Stephen Strasburg to get El Chapo treatment?

I am sure that Washington National’s fans and Stephen Strasburg fantasy owners are holding their breath with the latest mishap of a career full of injuries. The information reported on this injury is somewhat vague, but Strasburg appears to be suffering from an upper back strain after dislocating “a couple of ribs” during a workout incident. Considering this information, I assume this to be a posterior (toward his back rather than toward his chest) dislocation of his ribs, with the subsequent upper back issue being due to the trauma of the ribs coming out-of-place and then being put back into place, which caused irritation to the tissues in that area. I think for this particular player that any injury needs to be taken seriously, but even if this was not Stephen Strasburg I would have a moderate level of concern with this type of injury.

When most people hear the term dislocation they think of a bone moving to a place where it should not be. When I hear the term dislocation, I think of the structures and tissues that need to be overpowered and damaged to allow the dislocation to occur. Additionally, I think of El Chapo and how he escaped from prison. A bone dislocation can be very similar to a prison break as there needs to be force and there needs to be an overpowering of many layers of protection for either to be successful. Furthermore getting the bone back in place can be just as traumatic depending on the methods used to achieve this. El Chapo was captured with a finesse method which would be similar to a Physical Therapist or other healthcare professional carefully pushing the rib back into place with the help of other muscles and positioning. On the other hand, his capture could have gone another way with the inclusion of firearms and brute force; which represents the dislocation that is popped back in by a friend at the pickup football game. In most cases this method causes more damage getting the bone back in, as compared to the damage caused on the way out.

Similarly, with Stephen Strasburg, I am worried about the trauma during the dislocation, and I also worry about the trauma suffered when the bones were reduced (put back into their proper place). The tissues that suffer during this trauma are the ones we need to focus on, in order for the joint and the surrounding area to return to normal. In this case, the costal cartilage on the chest side which connect the ribs to the sternum; the various ligaments that connect the ribs to the thoracic vertebrae on the back side; and whatever other muscles and soft tissues that are positioned near the site of the dislocation; are all at risk for trauma and injury. Considering Strasburg is primarily complaining of discomfort in his upper back, we can assume that the structures that received the most trauma were the tissues in that area. Each rib has a group of ligaments to secure it to the thoracic spine, and as the rib moves to the surface there are layers of muscles that would be irritated or even injured by a rib pushing into them. Without knowing the severity of tissue strain, it is difficult to give an exact timetable for Stephen Strasburg’s injury. In a general sense, I would give the irritated soft tissues in his back at least 3 weeks to heal.

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With soft tissue healing, much of the assessment relies on time, as we know how long most tissues take to heal; but we also use performance followed by assessment of how the tissues react to the performance. The issue with this approach with a player who has an extensive injury history and has not shown himself to be an exceptionally fast healer is that assessing that performance too early may cause a setback rather than just allowing you to gather the information you want. If this were another position or another sport, I think this would be considered a minor injury that I would pencil in for a quick return. However, when you consider the length of the baseball season and the time this provides you to make sure you get this right, I would take my time with a 3 week minimum. If Stephen Strasburg attempts to come back too early, this could turn into a lingering issue for the rest of the season. The anatomy of this injury gives Strasburg no options as to avoiding the use of this area as the upper back area is directly connected to his scapular movement, and his scapular movement is one of the two most important pieces to his throwing motion. If Strasburg would have tried to be a tough guy and push through on this past Sunday, the discomfort that he felt when trying to warm up for his start against the Brewers would have progressed with every pitch to the point of pain and dysfunction. The risk of repeated dislocation is always in play when you don’t allow the structures that allowed the first dislocation to regroup and heal. The thought of him going out there and trying to pitch right after the ribs were reduced would be like putting El Chapo right back in the same cell he escaped from, before you can close the hole and change the prison guards.

The Washington Nationals and fantasy owners should embrace the thought of Stephen Strasburg taking at least 3 weeks off to heal as anything sooner than this would seem to be risking the chance for a chronic situation that could put his season in jeopardy, after such a good start. If managed properly with the appropriate rest, physical therapy, and gradual return to throwing; there is no reason Strasburg will not return at near 100 percent in about 3 weeks.

Baseball and the Mafia!

The Mafia is one of the most fascinating organizational structures that I have ever studied. Take for instance the fictional Corleone family from “The Godfather” movie. Vito Corleone was the boss and while he was well and calling the shots, the Corleone family thrived. The family could survive arrest or hits to their soldiers all the way up to high-ranking captains, as long as Vito was running the show. If a rival family wanted to disable or cause dysfunction in the Corleone family, getting to Vito was the quickest way to do this. Getting to the boss is pretty tough as you have to go through layers of underboss, captains, and soldiers to get to him OR you have to find the perfect opportunity to catch him when he is vulnerable. Regardless of the tactic to get to the boss, once he is hit, everyone below him is affected and likely to have limited value on their own.

 The human body and the Mafia are somewhat alike. The body has bones which can be considered the boss; tendons, ligaments and fascia which would take on the underboss and captains roles; and muscles that act as the soldiers on the front line. Similar to the Mafia, the primary role of each of these accessory soft tissues are to protect the bones. Each section of the body can be considered as its own family. Certain families, such as the lumbar spine or the pelvic area may be larger and more powerful families.  The smaller families like the forearm and the hand regions are important but don’t necessarily threaten the whole Cosa Nostra if they are injured. Like the boss, bone is usually difficult to get to unless it is hit with enough force to overpower the layers of protection created by ligaments, tendons, fascia, and muscles. In some cases bone is fractured because the body is put in such a vulnerable position that very little force will cause the bone to break.

 J.D. Martinez of the Detroit Tigers almost became the latest example of how a bone fracture can shut down an entire section of the body, but it appears he has dodged the traditional ramifications of a bone fracture. Martinez has a small elbow fracture as a result of excessive force during his collision with a right field wall. Luckily for Martinez, the forearm and elbow family are not one of the bigger families which could shut his whole system down, however for a baseball player, the elbow is like a hitman and therefore essential to the overall operation.

Like an injury to the boss; the worst part about bone fractures is that they typically shut everything else down. After a fracture, the injured area is typically treated with immobilization, which means the bone, the ligaments, the tendons, and the muscles get no action until the bone is healed and ready to get back to business. This period of inactivity will usually cause soft tissue structures to get stiff, weak, and lack coordination. Conversely, injuries to the soft tissues that protect bones will likely result in treatment for that particular soft tissue, and this does not typically cause the bone and other soft tissues to be put on hold. Ligaments and tendons rely on bracing or splinting, while their captain and soldier counterparts may choose to simply rely on more soldiers and protection during periods of weakness. There are some ligaments and muscles that play very significant roles, such as the anterior cruciate ligament or maybe the rotator cuff group. These soft tissues are similar to some of the soldiers and captains who earn large for the family, and can’t be replaced. Apart from a few uniques situations, bones and joints can usually continue to function during a soft tissue injury while the inverse is usually not true.

J.D. Martinez appears to have been lucky as he is reported to have a non displaced fracture which will not need immobilization or casting. It appears that he is being encouraged to continue moving in a limited manner to avoid many of the negative effects that I described above. In essence, this elbow fracture is more like a graze rather than a clean hit. J.D. Martinez has the privilege of letting his elbow family continue doing business on a limited basis while the boss heals from the graze wound. The only worry I have if I am invested in Martinez, is that without a cast or any type of immobilization, you leave the restrictions much to the athletes discretion. Many times, I will explain to patients that they can treat pain like a wall–“go all the way up to the wall, but don’t try to go through the wall.” With athletes, you typically find that they will push things to the limit; which in this case could cause some unwanted inflammation and swelling that could push this recovery to the long end of his four to six-week timetable.

Overall this is not an injury to worry much about as there should not be any long-term ramifications. Martinez may return closer to four weeks if he can follow his Physical Therapy regimen precisely and has the benefit of being a fast healer. His conditioning should be fine as his limitations are minimal. Fantasy owners should keep an ear open for the usual trigger words such as swelling, tightness, inflammation, soreness, etc; as any of these issues in the right elbow region could cause some bio mechanic issues to his swing or throwing motion. With good adherence to his Physical Therapy, these should all be easy issues to manage. If it were me, I would stick with Martinez and expect his productivity to resume shortly after he returns.

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