Angels & Demons & Wings
I'll leave it up to the media to tell us what's going on with Angel Guzman's shoulder problems.
On second thought, I'd better not.
Once again the media doesn't get it. From Howard Schlossberg's piece in the Daily Herald:
While surgery is a possibility, the Cubs are aware that most major rotator-cuff surgeries, while successful in and of themselves, don't always enable the player to make a comeback.
Thank God it wasn't Bruce Miles writing this (I love Miles work). It does show, once again, a lack of understanding regarding what gets reported.
To quote Dan Aykroyd, "Just the facts, ma'am":
1. The Cubs.com article reports, Angel Guzman's MRI showed a "significant tear in a ligament in his right shoulder" which medically speaking translates into a torn inferior glenohumeral ligament (see diagram, item C). If the glenoid or socket's labrum is also torn, this means the entire front of his shoulder is very loose and may be detached. This is an injury that leads to instability, as in shoulder dislocations or subluxations (partial dislocations). This is what Aramis Ramirez had last season in his glove side shoulder (not his throwing shoulder).
2. Angel Guzman HAD a glenoid labral tear repaired in 2003. The labrum is the fibro-cartilagenous rim of the socket (glenoid). The middle and inferior glenohumeral ligaments are adjacent and embedded in the capsule of the shoulder joint in front of the shoulder and they attach to the labrum. These ligaments do not have to be injured for the labrum to tear or detach from the glenoid.
3. Angel Guzman DOES NOT HAVE a rotator cuff tear. The muscle-tendon commonly understood to tear when referencing a rotator cuff tear is the supraspinatus (see MRI image of supraspinatus tendon tear) which is on top and attaches to the greater tuberosity of the humerus (arm bone). The rotator cuff muscles and tendon attachments are immediately outside the shoulder capsule layer, so it is quite separate from the labrum and capsular ligaments.
Guzman's shoulder woes date way back and include labrum repair surgery in 2003. Jim Callis from Baseball America had this on Guzman back on November 26, 2003:
The Cubs thought Guzman was ready to make a Mark Prior-like ascent in 2003, beginning the season in Double-A West Tenn and getting to the majors by midseason. If Chicago didn’t have so much pitching, he could have pressed for a big league job. Guzman led the Cubs with a 1.13 ERA in the Cactus League, and his teammates voted him the most impressive rookie in big league camp. He caught fire in late May, going 3-1, 1.01 over his next five starts. After shutting out eventual Southern League champion Carolina for seven innings on June 20, Guzman was picked to pitch in the Futures Game and would have been the logical callup when Prior hurt his shoulder in mid-July. But Guzman never threw another pitch in 2003, as his shoulder was bothering him. Doctors diagnosed a slight tear in his labrum, and he had it corrected with arthroscopic surgery.
Also remember they shut down Guzman last September with shoulder pain that got labeled a triceps strain based on exam and an MRI. No commentary on other shoulder pathology was mentioned. The Cubs must have felt his shoulder was OK with the rest from an early shut down although one wonders what impact his recovery from January knee arthroscopic surgery might have had on his throwing.
The FEAR of full recovery in a pitcher's throwing shoulder in repairing this is warranted. See Mark Prior if you want to see how well someone recovers from instability surgery. Although from what I've read Prior had capsular laxity and not a detachment of the labrum and there is a difference. Capsular laxity gets surgically addressed by a procedure that tightens up the capsule (capsular shift) and a detachment needs to be reattached. In reattaching the capsule-ligament complex, the trick is to do it where it's not overly loose or tight, so in a pitcher this is the problem because they need more laxity than non-throwing athletes, just not too little, as they'd lose extension and external rotation and not too much or the instability persists.
So near term, Angel Guzman will get a second opinion, probably from orthopedic guru Dr. James Andrews, in Birmingham, Alabama. He'll probably go the ARam route in trying to rehab for 3 months and if that fails go the repair route. That's what 2nd opinions are for though.
So for all the sportswriters out there, here's the rest of my mini-primer on shoulder anatomy:
The rotator cuff is a group of 4 muscles that surround the shoulder in front (subscapularis), on top (supraspinatus) and behind (infraspinatus and teres minor). These muscles lie immediately outside the shoulder capsule which is the fibrous tissue (all joints have capsules) that connects the two major parts of a joint, in this case the glenoid (socket component of the scapula or shoulder blade) and humeral head.
The acromion is the bony overhang from the scapula that connects the shoulder blade to the clavicle (collar bone) or the AC joint (acromio-clavicular). The acromion is also an attachment for the larger and more superficial deltoid muscle. Impingement syndromes often are related to spurs or curve-shaped components from the anterior acromion and the AC joint. When the AC joint is injured, that is called a separated shoulder. It is the glenohumeral (ball and socket) part of the shoulder that is injured when a dislocated shoulder is described.
The long head of the biceps attaches at the 12 o'clock position just above the glenoid socket. It attaches into the fibrocartilaginous glenoid rim which surrounds the socket in which the capsule attaches as well. This can be injured inside the joint, known as a SLAP lesion (superior labrum, anterior to posterior) or it can be injured outside the joint from impingement when the humeral head rubs against the acromion.
Shoulder bursitis also comes from similar impingements. The bursa is a normal layer of tissue that helps the gliding between two impinging surfaces and when it gets inflamed, it thickens, making the space between the two surfaces tighter, a vicious cycle.
Finally, Since Guzman was shut down last year from a triceps injury near the shoulder, I'll mention that the triceps isn't usually a consideration in shoulder injuries. Still, it does have one of it's three attachment sites just below the very bottom of the glenoid socket.
Update: Sun-Times writer, Gordon Wittenmeyer just posted this interview with Angel Guzman
Cubs pitcher Angel Guzman says he plans to have surgery on his injured shoulder, even though he's been told few pitchers ever come back from that kind of surgery.
"It's going to be tough," said Guzman, 28, who was diagnosed over the weekend with a significant ligament tear near his armpit and instability in the shoulder. "But it's better than not having it and not having a chance. Doing it, I have a small chance, but there is a chance. So I'm going to take the chance."
Guzman says the decision isn't final. He plans to see famed orthopedist James Andrews – who already has done operations on Guzman's shoulder and elbow -- as soon as this week and then consult with his agents and his family.