Red Sox nation breathed a sigh of relief when news broke Friday afternoon that David Price would not be undergoing surgery on his left (throwing) elbow. Concern about Price’s elbow began on Wednesday. He had pitched a simulated 2-inning game on Tuesday and developed increasing soreness in the elbow that was more than his usual training camp soreness according to comments from Manager John Farrell. He underwent an MRI of his elbow which was reportedly “inconclusive” so the decision was made to obtain a second orthopedic opinion.
Price made the trip to see Dr. James Andrews and Dr. Neal ElAttrache at the NFL combine, where Andrews is evaluating players as acting team physician for the Washington Redskins and ElAttrache is with the LA Rams. In the baseball world, a sore pitching elbow is cause for concern for an ulnar collateral ligament (UCL) injury. The UCL is a major rubber band-like stabilizer for the medial elbow joint, particularly when the elbow is bent. When the ligament is torn or becomes stretched from repetitive stress (such as in pitchers), reconstruction is often required. The most common technique is called “Tommy John” surgery, named after Tommy John, a left-handed MLB pitcher who underwent the surgery in 1974. This surgery is season-ending.
Friday afternoon, John Farrell said that Price had a “very positive exam [with Dr. Andrews and Dr. ElAttrache] given some of the concern a couple of days ago.” While there is no definitive timetable for his return, he will begin with 7-10 days of rest and be re-evaluated at that point.
So….is this good news? Relatively good news? Non-devastating news? Here are the possibilities.
Whenever a patient has a group of symptoms (in this case, pain most likely in the medial/inner elbow), doctors come up with a list of possible diagnoses called a “differential diagnosis.” While ulnar collateral ligament injury is probably the most concerning diagnosis, there are a few other structures in that area of the body that could be injured.
The above image is from an AAOS patient information article on elbow injuries. I labelled each elbow illustration with an arrow pointing to the medial elbow and those arrows also correspond to 3 major structures that pass through the medial elbow. In the left drawing you can see that the ulnar nerve runs along the medial elbow. This nerve can get inflamed and be painful, it can pop or “sublux” in and out of its groove, if you whack it it hurts like heck (hitting your “funny bone”…which isn’t a bone at all) and if you lean on it a lot watching tv or sleeping your ring and pinky fingers get numb. I don’t think that Price has an issue with his ulnar nerve, but it’s still on the list.
In the center drawing you see the muscles of the forearm which attach on the medial epicondyle by way of their tendons. These are called the “flexor muscles and tendons,” referring to the fact that they flex or bend the wrist. Inflammation of the attachment of the wrist flexor tendons is called “medial epicondylitis” or “golfer’s elbow” and it is treated with rest, anti-inflammatories, sometimes wrist immobilization and therapy. If David Price truly does have what is rumored to be a “strain” then it is most likely a strain/overuse injury to the wrist flexor muscles. Quick refresher on the “strain/sprain” difference: a “strain” is an overuse injury to a muscle or tendon, while a “sprain” refers to an injury that occurs to the rubber band-like ligaments that attach one bone to another bone. Therefore, if the reports coming from around the Red Sox organization are medically accurate, a “strain” would not at all be referring to the ulnar collateral ligament.
Which brings us to the final drawing on the right which shows the ligament that stabilizes the medial elbow, the ulnar collateral ligament (UCL). Why do pitchers so commonly injure their UCL? In this case, a picture speaks a thousand words (thank goodness because you probably needed to stop for lunch in the middle of this entry).
Photographer: Chris Williams/Icon Sportswire
Above is a photo of David Price during the late cocking/early acceleration phase of his pitch. You can clearly see that his medial elbow is stretched in an almost unnatural position – for anyone other than a pitcher. The UCL undergoes great amounts of stress at this angle. In young children, in whom the bony attachment is weaker than the ligament itself, one forceful pitch can actually pull a piece of bone off from where the UCL attaches, requiring surgery to repair. (Incidentally that was the first surgical procedure I scrubbed into during my sports medicine fellowship)
Pete Abraham, who covers the Red Sox for the Boston Globe, has done some excellent reporting on Price’s elbow injury. This is what he reported yesterday after Price met with Dr. Andrews and Dr. EllAttrache:
No season-ending surgery is excellent news for David Price and the Red Sox. Farrell added that PRP injections would also not be considered in the immediate future for Price. PRP is a platelet and growth factor rich concentrate made from the patient’s own blood that, when applied to injured tissue, is thought the improve the healing process. However, it does so by provoking a significant inflammatory response in the healing tissue which initially sets the patient back and requires time to recover. It is reportedly used in MLB pitchers with UCL injuries in hopes to prevent or delay Tommy John reconstructive surgery. Whether or not Price is planning for a PRP injection should not be looked at as evidence that he does or does not have a UCL tear, however. Everything that has been reported SOUNDS good – it makes me feel cautiously optimistic that Price may be dealing with either a wrist flexor strain or possibly a UCL sprain that they think will respond to rest. His treatment will likely include anti-inflammatories, massage, stretching and other modalities to promote healing. Initial reports of a 7-10 day rest period with re-evaluation may be overly optimistic. I will be surprised if Price is back on the mound before April. It’s not great news when a Cy Young Award-winning pitcher is dealing with elbow pain in Spring training. This could be a sign of bigger issues to come.
But for today, I’m going to embrace some sunshine. It’s March and the temperature in Boston is 15 degrees. Last week it was almost 70. It’s time for us all to summon our inner Dan Roche, ever the optimist, and enjoy a bit of good news….
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