Beware The Five Inch Screw

Matt Garza heads to the DL for a "bone contusion" just above the elbow and his 25 man roster replacement, Lou Montanez finally winds up in the Cub starting lineup with a memorable night. As you recall, Montanez was the Cubs 2000 first round amateur draft pick  (3rd pick overall) as a high school SS and after a stay in Cubville East (the Orioles System), he now resurfaces with the Cubs in RF. Getting back to Garza, let me think out loud with you readers about what seems to be the problem.

From TCR's last thread:

Let me stipulate that I AM NOT A DOCTOR (but I play one on tv)...so my opinions are just based on long miserable experience with the Cubs.

Garza's injury is being reported as a "bone contusion." Correct me if wrong but in my experience that's the same as saying he has a bone fracture except the fracture has no deliniation. Also, it's in his elbow so that implies that it involves cartilage as well as bone. This doesn't sound like something that heals in a week. Contusions often take longer than outright fractures to get better.
If the Cubs bring him back after missing one more start...look out.

In Garza's situation, using the term "bone contusion" is clearly an MRI diagnosis. I do have some issues with using this term here and (hopefully) I can provide some clarifications of muddy concepts being bandied about.

 I love my headline (nope, I'm not going there, so shame on you) but you need to read on for some Serious Splainin' Lucy.


The diagnosis of "bone contusion" means that Matt Garza's X-Rays are negative for a fracture and the elbow MRI does show an abnormal signal in the area that his elbow is tender. The MRI is magnetic imaging which reflects changes in water content of tissues, so anything that changes the normal pattern on the imaging gets a descriptive term (an abnormal signal).  If there is no linear signal seen in the bone, they won't use the term fracture. Not to be funny here, there are shades of gray to these signals. I assume the abnormal signal is in the bone (in this case the distal humerus) and probably does not extend to the soft tissues adjacent to the bone or joint, otherwise they would be worried more about the ligaments or tendons too.

Here's the local anatomy in a nutshell (some nice diagrams at the link). The medial or inside part of the elbow bone is called the medial epicondyle of the distal humerus and includes the flexor/pronator tendon origins (often referred to as "golfers elbow" when inflammed) and the nearby ulnar collateral/UCL or "Tommy John" ligament. The outside portion of the elbow bone is the lateral epicondyle and the tendon attachments, if inflammed, would be what is commonly referred to as "tennis elbow, or in medical lingo, "lateral epicondylitis" involving the extensor tendon origins that functionally extend the wrist.

For the diagnosis to be a contusion there usually is a history of direct trauma to the area. So I ask, when did that happen? Garza does not seem to indicate there was a direct trauma as his quotes below indicate. The Cubs doctors may be thinking it's a repetitive stress injury but are not willing to call it a stress fracture based on the abnormal uptake pattern on the MRI being more diffuse (rather than focal or linear) but the radiologist didn't come up with a better term for the signal abnormality. If this is the case the term "bone contusion" is misleading and what they really mean is the signal abnormality on the MRI is an early precursor to a stress fracture. The difference here can be subtle and it has to do with the normal bone remodeling process. If the repetitive stress/ trauma overwhelms the pace of bone remodeling,  a structural break can occur, initially on microscopic level and just like a small car windshield crack that propagates beyond the ability to seal the defect, when a microscopic fracture propagates, the body shifts to a larger scale process of fracture healing and a clinically significant stress fracture occurs. This invokes more inflammatory changes as cells are mobilized that can lead to fracture healing. If my speculation is correct, the DL decision is an attempt to interceding before the problem becomes a stress fracture. This would be analogous to a leg injury from distance running often called "shin splints" which can progress to a formal stress fracture of the leg if the repetition continues and eventually overwhelms the bone remodeling process.

It's unlikely that there is any cartilage involvement in a bone contusion unless the direct trauma also affected the joint (that would make the diagnosis of an articular  or intra-articular fracture) and one would see fluid (blood) in the joint on the MRI to make one consider that being the case.

From a Tribune article on Garza's elbow condition, Garza is quoted:

"There's a lot of reasons things like that can happen," he said. "It's just one of those things that happen, more wear and tear. Like, if you're a runner and your knees are sore, that's usually what it is -- a bruise."

The above quote bothers me as a "contusion" means some direct trauma and "wear and tear" is more of a repetitive stress problem. The "if you're a runner and your knees are sore" equals a bruise quote clearly comes from a lack of understanding orthopedic anatomy and diagnoses. I hope that's not what his doctor really told him.

Garza also is quoted in a video interview at CSN Chicago  and reported at SB Nation saying that the injury is the result of throwing in cold weather and coming from the Rays, Garza isn't used to the cold (tongue meet cheek).

Again, this points to repetitive stress injury, not contusion.

In contrast, I recall Mark Prior's "bone contusion" to his right elbow when he was hit by a line drive by Brad Hawpe in 2005. They ultimately called the injury a "compression fracture." It was certainly more extensive than a "bone bruise" (OK, a severe bone bruise) yet his X-Rays were negative for a fracture so it took MRI imaging for the final diagnosis.

Finally, I remember former Brewer-WSox-Cardinal pitcher Cal Eldred, who had a diagnosis of "stress fracture" of his pitching elbow. He started the 2000 season with a 10-2 record with the White Sox but due to the stress fx, in August of 2000, had a 5 inch screw placed across the stress fx to try and heal it. He was mostly out until 2003 when he tried a brief comeback with StL before ending his career in 2005.

So, in summary and reading between the lines, I'm not sure what kind of estimate to recovery Garza has. If it's a "pre-stress fracture" or shin-splints equivalent at the elbow, it might be just the 2 weeks on the DL in the best case scenerio and that's enough rest for the bone to remodel. If he's not better or if this happens again...well, lets hope it doesn't become a recurring problem because a stress fracture at the elbow can be a bear to resolve.

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Comments

Dr. Hecht, one thing that always amazed me about pro sports teams is how they sell the team Dr. position to the high bidder instead of seeking out their own top choice(s) for the position. How do other doctors feel about that? Doesn't it lead to possible questionable diagnosis and treatment sometimes? Didn't the Reds team Dr. get sued a couple of years back for misdiagnosing elbow or shoulder injuries for a pitcher or two?

I always wanted to ask a Dr. about this.

Thanks, Cubster. I always have a much clearer understanding of these issues when you write one of your explanatory pieces.

I don't recall hearing of this kind of condition before in the throwing arm of a baseball player (I wasn't paying attention back in 2000 to Eldred). Is this as rare as it seems?

Is there an inverse correlation between the wisdom and knowledge of a team's blogging community and ineptitude of the team's management?

Nevermind, I just remembered Bleed Cubbie Blue. Still the TCR community blows me away when I think about what a worthless sack of shit the entire front office fucking organization is.

Bear in mind, I did just finish teaching 150 screaming Korean children, so I might not be in the best of moods.

From Bruce Miles:

Garza: The Cubs said there was no ligament damage and that Garza might be able to start in the series at St. Louis, which begins Friday, June 3.

Soto: GM Jim Hendry said catcher Geovany Soto would play in an extended-spring-training game tomorrow in Arizona and then head to Class AA Tennessee for two games. Geo figures to rejoin the Cubs this weekend.

Cashner: Hendry said the news on Andrew Cashner was good. Cashner saw Dr. Lewis Yocum in L.A. yesterday about his strained right rotator cuff, and Yocum said there was no further damage and that surgery is not needed. Cashner, who has been shut down, will have to restart his rehab.

Wells: Randy Wells has rejoined the team. He’ll start Saturday against the Pirates after Doug Davis pitches Friday.

I really hope the Cubs just put Cashner in the pen and leave him alone.

Random Cub History question:
How on earth was Steve Swisher the Cub rep at the 1976 AS game?

He was hitting .322 in late May and still at .292 in late June, around the time the managers were likely making selections. There are also a number of reports online that Anderson selected him because he killed Reds pitching that year. I've even seen the same ".394 batting average against them" stat cited numerous times--but a quick check at baseball reference shows that is not true. He finished the season at .323 vs. the Reds, and was only 5-19 before the all-star break.

Bill Madlock (defending AS game MVP and on his way to a batting title) should have been the pick. No one else really even had a good season. Burris and Reuschel ended up at 14-12 and 15-13, with 3.46 and 3.11 ERAs respectively, but at the break, Reuschel was 8-6 with an ERA well over 4.00, and Burris was 4-10. Monday and Cardenal had OK season in the OF, but not All-Star caliber, especially compared to others in the league.

So best guess: It seems like with Rose at 3B that year and winning the fan vote, Anderson had to take Schmidt as a reserve and also felt he had to take Cey who was hitting .330 in late June for the Dodgers who were fighting the Reds for first. He didn't feel like going with three reserves at 3B, and so he looked to add a second 1B, 2B, or C. Catcher was more important to have a second back-up at, and the Cubs couldn't fill either of the other two positions anyway, and he had to take a Cub. Swisher had a good first half, had some success against the Reds in previous seasons, and had just gone 4-10 against the Reds in a mid-June series. And he wasn't going to play anyway, so what did it matter. My best guess.

Hmm... at the end of June he was hitting .265 with 2 HR and 22 RBI. Ugh. Even Ted Simmons dow season at the break of .281/.356/.377 with 2 HR and 42 RBI was better....

Wisc, that's a pretty solid guess!

Did they have the requirement that each team have an All Star back then? I thought that was more recent.

No, that was the case back then, also -- in practice, if not explicitly. I remember it being discussed.

I'm reposting a comment I wrote a few threads ago from when you first raised this question:

Why Steve Swisher?

In short, too many big names/great years from the 3B's and OF's and lousy competition at catcher.

I wondered that myself at the time, even though he had a good first half (for him) that year -- was batting .268 at the All Star break (July 13), though only 3 HR & 25 RBI (his avg. was as high as .292 as late as June 19). Bob Boone, the other NL reserve catcher, had .308/4/40 at the break, so the competition at catcher wasn't particularly stiff. The other usual '70's All Star catchers weren't doing that well that year: Manny Sanguillén was .295/1/18 and Gary Carter was .239/4/21. Sanguillén was at the end of his All Star run ('71, '72 & '75) and Carter was only in his 2nd full season (although was an All-Star in '75, his rookie year). Even the starting catcher, Johnny Bench, was having a down year: only .234/9/45 at the break.

Why not Bill Madlock (3B), Rick Monday (OF) or Jose Cardenal (OF)?

The NL All-Star 3B's were Pete Rose (starter), Mike Schmidt and Ron Cey (who hit .319/12/46 in the 1st half that year) and Madlock was "only" hitting .309 at the break with less power -- he scalded the ball in the 2nd half at a .377 pace.

How about the outfielders? The starters (voted in by the fans) were George Foster, Greg Luzinski & Dave Kingman. The reserve outfielders were:
César Cedeño .297/14/48 & 142OPS+ (28 SB)
Al Oliver .360/12/49 & 178OPS+
Ken Griffey, Sr. .340/4/50 & 152OPS+
Bake McBride .345/3/18 & 145OPS+

Rick Monday .286/15/47 & 152OPS+ (3 SB)
Jose Cardenal .303/6/32 & 120OPS+

Clearly, Monday was hitting well enough from an OPS+ standpoint but his average was significantly lower than the competition and Cedeño (whose BA was closer) was a flashier & sexier pick at the time.

I love this site.

http://www.minorleagueball.com/2011/5/24/2187...

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Justin Bour
Any insight on whether or not his breakout is “real”? Always had a good approach and the Cubs reportedly worked hard with him to develop a power stroke in the winter.

by toonsterwu on May 24, 2011 11:25 AM EDT reply

bour
as you know, numbers are outstanding so far, no statistical red flags stand out. He turns 23 this week….if I were the Cubs, I would think about promoting him to Double-A in July to see if he can maintain this performance.

by John Sickels on May 24, 2011 4:45 PM EDT up reply

I've been on the Bour bandwagon all season
but I’m a little worried about his troubles with lefties. The split is enormous. (.200/.213/.289 v. LHP to .382/.453/.748 v. RHP).

by Bradsbeard on May 24, 2011 11:52 PM EDT up reply

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Is Darwin Barney for Real?
by Superman on May 24, 2011 11:41 AM EDT reply

barney
No..he’s not a .315 hitter.

but I bet he can hit .280 with great defense for a long time.

by John Sickels on May 24, 2011 6:33 PM EDT up reply

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Scratch this question...
I have one about the possibly awesome DJ LeMahieu. He’s currently hitting .371/.397/.501 or something in that vicinity, and he’s got a 10/19 BB:K. His career minor league batting average coming into the year was .314, and he’s been called the best pure hitter in the Cubs’ system by BA. He’s a 6’4 205 or so guy who used to play SS and profiles best as a 2B. What kind of upside do you see in a player like this? Basically, is this the kind of prospect who could really surprise as he gets older?

I hope this doesn’t disqualify me…he’s a very interesting prospect and I’m very curious to see how his career unfolds.

by SenorGato on May 24, 2011 2:34 PM EDT up reply

DJLeM
I think he’s a sleeper…it has just been the lack of home runs that has kept him from being more well-regarded. if he produces more power, he will really sneak up on people within the next year

by John Sickels on May 24, 2011 7:34 PM EDT up reply

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LeMahieu is sporting a .405 BABIP on 19% LD rate (compared to last year's more reasonable .350 on 20% LD rate) - don't get too excited yet.

Vitters, his evil twin, has a .259 BABIP with a 17% LD rate.

Wouldn't your BABIP be higher if your BA is higher?

Put more simply, is there any way to improve as a hitter without stat-minded folks calling you lucky?

That's an interesting philosophy of life. This guy's the boss, he's just lucky. This guy's rich, he's lucky. This guy's the manager or the GM, pure luck!

Put more simply, is there any way to improve as a hitter without stat-minded folks calling you lucky?

hit more home runs, walk more, strike out less, hit more line drives, hit the ball to all fields (somewhat in order of importance)

Not walk more though if we're just talking about BA - though it makes you a better offensive player.

most people average out to a norm. not many can precisely hit a ball all over the field.

unlike OPS which ignores a huge amount of players who make their money getting on bases and/or turning singles into doubles+ via steals (along with the other things speed on base brings)...BABIP covers a lot more players "fairly" as far as a broad reaching stat goes.

Barry Bonds once hit .370 with a .330 BABIP.

The point isn't that BABIP and BA are correlated, the point is that BABIP can tell you who is lucky and who is unlucky. Ever see "Bull Durham"? Remember the scene when Costner talks about how one lucky hit a week separates a .265 hitter from a .300 hitter? He's talking about BABIP luck.

"Barry Bonds once hit .370 with a .330 BABIP."

Sure, because HRs are pure hits, and BABIP tries to cancel them out. BABIP subtracts HRs from hits and also from at-bats, while it subtracts K's only from at-bats. If you hit a lot of home runs and don't strike out much, your BABIP is going to come down below your BA. It doesn't say anything about luck, just that you hit a lot of home runs and don't strike out much.

We weren't talking about Bonds, we were talking about LeMahieu, who doesn't strike out much and doesn't hit home runs. His BABIP is going to be marginally higher than his BA because of the handful of K's that get subtracted from his at-bats. When he hits .370, his BABIP is going to be much higher than when he hits .314.

So how does he (not Bonds) become a better hitter without raising his BABIP?

Rob says he should hit more home runs. That's fine, I understand: if you have a statistical orientation, nobody is a good hitter unless he hits home runs. Without home runs, a high BA is attributable to luck.

Rob also says he should draw more walks. That's puzzling, because walks don't factor into BABIP, unless Rob means that by turning, say, 10 of those 69 hits into walks, LeMahieu's average would drop from .369 to .331, and his BABIP would drop from .398 to .357.

And that would be better, less lucky. A walk, in other words, is better than a hit.

If Lemahieu maintains a high BABIP over a long period of time, especially if he couples it with a very high line drive percentage, then many of the people pointing out his high BABIP right now will stop pointing it out, or they will point him out as a player with a very high career BABIP. Until then, experience tells us to be a bit wary and hope that he develops some power and/or patience to go along with his ability to put the bat on the ball. It'd also be nice if he fielded a position well.

Rob also says he should draw more walks. That's puzzling, because walks don't factor into BABIP, unless Rob means that by turning, say, 10 of those 69 hits into walks, LeMahieu's average would drop from .369 to .331, and his BABIP would drop from .398 to .357.

you asked is there anyway to improve as a hitter, not just improve your batting average. The only people that still thing batting average is the best valuation of a hitter are you and Dusty Baker. The question, particularly with minor leaguers, is can they sustain their success or is just a hot streak and what will their numbers translate to when they get to the majors and better defenses and better pitchers.

Rob says he should hit more home runs. That's fine, I understand: if you have a statistical orientation, nobody is a good hitter unless he hits home runs. Without home runs, a high BA is attributable to luck.

Derek Jeter was a good hitter, Ichiro Suzuki is a good hitter, Tony Gwynn was a good hitter, see if you can figure out why they are as opposed to Darwin Barney.

Do you know why Tyler Colvin suddenly became useful last year? Cause he started hitting home runs.

". . . you and Dusty Baker."

I wonder which is more likely, that Baker will make the Hall of Fame as a manager or that a man who talks about BABIP will manage a team.

Anyway, the Wikipedia article on BABIP says it is more usefully applied to pitchers than to hitters.

pretty sure Manny Acta knows all about it, he's a big sabermetrics fan and reader of Baseball Prospectus among other sites.

Anyway, the Wikipedia article on BABIP says it is more usefully applied to pitchers than to hitters.

more usefully doesn't mean not at all useful for hitters though.

Justin Bour (A+) and Ryan Flaherty (AA) are having very similar years at the plate. Both would seem to be due for a promotion if they can continue their current production for another month or so, but both look like platoon hitters right now.

"I like to let 'Z' hit when he wants," Quade said. "He was down there stretching forever, getting ready and swinging and doing whatever he does."

http://articles.chicagotribune.com/2011-05-24...

Just a reminder 3/5 of your rotation is hurt.

40% to go...

the risk of getting hurt swinging one at-bat is greater than throwing 120 pitches? or even fucking close?

Let's ask Marlon Byrd?

... or Adam Greenberg?

or Dave Dravecky or Chad Fox?

Ok.
If Zambrano had hurt himself pinch hitting....wouldn't Quade be run out of Chicago on a rail?

Is that what it takes?

who in Chicago cares about Zambrano anymore?

If he gets hurt doing what he suppose to do, I don't have a problem.

But yeah ask Marlon Byrd, or ask Z who two years ago threw out his back swinging the bat.

he's a pitcher in the NL, I know fans and teams have been brainwashed into believing they should just go up there and bunt and then go back to the dugout and paint their toenails. But assuming you like the NL style of play, pitchers that can hit should be used as the asset they are and the risk of injury is pretty small compared to what he's allegedly being paid to exclusively do.

But if you just want a DH and boring pitchers, there's another Chicago team to root for...

If he gets hurt doing what he suppose to do, I don't have a problem.

He's supposed to play baseball. Would you be behind letting Matt Garza stay in to hit for himself, even if he's coming out of the game? That seems to be the alternative you're advocating.

Was Z pitching?

You mean, in my scenario is Z throwing one pitch and Garza is throwing the next? No, Z is on the bench and he comes in to PH for Garza. Z isn't going to pitch in the game, and the manager doesn't want to use a positional player to PH in the situation.

What's your solution, just to forfeit the at bat?

"Z isn't going to pitch in the game, and the manager doesn't want to use a positional player to PH in the situation."

That's the point, the situation does not call for the risk.

He had positional players available, they had an 8 run lead.

The manager is an idiot.

i think that was meant as a reply to jacos, but in case it was me.

If Garza was a decent hitter, which he is not, then I wouldn't mind so much if he stayed in to hit. It would also depend on the situation and the bench available of course.

I could throw my wallet in my backyard tonight and it will probably still be there tomorrow.

But why do that?

If was 15th inning tied game, no bench, yeah go ahead, but consider the situation.

[edit]

"I like to let 'Z' the veterans hit when he wants do whatever the fuck they want," Quade said.

yes...

While we're talking prospects--could Steve Clevenger be for real. He started to hit some home runs late last year and is showing some power this year along with a great average and not many k's. Wonder about his catching skills since he was originally signed as an infielder. Bats left besides.

Well Clevenger's no Robinson Chirinos....but he's looking good?

Clevenger looks like a better prospect this year than in previous years, but it looks like he's regarded as a potential backup and future coach. He'd probably have to be able to maintain a high average to get significant playing time. I thought the reports on him are that he's pretty dependable behind the plate but that his arm is basically average.

He can't play MLB catcher unless he started catching at age 6.

You're becoming more and more like Manny everyday.

Is that all it takes to become Manny in your mind, make fun of stupid shit you say?

Do a little self-reflection. Just in the past 15 minutes you've posted five comments all telling someone else that they are wrong in some way. And that's pretty much all that you do. It gets old after a while.

Umm... I didn't say anything that you made fun of. Good try though.

First, let me say, nice column Dr. Hecht!

Check this out. ESPN just ranked baseball's owners.

23. Tom Ricketts, Cubs: He told a Chicago reporter last week that "I can't stand it when I hear someone say they can't afford to go to a game. It might be hard to get tickets for a Yankees or Sox game, but there's no reason why they can't afford to go to another game." It must be nice to be so detached from the real world.

http://sports.espn.go.com/espn/page2/story?pa...

http://espn.go.com/blog/the-gms-office/post/_...

Cubs on the list

1) ARam
2) Pena
3) Ryan Dempster
4) Zambrano

I saw that earlier and meant to post the link and then make fun of it.

Ramirez's 2012 option is guaranteed if he's traded, not going anywhere.

Pena could be moved.

Unless Dempster really feels like giving Hendry a break, Dempster really doesn't want to leave Chicago where I'm sure his kid is getting the care she needs.

Z, can't see a reasonable solution of how much Cubs would have to absorb to move him and then Z agreeing to it.

Agreed it is short on facts, but Z certainly knows and Dempster must assume that they are on their last contracts with the Cubs.

The Astros list is even more idiotic... does Bowden not understand that teams typically trade players facing free agency - not good ones signed to affordable contracts for big market teams?

completely random change of subject: castro gets 200 hits this year, true or false...

and tacking on...

d.barney gets 200 hits this year, 25 or less xbase hits. true of false... =p

go theriot jr go

barring injury, true

Idk. Theriot is Barney light.

Barney has better speed, glove, range, arm. Also, made it to the majors 5 yrs. earlier.

I'd rather have Barney of the two.

agreed, except for speed...not like theriot is a burner, though.

i'd rather have barney, too.

It's the Rey Sanchez/Jose Vizcaino debate all over again. Just with worse infielders.

And by 5 years earlier, you know you really mean 1 year, right?

Theriot had the advantage over Barney in patience alone, if we're looking at minor league numbers. Otherwise, I agree, Barney is better in pretty much every category.

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