Bigfoot

The newest addition to the Cubs pitching staff, 37 year old (38 on April 2nd) Jon Lieber is apparently ready to pitch. His tenure in Philadelphia ended abruptly last season in the 6th inning, on June 20th, while backing up home plate on a play in Cleveland. It was one rotten day for him already as he had given up 7 runs on 10 hits and was on the hook for his 6th loss. Initially, and at least for the first few days, it didn’t look like anything serious, probably just the run of the mill lateral ankle sprain.

This was the initial report from the Phillies mlb.com site:

June 21st: Ken Mandel, of Philadelphia.Phillies.MLB.com, reports Phillies SP Jon Lieber (ankle) injured his right ankle Wednesday, June 20, while backing up home plate. Lieber had the ankle checked out and it turned out to be largely a muscular injury. Because of off-days, the Phillies should be able to give him extra time to heal and he won't be needed until Friday, June 29, at the earliest.

Mirroring this information, Will Carroll, from Baseball Prospectus, in his Under the Knife column on 6/22/07 said:

The Phillies are also waiting to see how Jon Lieber responds after spraining his ankle in Wednesday's start. He limped off the field after rolling the ankle running to back up home plate after a hit. It didn't look serious, but we should know more by the time his bullpen session comes up this weekend.

Day three injury update:

June 23: Ken Mandel, of Philadelphia.Phillies.MLB.com, reports Phillies SP Jon Lieber (ankle) had his ankle wrapped Friday, June 22, however, he is still expected to make his next start Wednesday, June 27.

Now we know that this was no conventional ankle sprain.

Lieber apparently was having some problems with his foot starting the first week in March in spring training (per a C. Muskat interview this year). Older pitchers expect to have a lot of aches and pains. Apparently it wasn’t enough of a nuisance to get an MRI at the time. Still, it certainly could have been that Lieber's foot was giving him some soreness at the start of the season with the tendon having degeneration, inflammation or wear problems and it finally ruptured with the June 20th injury.

Looking at Lieber’s last 5 starts with the Phillies, four were awful, including three-10 hit outings each over 5 innings and one 13 hit outing over 6.2 innings. Nobody was blaming those outings on a inflamed foot tendon and it must not have been overly obvious as in the midst of that ugly string on June 9th, he did throw a beautiful complete game 3 hit shutout against the Royals.

With an acute injury in Cleveland and significant swelling, MRI imaging of the foot/ankle was obtained and it showed that the injury was something fairly uncommon. He had a rupture of the peroneus longus tendon, well below the outside of the ankle as the tendon goes toward the bottom of the foot.

Then, after the Phillies team orthopedist evaluation, came second opinions by sub-specialty trained foot and ankle orthopedic surgeons.

Finally, USA Today reported:

AP--Jon Lieber will undergo season-ending surgery on Friday (July 6th) to repair a ruptured tendon in his foot.

Lieber was 3-6 with a 4.73 ERA in 12 starts this season. He was the Phillies' opening-day starter in 2005 and '06, but will become a free agent after this season. "He pitched some good baseball for us," said Phillies manager Charlie Manuel. "If things had been a little bit different, he could've pitched better. He had the talent." Lieber will have the surgery at the Mercy Medical Center in Baltimore, the team said.

Jon Lieber had his peroneal tendon repair surgery on July 6th at Mercy Medical Center in Baltimore, The head of this center's foot and ankle department is Dr. Mark Myerson, who is one of the most renown foot and ankle surgeons and who apparently trained the Phillies local foot and ankle specialist (Dr. Steven Raiken). We are talking high end orthopedic sub-specialists here (their practices focus only on foot & ankle care). I'm not sure which surgeon did the tendon repair but it appears he was in very good hands.

More newswire stuff:

Philadelphia Phillies SP Jon Lieber (foot) had successful surgery, Friday, July 6, to reattach a tendon in his right foot, according to the Associated Press. He'll be in a walking boot for three to four weeks.

Sat, 14 Jul: Phillies | Lieber moved to 60-day disabled list

Tue, 7 Aug 2007: Phillies | Lieber cleared to begin rehab program

Finally, from C. Muskat, at the cubs.com site:

Lieber…finished his rehab in early October. Now, he said, everything is fine, and Lieber is back on his normal off season routine.

From my perspective as an orthopedic surgeon, this was an injury I had to do some literature review to learn more, as I haven’t seen an isolated peroneal longus rupture. I've read the chapter in Dr. Myerson's textbook. I’ve seen and treated many peroneal tendon subluxations (partial dislocations) where the two peroneal tendons (longus and brevis) slip around the injured or stretched retinaculum that supports these tendons just behind the ankle. That situation was the infamous “bloody sock” injury that Curt Schilling had back during the 2004 World Series. Schilling’s memorable treatment was very unconventional as the former Red Sox team physician, Dr. William Morgan, put stitches through the skin deep enough to stabilize the slipping tendons as a temporary measure to get him through the playoffs. In the offseason, he had more definitive reconstruction of the injury.

Here is a link to the anatomy of the outside of the ankle/foot.

The peroneus brevis tendon attaches to the base of the 5th metatarsal and is responsible for eversion (outward rotation) of the foot. The longus tendon goes under the foot and ultimately attaches to the undersurface of the 1st metatarsal. This stabilizes the 1st metatarsal and foot from rolling over in both push off and landing, so it’s function is very important in pitching from a mound.

Lieber’s injury was a bit lower down (distal) into the outside portion of the hind foot, well below the ankle. I could see why there might be a delay in diagnosis and confusion with a conventional ankle sprain which is a lateral ligament injury (ligaments between the fibula and talus/calcaneus and tibia). Lateral ankle sprains will look similar to this injury with lateral ankle and foot swelling and an X-Ray that doesn't show a fracture. For most ankle injuries, it’s conventional to get X-Rays to make sure there is no fracture. MRI’s are usually not ordered unless the ankle sprain is taking too long to heal. Most severe lateral ankle sprains take 2-6 weeks to heal. In Lieber’s case, the correct diagnosis was made very quickly. So getting the MRI early on meant Lieber’s swelling and tenderness initially didn’t match up to where a typical ankle sprain should have been tender. Score one for the Phillies athletic trainer and Orthopod showing excellent clinical decision making, a very fine job indeed!

In the case of a peroneal longus tendon rupture, there is a tunnel/groove in the outer hind foot, which involves the cuboid bone where the peroneal longus tendon passes and often there is a spur or small (sesmoid) bone that can lead to friction and subsequent tendon rupture. One of the larger published series I found on this had only 41 patients of which only 11 patients had isolated peroneal longus rupture as Lieber had. So it’s a pretty rare (or at least not commonly diagnosed) injury. In the days before MRI scans (the early 1980’s) this injury had virtually not been reported on in the ortho literature. Also, I couldn’t find any previously treated professional pitchers with this injury, but the orthopedic literature suggests athletic patients do well when the tendon rupture is surgically repaired.

Thus, if you see Derrick Lee backing up the catcher on throws from the outfield when Jon Lieber is pitching, you’ll be a bit more understanding. That is, unless Jon Lieber has already let in 7 runs by the 6th inning.

Comments

Recent comments

Subscribe to Recent comments
The first 600 characters of the last 16 comments, click "View" to see rest of comment.
  • trevor clifton (high-A) could be interesting in a couple seasons...could even become a high/middle rotation guy. he's got a lot of pluses in his pitching except control.

    eric leal's (high-A) progression through the minors should be worth watching even if only projects to be an mid/end-rotation starter.

    we also gotta keep a long-distance eye on guys like jose paulino (ss-A) and preston morrison (A).

    crunch 4 min 24 sec ago view
  • As Johnny Bach used to say when it was time for the MJ Bulls to crank up the defensive pressure: "Release the Dobermans!", and Jordan, Pippen, Rodman and Harper would just suffocate the other team.

    I'd love to add Carl Jr. to that group - he's got the stuff.

    billybucks 24 min 17 sec ago view
  • Historically, the Moneyball guys have been great at identifying productive hitters. Not so much with pitchers.

    billybucks 25 min 28 sec ago view
  • Wow - Pierce Johnson with an ERA of 8.01 in 42IP!

    What a stud prospect! Must be pitching with a pierced johnson.

    Looks like Ryan Williams is the only legit prospect there. That is sad...

    The E-Man 27 min 39 sec ago view
  • Well it would seem that's all they need now. "Stropy" can have his moments, but he's been more consistent post-asg.

    The E-Man 36 min 26 sec ago view
  • Take THAT, Cardinals -- you beat Fernandez, we beat Sale.

    I really like Lackey as a 6-inning pitcher.

    billybucks 1 hour 3 min ago view
  • Three amigos? Because the Dominican, the Venezuelan, and the Cuban?

    Maybe the three-headed dragon?

    John Beasley 1 hour 19 min ago view
  • Who says Contreras can't frame? Stone cold robbery of Eaton with that called third strike for the first out in the eighth

    Eric S 1 hour 50 min ago view
  • Three amigos time?

    7-8-9th

    jacos 2 hours 4 min ago view
  • he should hit more of those. that would be an ideal outcome. /moneyballs

    crunch 6 hours 20 min ago view
  • Russell with 19 RBI in July so far. Grand Slams help.

    billybucks 7 hours 2 min ago view
  • ...and Familia with back-to-back blown saves. Blows a one-run lead vs. Rockies today, gets his 2nd consecutive loss.

    I am OK with the Mets missing the playoffs and suffering crushing losses at home --- just want them to beat St. Louis.

    He played with fire twice agains the Cubs -- unfortunately, the Cubs couldn't stop swinging.

    billybucks 7 hours 6 min ago view
  • How about Kyle Farnsworth? I know he was consistently upper 90s.

    videographer 9 hours 1 min ago view
  • If he puts up Soriano numbers I will be ecstatic

    jacos 10 hours 48 min ago view
  • I think Javy is learning--but he's learning to make contact, not learning to lay off pitches out of the zone. A quick glance at his plate discipline numbers on Fangraphs shows that his contact rate is up, especially his contact rate out of the zone, but his swing rate is up too, especially his swing rate out of the zone.

    Charlie 11 hours 23 min ago view
  • I definitely saw ballpark radar guns go up to 102 on Kerry Wood back when he was still a starter, but who knows how accurate they were.

    Charlie 11 hours 36 min ago view