exceptions -- the nonplain film identified fracture outcome is exactly the same as if the fracture was never identified. Imagine, if every time somebody fell down resulting in an X-ray to rule-out fracture, and the X-ray was negative, all those people receiving a CT -- "just to be on the side" (and pay a few bills). Imagine the magnitude of that practice inflicted across the population. The unnecessary expense would probably rival the gross national product of Canada, and the superfluous radiation exposure would not do anyone any good either.
We are convinced that Rollins is fine, and he will be clubbing the ball and tearing up the base paths precisely three weeks from his original point of injury. You can bank on it.
Thursday, April 24, 2008
What Next for the Reds?
Wayne Krivsky out, Walt Jocketty in as Reds general manager. The move itself is no surprise -- an involved owner like Robert Castellini doesn't bring in a big-name GM like Jocketty just to serve as window dressing -- although the timing did catch most Reds watchers off-guard.
Not that any of those Reds fans will miss Krivsky, who was viewed by most as in over his head. In reality, Krivsky's record is much more mixed than terrible. While he certainly made his share of moves that do qualify as terrible, he also rebuilt the Reds' farm system into one of the best, and had success taking cheap flyers on players nobody else wanted.
But now Jocketty is in charge, and what does that mean for the Reds? Well, it might increase the odds of manager Dusty Baker being dumped. Baker was Krivsky's hire, and Jocketty might prefer his own man in there. But the guy Castellini and Jocketty both want -- Tony LaRussa -- already has a job. And besides, Baker is the kind of veteran baseball man that Jocketty probably prefers. So the move may come out a wash as far as it relates to Baker.
Expect pitcher Homer Bailey to be in the big leagues within a month, taking Matt Belisle's spot in the rotation.
Expect Adam Dunn to be traded for some combination of catching, bullpen and/or shortstop prospects around the All-Star Break.
And superprospect Jay Bruce to be ensconced in centerfield at least by the All-Star Break.
And expect Jocketty to attempt to convince Ken Griffey Jr. to spend the last few months of 2008 with a contender rather than with the Reds.
This is all assuming, of course, that the Reds don't suddenly turn into contenders themselves. Fact is, despite their slow start, the Reds have seen some very good things happen in the early going: pitchers Johnny Cueto and Edinson Volquez have proved to be real-deals; infielder Jeff Keppinger has shown he really can hit; Joey Votto has grabbed first base with gusto.
There is much for Walt Jocketty to work with.
Not that any of those Reds fans will miss Krivsky, who was viewed by most as in over his head. In reality, Krivsky's record is much more mixed than terrible. While he certainly made his share of moves that do qualify as terrible, he also rebuilt the Reds' farm system into one of the best, and had success taking cheap flyers on players nobody else wanted.
But now Jocketty is in charge, and what does that mean for the Reds? Well, it might increase the odds of manager Dusty Baker being dumped. Baker was Krivsky's hire, and Jocketty might prefer his own man in there. But the guy Castellini and Jocketty both want -- Tony LaRussa -- already has a job. And besides, Baker is the kind of veteran baseball man that Jocketty probably prefers. So the move may come out a wash as far as it relates to Baker.
Expect pitcher Homer Bailey to be in the big leagues within a month, taking Matt Belisle's spot in the rotation.
Expect Adam Dunn to be traded for some combination of catching, bullpen and/or shortstop prospects around the All-Star Break.
And superprospect Jay Bruce to be ensconced in centerfield at least by the All-Star Break.
And expect Jocketty to attempt to convince Ken Griffey Jr. to spend the last few months of 2008 with a contender rather than with the Reds.
This is all assuming, of course, that the Reds don't suddenly turn into contenders themselves. Fact is, despite their slow start, the Reds have seen some very good things happen in the early going: pitchers Johnny Cueto and Edinson Volquez have proved to be real-deals; infielder Jeff Keppinger has shown he really can hit; Joey Votto has grabbed first base with gusto.
There is much for Walt Jocketty to work with.
Thursday, April 17, 2008
Pitcher Erik Bedard's Status? Vexing
Seattle Mariners superstar southpaw Erik Bedard -- the American League's 2008 Cy Young recipient-in-waiting -- is on the trainer's table again with a bum hip, doubtless receiving a wide variety examinations, radiological imaging studies and physical therapy modalities followed by a raft of anti-inflammatory injections, oral medications, potions, liniments and incantations.The Mariners medical staff (along with a sizable representation of the Mariners Nation) likely would take a dead cat to a graveyard at midnight under a full moon and swing it three times if they thought it would do any good. Heck, manager John McLaren would probably sacrifice a virgin if he could find one.
What's most troubling is that Bedard (1-0, 3.27) has had his left hip chirp at him before, and it may very well be that it is worse than the team describes it. Certain things do not add up.
Remember the report that the injury was holding up the trade with Baltimore? Yet McLaren says the injury occurred when Bedard was "throwing in the outfield." Then Bedard was quoted as saying he woke up with the problem. Well, which is it? And why was he throwing on flat ground in the outfield?
Some fans may be reassured because Bedard's problem is in his hip and not his shoulder or elbow. But it would be foolish to think his lower extremities are unimportant.
Look at the action photo of Bedard. Yes, he knows how to pitch, and he has a lightening bolt coming from his shoulder joint. But look at his left leg! His power is largely generated from his legs. All hard throwers will tell you the secret to their heat is in the legs.
Now, is it possible that his is a new, true-true-and-unrelated injury related to casual throwing in the outfield? Possible -- but doubtful.
There is some loose talk about that Bedard is suffering from an "impingement" syndrome of the hip. What's that? Perhaps he has ileotibial band syndrome or simple trochanteric bursitis -- not dissimilar from what Mets first baseman Carlos Delgado was complaining about a few weeks ago. If Bedard is feeling a snap or a click, it may not be the hip joint at all, but inflammation of the musculoskeletal structures about the hip joint.
Regardless -- all the miracles of modern sports medicine notwithstanding -- Bedard is just going to have to rest, and with that, his arm will unavoidably wither.
Bedard can perform physical therapy, lift weights or participate in long toss, but to be a sharp pitcher, on his game, he has to pitch. He is just going to have to take a break. He'll be back, but it's a good bet he won't get 20 starts this year. Bye, bye, Cy Young. See you in 2009.
Wednesday, April 16, 2008
ID Crisis Cited in C.C.Sabathia's Woe
Ignoring rampant speculation that Cleveland Indians ace C.C. Sabathia's slow start is attributable to overwork last year, Akron Beacon Journal writer Sheldon Ocker has suggested Sabathia's woes may be attributable to an identity crisis.
Sabathia may be trying to rediscover whether he's a crafty lefty or a high-heat hurler, said Ocker, who covers the Indians on a daily basis.
"He used to come in with his 97-mph fastball and just try to blow it past people," Ocker told XM radio host Charlie Steiner. "Then he decided he wanted to mix in off-speed pitches and throw in the low 90s, which worked. Now he might be trying to remember, 'how did I do that?' "
Sabathia's ERA on the young season is 11.57, with an 0-2 record over 14 innings. Many have speculated that Sabathia is suffering from a tired arm after leading the league by throwing what was for him an unprecidented 242 innings last year.
But without him complaining about soreness or fatigue, the slow start remains a mystery, with predictions abounding that it is a matter of time before Sabathia rediscovers his form.
Sabathia may be trying to rediscover whether he's a crafty lefty or a high-heat hurler, said Ocker, who covers the Indians on a daily basis.
"He used to come in with his 97-mph fastball and just try to blow it past people," Ocker told XM radio host Charlie Steiner. "Then he decided he wanted to mix in off-speed pitches and throw in the low 90s, which worked. Now he might be trying to remember, 'how did I do that?' "
Sabathia's ERA on the young season is 11.57, with an 0-2 record over 14 innings. Many have speculated that Sabathia is suffering from a tired arm after leading the league by throwing what was for him an unprecidented 242 innings last year.
But without him complaining about soreness or fatigue, the slow start remains a mystery, with predictions abounding that it is a matter of time before Sabathia rediscovers his form.
Friday, April 11, 2008
Clay Buchholz Tries to Hold Off Bartolo Colon
With veteran Bartolo Colon injured, young Red Sox hurler Clay Buchholz now has a reprieve from what had been a probable demotion to Triple A Pawtucket.
Though nothing is official, Buchholz in all likelihood would have been demoted by now if Colon had not pulled up sore with a rib strain.
Colon, 34, had been anticipated to be named to the major league roster last week until doctors determined he should rest, effectively holding off his probable candidacy to replace Buchholz, 22. Buchholz is believed to have been ticketed to Pawtucket as coaches had been concerned over his inexperience and more than 10 ERA during spring camp and 5.03 ERA in the early going this season.
Though Buchholz pitched a no-hitter last year, he has options remaining and Colon had been throwing in the mid-90s in Pawtucket.
The Red Sox signed the free agent Colon to a $1.2 million, incentive-laden, one-year contract that goes into effect once Colon makes the roster. He was initially signed to replace injured staff ace Curt Schilling, who despite claims to the contrary is likely gone for the remainder of the year, perhaps forever.
Many scoffed at the Colon decision as he was only 6-8 with a 6.34 ERA in limited action with the Angels last year, having dealt with chronic elbow inflammation and rotator cuff problems. Colon started just 10 times in 2006, going 1-5 with a 5.11 ERA.
But Colon had been throwing well, dieting and exercising in Pawtucket, and had brought his weight down somewhat, though he appears to tip the scales at considerably more than the 245 pounds at which he is now listed.
Thursday, April 10, 2008
Rays to Unveil Newest Wonder Jeff Niemann
Though he still cannot be regarded as a finished product, 25-year-old former first-round pick Jeff Niemann will be rushed into action as the Tampa Bay Rays newest pitching wonder, when Niemann will be named temporarily to the No. 5 spot in the rotation.
An announcement is pending.
The 6-foot-9, 260-pound Niemann -- fourth overall pick in the 2004 draft -- will take the place of No. 2 starter Matt Garza, who has been sidelined by what is described as a "radial nerve irritation" in his throwing arm. Garza will miss at least two weeks.
Niemann will be called up from the Triple A Durham Bulls, where he is 2-0 with a 3.27 ERA in the young minor league season, after going 2-0 with a 1.50 ERA in limited action with the parent club this spring. He was 12-6 with a 3.98 ERA in 25 starts with the Bulls last year.
Niemann's lively slider was the talk of camp this spring. He signed a $5.2 million contract in 2005, but until now has been unable to reach the 40-man roster after a setback due to shoulder and clavicle distress nearly three years ago.
An announcement is pending.
The 6-foot-9, 260-pound Niemann -- fourth overall pick in the 2004 draft -- will take the place of No. 2 starter Matt Garza, who has been sidelined by what is described as a "radial nerve irritation" in his throwing arm. Garza will miss at least two weeks.
Niemann will be called up from the Triple A Durham Bulls, where he is 2-0 with a 3.27 ERA in the young minor league season, after going 2-0 with a 1.50 ERA in limited action with the parent club this spring. He was 12-6 with a 3.98 ERA in 25 starts with the Bulls last year.
Niemann's lively slider was the talk of camp this spring. He signed a $5.2 million contract in 2005, but until now has been unable to reach the 40-man roster after a setback due to shoulder and clavicle distress nearly three years ago.
Tuesday, April 08, 2008
Andruw Jones' Slow Start Sows Discontent
It's hardly what you would call a shrill crescendo, but the murmur of discontent over Andruw Jones and the general state of the Dodgers outfield is flying all the warning flags of a gathering storm.
Jones so far in the young season cannot even hit his weight, with Fox Sports Radio's Ben Maller the most recent to join the chorus of boo-birds over Jones' poor performance after signing a two-year contract for more than $18 million a year.
More than just the fact that Jones is not hitting, to some observers it seems he has gained so much weight and lost so much speed that he no longer can field with the same effectiveness that made him a Gold Glover for the Braves.
"He looks terrible," intones Maller, wondering whether Jones will ever reach the 30-homer threshold again, let alone 40. Maller sees Jones as being too heavy, too slow and too old, though Jones has insisted he is the same weight as when he led the league with 51 homers a scant three seasons ago.
Maller is hardly alone in the criticism.
"He doesn't look like the same player to me," remarked Padres broadcaster Jerry Coleman after watching Jones come up short in an attempt to run down a deep fly in a recent game in San Diego.
If Jones .115 batting average were attributable to merely a slow start that would be one thing. But this is nothing new, Jones having hit just .214 for the spring and .222 all last year.
The player Jones usurped in center field, Juan Pierre, is doing even worse at .067, but at least he has an excuse as an everyday player who has been cruelly benched by manager Joe Torre, then pulled in and out of the lineup from day to day. It's hardly a circumstance in which Pierre can be expected to find his rhythm.
So far Pierre and fellow outfielders Matt Kemp and Andre Ethier have borne the punishment for Jones' shortcomings, as Jones is being given every opportunity to play everyday at the expense of the others. How much longer this continues only Torre can tell, but bets are good that unless Jones finds himself in a week or two, he will be permitted to stink up Chavez Ravine for months to come.
Jones so far in the young season cannot even hit his weight, with Fox Sports Radio's Ben Maller the most recent to join the chorus of boo-birds over Jones' poor performance after signing a two-year contract for more than $18 million a year.
More than just the fact that Jones is not hitting, to some observers it seems he has gained so much weight and lost so much speed that he no longer can field with the same effectiveness that made him a Gold Glover for the Braves.
"He looks terrible," intones Maller, wondering whether Jones will ever reach the 30-homer threshold again, let alone 40. Maller sees Jones as being too heavy, too slow and too old, though Jones has insisted he is the same weight as when he led the league with 51 homers a scant three seasons ago.
Maller is hardly alone in the criticism.
"He doesn't look like the same player to me," remarked Padres broadcaster Jerry Coleman after watching Jones come up short in an attempt to run down a deep fly in a recent game in San Diego.
If Jones .115 batting average were attributable to merely a slow start that would be one thing. But this is nothing new, Jones having hit just .214 for the spring and .222 all last year.
The player Jones usurped in center field, Juan Pierre, is doing even worse at .067, but at least he has an excuse as an everyday player who has been cruelly benched by manager Joe Torre, then pulled in and out of the lineup from day to day. It's hardly a circumstance in which Pierre can be expected to find his rhythm.
So far Pierre and fellow outfielders Matt Kemp and Andre Ethier have borne the punishment for Jones' shortcomings, as Jones is being given every opportunity to play everyday at the expense of the others. How much longer this continues only Torre can tell, but bets are good that unless Jones finds himself in a week or two, he will be permitted to stink up Chavez Ravine for months to come.
Monday, April 07, 2008
Outlook for John Smoltz Still Unclear
Though John Smoltz struck out six while surrendering just two hits in his most recent victory -- his decision to take himself out of the game after throwing just 78 pitches over five innings points to continued health difficulties for the 41-year-old Atlanta Braves ace.
Having missed time early last year and again this spring due to discomfort when he throws, Smoltz appears to be taking it easy on his troubled shoulder to make sure not to overstress it, which of course could undercut his potential numbers of starts for the remainder of the season.
Smoltz took himself out early in the 3-1 win over the Mets even though he hates to come out of a game before the sixth inning, having averaged approximately 6.5 innings per appearance last year and over the past four years since he left the bullpen for the rotation.
Smoltz frequently lasts into the seventh inning and occasionally beyond, and has a dogmatic objective to do so, which can be expected to be his goal for the rest of the year if he can only stay healthy.
Having missed time early last year and again this spring due to discomfort when he throws, Smoltz appears to be taking it easy on his troubled shoulder to make sure not to overstress it, which of course could undercut his potential numbers of starts for the remainder of the season.
Smoltz took himself out early in the 3-1 win over the Mets even though he hates to come out of a game before the sixth inning, having averaged approximately 6.5 innings per appearance last year and over the past four years since he left the bullpen for the rotation.
Smoltz frequently lasts into the seventh inning and occasionally beyond, and has a dogmatic objective to do so, which can be expected to be his goal for the rest of the year if he can only stay healthy.
Saturday, April 05, 2008
Torii Hunter Better Bargain than Andruw Jones?
Preliminary impressions on the young season seem to confirm various opinions that the Angels $18-million-a-year deal with Torii Hunter will easily outshine the cross-town Dodgers $18-million-a-year deal with Andruw Jones, not only because of Hunter's superior hitting but perhaps even his fielding as well.
Hunter came to the Angels more highly touted than Jones after after Hunter hit .287 with 94 RBI and 28 homers last year for the Twins, compared to Jones' .222 average with 94 RBI and 26 homers for the Braves. But the Dodgers rationalized that Jones was due for a comeback year, and that his defensive play would make the deal worthwhile in any case as he and Hunter were comparable in the field.
But the kicker now seems to be that Jones no longer can be regarded as the unmistakable Gold Glove fielder he was when he played for the Braves. Jones -- trying to add muscle mass during the off-season -- seems to some observers to be so heavy now that he can no longer run the way he used to.
"He doesn't look like the same player to me," said Padres announcer Jerry Coleman after watching Jones fail to catch up to a long fly during a broadcast of a recent game between the Padres and Dodgers in San Diego.
Coleman said Jones looks noticeably heavier and slower.
Because it is still early in the year and because the Angels in effect paid more for Hunter than the Dodgers did for Jones (Hunter's contract is for five years as compared to Jones' cheaper two-year deal), it may take several seasons before the two contracts can be evaluated to see which Los Angeles team came out ahead.
But with early impressions taking shape, an old expression comes to mind: you get what you pay for.
Hunter came to the Angels more highly touted than Jones after after Hunter hit .287 with 94 RBI and 28 homers last year for the Twins, compared to Jones' .222 average with 94 RBI and 26 homers for the Braves. But the Dodgers rationalized that Jones was due for a comeback year, and that his defensive play would make the deal worthwhile in any case as he and Hunter were comparable in the field.
But the kicker now seems to be that Jones no longer can be regarded as the unmistakable Gold Glove fielder he was when he played for the Braves. Jones -- trying to add muscle mass during the off-season -- seems to some observers to be so heavy now that he can no longer run the way he used to.
"He doesn't look like the same player to me," said Padres announcer Jerry Coleman after watching Jones fail to catch up to a long fly during a broadcast of a recent game between the Padres and Dodgers in San Diego.
Coleman said Jones looks noticeably heavier and slower.
Because it is still early in the year and because the Angels in effect paid more for Hunter than the Dodgers did for Jones (Hunter's contract is for five years as compared to Jones' cheaper two-year deal), it may take several seasons before the two contracts can be evaluated to see which Los Angeles team came out ahead.
But with early impressions taking shape, an old expression comes to mind: you get what you pay for.
Friday, April 04, 2008
Expect Victor Martinez to Return to Field
The Cleveland Indians suggest that star catcher Victor Martinez -- already available to pinch hit -- will return to full-time play as early as this weekend.
Martinez went down with a hamstring strain in a baserunning mishap, but while the injury looked bad when it happened, catchers rarely sustain serious hamstring problems because their job description requires that they squat long and often -- thus keeping their hammies stretched and in superb condition.
Martinez went down with a hamstring strain in a baserunning mishap, but while the injury looked bad when it happened, catchers rarely sustain serious hamstring problems because their job description requires that they squat long and often -- thus keeping their hammies stretched and in superb condition.
Thursday, April 03, 2008
Squat Thrusts Catchers Into Hammy Haven
Cleveland's Victor Martinez's pinch-hit appearance after missing time with a pulled hamstring is hardly surprising considering that Martinez is a catcher.
Catchers -- as a general rule -- have the best conditioned hamstrings in baseball because they are constantly squatting. The squatting stretches the hamstring so much and so often that they seldom experience such an injury -- thus making Martinez's baserunning mishap highly unusual.
Expect Martinez to be back to playing regularly before the end of the weekend, or not much after. Ironically, Martinez doesn't even need his hammy to catch, just to run, which is not a big part of his game.
Catchers -- as a general rule -- have the best conditioned hamstrings in baseball because they are constantly squatting. The squatting stretches the hamstring so much and so often that they seldom experience such an injury -- thus making Martinez's baserunning mishap highly unusual.
Expect Martinez to be back to playing regularly before the end of the weekend, or not much after. Ironically, Martinez doesn't even need his hammy to catch, just to run, which is not a big part of his game.
Doug Davis and the Risks of CT Scans
Arizona pitcher Doug Davis -- about to miss time due to medical treatments -- has won the admiration, respect and well wishes of his teammates. Putting off thyroid cancer surgery to make a couple of starts in April will do that for you. "When I first heard about it, I'm not going to say I wasn't crying," Davis said. "Of course I was." (Tony DeMarco, NBC Sports).
Doug Davis has thyroid cancer. According to repots, he is suspected of having follicular carcinoma. Generally there are four major types of thyroid cancer (in worsening order of prognosis/seriousness and risk for early mortality from the disease):
1. papillary;
2. follicular;
3. medullary;
4. anaplastic
In Davis' case, his cancer may be related to a familiar propensity to acquire the disease -- two first-order family members have a history of thyroid cancer.
However, papillary and follicular carcinomas are also definitely associated, as an independent risk factor, with radiation to the neck. Brilliant and classical epidemiological work by UCLA medical professor JR Hoffman, et. al., in multiple peer-review accepted scientific publications, have clearly illuminated the fact that as many as 1,000 cases of thyroid cancer are diagnosed each year in the US as a direct result of cervical spine x-rays -- the vast majority of which, over 90-percent estimated in various studies, are medically unnecessary.
When you were a kid, didn’t your mother repeatedly bellow one or both of the following to you: "... stop doing that before you put your eye out!!!" Or: "...get down from there before you break your neck!!!" Doubtless this ubiquitous parental admonishment has advanced the notion that every time your neck hurts due to some minor trauma (or even without history of trauma), you must immediately run to the nearest emergency room and get an X-ray -- who wants to have an undiagnosed broken neck, become a quadriplegic and spend the rest of your life in a wheelchair, aye?
Per standard routine, no self-respecting patient in America, with or without third-party entitlement for payment, is going to consider a learned medical practitioner’s opinion that the X-ray is usually not clinically indicated, based upon the history and clinical examination of the malady. Curiously, there is a large subset of the population that never believes the doctor -- they want the technology instead, "just to be on the safe-side." Right.
Generally, the patient (or their family and friend surrogates) are so adamant to insist on the X-rays, that some emergency departments acquiesce even before the patient is seen and the X-rays are ordered by the triage nurse in advance of the physician’s evaluation -- just to move the process along, satisfy the patient, add to the bill, and open that ER bed to somebody who really needs it.
As an emergency healthcare provider, having been confronted with that situation several thousand times myself, when I am really sure the neck x-ray is a waste of time and somebody’s money, or when especially when the patient is a child (see comment below), I will always offer the x-ray series under the proviso that: a) the patient understands that it is not medically indicated, and b) there is a risk of producing thyroid cancer some time in the future.
It is astonishing how many patients will recant their demand for the neck x-ray.
We’re talking just about neck x-rays and baseball players. The amount of radiation produced by a cervical spine x-ray series is miniscule compared to the total body dose of radiation received by computerized (axial) tomography – CT or CAT scans. One CT scan of the abdomen, for example, is the equivalent radiation of 500 chest x-rays (a chest x-ray is about triple the radiation exposure of a neck x-ray). How often do you hear about professional athletes getting a CT scan (not to be confused with MRI which is believed to be safer but fantastically more expensive)?
Examination by MRI is particularly good for soft tissue, but lousy for bony structures. So, if there is a bonk on the head, if there is a peculiar pain or tenderness with a normal plain x-ray, if there is back pain – CTs are often performed. As an aside, it’s important to recognize that fractures elucidated by CT and not by plain radiography are, by definition, not fractures, per se, at all. The "gold-standard" definition of a fracture - one that is evident by plain radiography.
If every time somebody hurt something and the x-rays were negative a CT scan was performed, we might identify lots of occult fractures for which the management is exactly the same – except the bill is enhanced and the patient has absorbed a load of radiation.
Radiation exposure, by the way, is cumulative over one’s lifetime, so exposure to children is particulary important. Over the course of a lifetime, we are exposed to a wide variety of radiation sources from the sun and our TV sets, for example, in addition to medical radiation.
When the dose is sufficient, accumulated over many years: "there’s your cancer, Madam – it’s your turn to die."
The cause of cancer is multifactorial: hereditary factors, viruses, environmental exposure, chemical exposures, and radiation, all of which have been described in the medical literature. I suspect (and the opinion is shared by many scientists more intimately familiar with the subject than me) that one day there will come a reckoning related to our penchant for CT scans for everything from headache, to sinus disease, to chest pain, to abdominal pain, to suspected kidney stones, and extremity trauma.
In 2002, for example, 60 million CT scans were performed in the US, accounting for 70-percent of medical x-ray exposures. According to a report by the National Academy of Science, a single dose of 10mSv is associated with a lifetime risk of a solid cancer or leukemia (with associated death) of 1 in 1,000. The radiation dose associated with a typical abdominal CT scan is 10-20mSv.
It is particularly problematic when patients undergo multiple CT scans. In one study, it was reported that patients with reecurrent renal colic (kidney stone) commonly experience total radiation exposures of 19.5-153.7mSv.
Physicians requesting CT scans for their patients are often unaware of the associated risks. Studies have reported that only 9-percent of emergency department physicians and only 47-percent of radiologists involved with CT scanning were aware of the increased risk of cancer posed by these studies. Failure to appreciate this risk of radiation exposure has a substantial impact on the process of informed consent.
Yes, hopefully when these tests are obtained, we should like to believe that the benefit outweighs the risk, but too often, especially with multimillion dollar professional athletes, it is clearly not. I wonder, if armed with that information, and Doug Davis strained his neck, while intimately familiar with his family history of thyroid cancer, if he would allow the team doctors to x-ray and/or CT his neck?
Doug Davis has thyroid cancer. According to repots, he is suspected of having follicular carcinoma. Generally there are four major types of thyroid cancer (in worsening order of prognosis/seriousness and risk for early mortality from the disease):
1. papillary;
2. follicular;
3. medullary;
4. anaplastic
In Davis' case, his cancer may be related to a familiar propensity to acquire the disease -- two first-order family members have a history of thyroid cancer.
However, papillary and follicular carcinomas are also definitely associated, as an independent risk factor, with radiation to the neck. Brilliant and classical epidemiological work by UCLA medical professor JR Hoffman, et. al., in multiple peer-review accepted scientific publications, have clearly illuminated the fact that as many as 1,000 cases of thyroid cancer are diagnosed each year in the US as a direct result of cervical spine x-rays -- the vast majority of which, over 90-percent estimated in various studies, are medically unnecessary.
When you were a kid, didn’t your mother repeatedly bellow one or both of the following to you: "... stop doing that before you put your eye out!!!" Or: "...get down from there before you break your neck!!!" Doubtless this ubiquitous parental admonishment has advanced the notion that every time your neck hurts due to some minor trauma (or even without history of trauma), you must immediately run to the nearest emergency room and get an X-ray -- who wants to have an undiagnosed broken neck, become a quadriplegic and spend the rest of your life in a wheelchair, aye?
Per standard routine, no self-respecting patient in America, with or without third-party entitlement for payment, is going to consider a learned medical practitioner’s opinion that the X-ray is usually not clinically indicated, based upon the history and clinical examination of the malady. Curiously, there is a large subset of the population that never believes the doctor -- they want the technology instead, "just to be on the safe-side." Right.
Generally, the patient (or their family and friend surrogates) are so adamant to insist on the X-rays, that some emergency departments acquiesce even before the patient is seen and the X-rays are ordered by the triage nurse in advance of the physician’s evaluation -- just to move the process along, satisfy the patient, add to the bill, and open that ER bed to somebody who really needs it.
As an emergency healthcare provider, having been confronted with that situation several thousand times myself, when I am really sure the neck x-ray is a waste of time and somebody’s money, or when especially when the patient is a child (see comment below), I will always offer the x-ray series under the proviso that: a) the patient understands that it is not medically indicated, and b) there is a risk of producing thyroid cancer some time in the future.
It is astonishing how many patients will recant their demand for the neck x-ray.
We’re talking just about neck x-rays and baseball players. The amount of radiation produced by a cervical spine x-ray series is miniscule compared to the total body dose of radiation received by computerized (axial) tomography – CT or CAT scans. One CT scan of the abdomen, for example, is the equivalent radiation of 500 chest x-rays (a chest x-ray is about triple the radiation exposure of a neck x-ray). How often do you hear about professional athletes getting a CT scan (not to be confused with MRI which is believed to be safer but fantastically more expensive)?
Examination by MRI is particularly good for soft tissue, but lousy for bony structures. So, if there is a bonk on the head, if there is a peculiar pain or tenderness with a normal plain x-ray, if there is back pain – CTs are often performed. As an aside, it’s important to recognize that fractures elucidated by CT and not by plain radiography are, by definition, not fractures, per se, at all. The "gold-standard" definition of a fracture - one that is evident by plain radiography.
If every time somebody hurt something and the x-rays were negative a CT scan was performed, we might identify lots of occult fractures for which the management is exactly the same – except the bill is enhanced and the patient has absorbed a load of radiation.
Radiation exposure, by the way, is cumulative over one’s lifetime, so exposure to children is particulary important. Over the course of a lifetime, we are exposed to a wide variety of radiation sources from the sun and our TV sets, for example, in addition to medical radiation.
When the dose is sufficient, accumulated over many years: "there’s your cancer, Madam – it’s your turn to die."
The cause of cancer is multifactorial: hereditary factors, viruses, environmental exposure, chemical exposures, and radiation, all of which have been described in the medical literature. I suspect (and the opinion is shared by many scientists more intimately familiar with the subject than me) that one day there will come a reckoning related to our penchant for CT scans for everything from headache, to sinus disease, to chest pain, to abdominal pain, to suspected kidney stones, and extremity trauma.
In 2002, for example, 60 million CT scans were performed in the US, accounting for 70-percent of medical x-ray exposures. According to a report by the National Academy of Science, a single dose of 10mSv is associated with a lifetime risk of a solid cancer or leukemia (with associated death) of 1 in 1,000. The radiation dose associated with a typical abdominal CT scan is 10-20mSv.
It is particularly problematic when patients undergo multiple CT scans. In one study, it was reported that patients with reecurrent renal colic (kidney stone) commonly experience total radiation exposures of 19.5-153.7mSv.
Physicians requesting CT scans for their patients are often unaware of the associated risks. Studies have reported that only 9-percent of emergency department physicians and only 47-percent of radiologists involved with CT scanning were aware of the increased risk of cancer posed by these studies. Failure to appreciate this risk of radiation exposure has a substantial impact on the process of informed consent.
Yes, hopefully when these tests are obtained, we should like to believe that the benefit outweighs the risk, but too often, especially with multimillion dollar professional athletes, it is clearly not. I wonder, if armed with that information, and Doug Davis strained his neck, while intimately familiar with his family history of thyroid cancer, if he would allow the team doctors to x-ray and/or CT his neck?
Wednesday, April 02, 2008
Book on Richie Sexson Sad, Sad Tale
A new autobiography is being written by Mariners first baseman Richie Sexson and it's for pitchers only. Whether it turns out to be truth, fiction or slander is yet to be determined, because only Sexson will be able to tell the ending.
But essentially, the point of the new book on the 33-year-old, 6-foot-8, slugger is that he no longer can get around on an inside fastball -- an assertion that proven true might explain his .205 batting average last year.
Though ESPN baseball commentator Buck Martinez and others have predicted a comeback for Sexson, one thing is certain: he will see a steady diet of fastballs until he demonstrates he can hit them the way he used to.
Though Sexson notched his first hit of the season in his most recent outing, he also struck out three times in that game, once on just three pitches from Texas Rangers right-hander Vicente Padilla.
Though Padilla is not especially known as a hard thrower, in that particular at-bat he simply reached back to throw a 97 mph fastball over the plate, all but screwing Sexson into the ground and he flailed at it helplessly.
The Mariners waited all last season for him to come around, but to no avail. It will be interesting to see how long the team will wait this year before running out of patience. A costly but simple solution would involve Raul Ibanez taking over at first base, giving Wladimir Balentien a shot to play the outfield on a regular basis.
But essentially, the point of the new book on the 33-year-old, 6-foot-8, slugger is that he no longer can get around on an inside fastball -- an assertion that proven true might explain his .205 batting average last year.
Though ESPN baseball commentator Buck Martinez and others have predicted a comeback for Sexson, one thing is certain: he will see a steady diet of fastballs until he demonstrates he can hit them the way he used to.
Though Sexson notched his first hit of the season in his most recent outing, he also struck out three times in that game, once on just three pitches from Texas Rangers right-hander Vicente Padilla.
Though Padilla is not especially known as a hard thrower, in that particular at-bat he simply reached back to throw a 97 mph fastball over the plate, all but screwing Sexson into the ground and he flailed at it helplessly.
The Mariners waited all last season for him to come around, but to no avail. It will be interesting to see how long the team will wait this year before running out of patience. A costly but simple solution would involve Raul Ibanez taking over at first base, giving Wladimir Balentien a shot to play the outfield on a regular basis.
Tuesday, April 01, 2008
Kielty Crazy for Coco Trade
Bobby Kielty's reluctant acquiescance to accept a minor-league assignment at Pawtucket seems to indicate his inside knowledge that the Red Sox are continuing to try to deal Coco Crisp.
If that assumption proves correct, it seems most peculiar in light of the fact that J.D. Drew is up to his old tricks on the trainer's table, which would greatly enhance the value of Crisp as a reserve.
If that assumption proves correct, it seems most peculiar in light of the fact that J.D. Drew is up to his old tricks on the trainer's table, which would greatly enhance the value of Crisp as a reserve.
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Doctor X -- the 'Baseball Medic' -- is an anonymous U.S. government trauma specialist with a Duke University sports medicine background and more than 20 years experience in emergency medicine. From time to time he considers MLB rumors, events and news reports as they pertain to baseball players' injuries, illnesses and various other disabilities, both on the field and off.
MLB Rumors editor Greg Fieg is a former sports news editor and award-winning writer whose bylines have appeared on the wires of the Associated Press and in numerous publications, including San Antonio Express-News, San Antonio Light, Houston Chronicle and Philadelphia Bulletin. He formerly was posted in various positions on the U.S.-Mexican border with Freedom Newspapers, and was a regular, independent contributor to United Press International.