So far, the answers to those question are no, not yet, maybe not, probably not, probably yes. However, Mike McCarthy has been adding to the ambiguity with the “information” he’s been providing on a daily basis about his star quarterback this week.  On Tuesday, word was that Rodgers got more tests (read: x-rays) on his shoulder and the medical staff responded to the results with a resounding “Meh” and declared Rodgers not cleared but not ruled out for the week 14 matchup against Atlanta. On Wednesday, Rodgers was a limited practice participant but threw short and intermediate routes, showed some zip on the ball, blah blah blah.

Make no mistake about it: medically speaking, none of this makes any sense.

If what McCarthy says is true, and the docs saw the x-ray and did not clear Rodgers to play, he ain’t playin.  Period.

So what’s actually going on?

The Packers are in desperation mode, big time.  They want every bit of an edge they can get to stay relevant in the NFC playoff race.  So why not throw a smoke screen about the status of their most essential player? The Falcons are reportedly preparing as if Rodgers is playing, so maybe mission accomplished.

Here’s why I’m saying this whole thing is gamesmanship and nothing more: if the bone is not healed enough on Tuesday for the docs to clear him to play, then it’s not going to be healed enough by Sunday.  In addition, the Packers medical staff are not doing another x-ray before the next game, mainly because they went to medical school and know that nothing is going to change.

So, the Packers aren’t going to openly admit Rodgers is not playing until the 11th hour, which is their right.  Rodgers is practicing so he can continue on his rehab path and maybe play week 15.  Keep in mind that is only when the risk of greater injury is eclipsed by the true need for him to play.  In other words, if the Packers know there is no chance for them to make the playoffs and there is a greater than 0% increase in Rodgers’ risk for sustaining a catastrophic injury, he’s probably not going to play.  If adequate healing takes place, then and only then will Rodgers play without a chance of making the playoffs.

The ONLY way I see Rodgers playing this weekend is if Mike McCarthy is fibbing or at least omitting much of what the docs told him.  Maybe there was a conditional lack of clearance, ie an “if Rodgers can practice well and not have any pain, his healing level puts him at a low risk to re-injure, so maybe he can still play” scenario.  This seems less likely than the “this shit ain’t healed, don’t fuck around, but don’t tell anybody yet” scenario.

All in all, I don’t think Rodgers is suiting up this weekend.  This is a bummer for a number of reasons, not the least of which is the fact that I traded for him in my fantasy league after his injury in the hopes of getting him back in time for the playoffs.  I should have known better.

On April 24, during game 2 of the 1st round of the Western Conference Playoffs,  the Oklahoma City Thunder’s title chances were dashed when Russell Westbrook sustained a knee injury in the most frustrating of ways.  Casually dribbling across halfcourt to call a timeout, Westbrook took a shot from the Rockets’ Patrick Beverly that left him limping and angry.  As it turned out, Westbrook had a tear in his lateral meniscus that required surgery.  Here’s a look at how it happened:

If looks could kill…

You can see that Westbrook’s knee does a little bit of a plant and twist when he got hit.  This is a classic mechanism for a meniscal tear.

The menisci are C-shaped and comprised of fibrocartilage, meaning it’s a little tougher and can withstand compressive forces a little better than other types of cartilage.  There are 2 menisci in each knee: medial (inside) and lateral (outside).  They lie on top of the tibia (shin) and have a concavity like an amphitheater to fit the femur (thigh).

The menisci are designed to absorb shock, provide a smooth, form-fitting surface for the femur to glide on, and withstand compressive and torsional forces to the knee.  You can see that the medial and lateral menisci are each shaped differently.  The lateral meniscus is more circular and has less attachments to ligaments in the knee compared to the medial meniscus.  While it is torn less often than the medial meniscus, the lateral meniscus actually takes on more twisting forces during cutting, jumping, landing, and running.

Tears happen when the knee is planted on the ground and the person twists on top of it.  The cartilage is essentially compressed and the bones grind together, catching the tissue and ripping part of it.  The location and size of the tear is crucial for determining whether surgery is required.  Small tears close to the outer edge of the meniscus have a good chance of healing on their own with rest and rehab, as the edge of the meniscus  has good blood supply.  However, larger tears are more difficult to heal on their own, and the further towards the middle the tear, the poorer the blood supply.  No blood, no dice.  Sometimes, the torn piece of cartilage will just be snipped out or even left alone if the blood supply is bad enough.

Westbrook’s tear required surgical repair, meaning there was a significant tear in an area with a decent blood supply.  The torn part of sewn back to the base, and rehab begins.  Typically, you’re on crutches for 4-6 weeks before you can put weight on the leg.  Gradually, range of motion, strength, balance, leaping, ankle-breaking, and vicious dunking are restored, all essential components of Russell Westbrook’s game.

No glory for the poor, dejected menisci until they get torn.  It’s unfair, really.

About a month ago, Westbrook underwent a second surgery due to recurrent swelling.  Fortunately, there wasn’t any more damage or compromise to the repair.  Doctors reported a loose stitch being the culprit, which the body will treat as a foreign object, creating swelling and possibly pain.  The recovery from that is relatively quick, and Westbrook was able to return to action Sunday.

Westbrook shot only 5-16, but went 11-14 from the line and finished with 21 points and 7 assists in an OKC win.  He should improve each week he’s back in action, but he may never quite be 100%.  Once the weight bearing surfaces of a joint are damaged, they don’t quite behave the same.  That’s not to say he’s going to injure it again, necessarily, but he’s at a slightly greater risk for breaking down over time.

He’s a nihilist. He doesn’t care.

For now, I look for Westbrook to shake off the rust and get back to playing his game.  This will be just in time for people to get back to criticizing him despite being him one of the most dynamic guards to play in the last 10 years. Oh well.

Derrick Rose has already gotten a lot of heat in the past year for how he handled the rehabilitation of his knee after undergoing ACL reconstruction surgery.  Now it seems that Rose is dealing with a another injury, albeit minor, the dreaded “neck soreness”.

Now, sitting here at my computer I have no idea why Rose’s neck is sore.  Maybe he slept funny.  Maybe he twisted it a bit chasing after his dog.  I haven’t a clue.  But whatever it is, it was bothering him enough for it to become newsworthy.  So what does a trainer do when the team’s most precious investment has neck pain? Throw some tape on it!

It also comes in fancy pastel colors.

The tape the Rose is wearing is called Kinesiotape.  Kenzo Kase, a Japenese chiropractor, invented the stuff about 30 years ago, initially using it on sumo wrestlers.  The tape experienced a huge popularity boost in the Unites States when Kerri Walsh, of volleyball gold medal fame with her partner Misty May, began sporting the tape because of a shoulder injury.  Everyone started saying “what’s that?” and, lo and behold, Kinesiotape was all over the shelves.

Kinesio tape also provides Olympic gold medals.

Kinesiotape is an elastic, cotton-based tape that can (allegedly) provide help in a number of ways.  The theory behind it is that it gently pulls and lifts the skin when applied, stimulating the vascular system and providing an increase in blood flow to a given area.  Depending on the shape of application and tension placed on the tape, one can gain pain relief, a decrease in muscle spasm, swelling relief, muscle activation or deactivation, or proprioceptive feedback (telling your brain where a part of your body is).

There is some research to support its use for a variety of injuries, but its not overwhelmingly positive.  However, some of the best support is in favor of using it for acute neck pain.  In other words, if your patient comes down with a sudden bout of neck pain you can reasonably slap some tape on there and see if it helps.  I’ve done this many times with my patient and it often works.  Is it science? Placebo? The answer is: who cares if it is safe, cost-effective, and it helps your patient?

“Keeping my neck stable,” Rose said when asked about the tape according to ESPN. “When you have a crick in your neck it’s kind of hard to turn side to side so it’s kind of keeping my neck in line and making sure my vertebraes are safe.”

Or is it like this magic rock that keeps tigers away?

I don’t think the tape is doing all that.  But most importantly: “He thinks it helps him,” says Bulls head coach Tom Thibodeau. “So we’re good with it.”

When your star player thinks it helps, whether its kinesio tape or magic underpants, you let him wear it.

It’s been a bad year for labrums of New York athletes.

Back on April 14^th, Carmelo Anthony of the Knicks injured his left shoulder in a game against the Indiana Pacers.  Turned out he sustained a torn labrum and rotator cuff, but he toughed it out and played through the injury despite aggravating it during the playoffs.  During the offseason, he opted to avoid surgery and utilize conservative management.  He says that despite taking a “huge risk” by not having surgery, he’s “ecstatic going from a torn rotator cuff and torn labrum to not needing surgery.”

In a stroke of simultaneous coaching stupidity and serendipity, Mark Sanchez sustained a shoulder injury during a meaningless series in the fourth quarter of the Jets penultimate preseason game in August.  Word on the street was that he too tore his labrum, and after several weeks of attempted rehab it was decided by Dr. James Andrews that surgery was necessary. After undergoing the procedure on October 8th, Sanchez will spend the year on the sidelines holding a clipboard in one hand and doing rotator cuff strengthening exercises in the other.

Here’s a brief description of what the labrum is and how it can get damaged.

The shoulder is, structurally speaking, not that stable.  It’s a ball and socket joint, but the ball is much rounder than the socket leading to a less than optimal fit. This means that we rely on other structures to hold everything together even more so than other joints.  I spoke a bit about this when Johann Santana tore the capsule in his shoulder: muscles, ligaments, cartilage, and other connective tissue are imperative to maintaining a stable shoulder joint.  This allows for greater mobility at the cost of stability.

The labrum is a ring of cartilage (think calamari) that surrounds the socket of the shoulder joint.  Its role is to aid in stabilizing the shoulder by deepening the socket – that is – to make the ball fit better.  It connects to the joint capsule/ligaments (the one that Santana shredded) and the bicep tendon and creates sort of a suction cup that helps keep everything from flopping around all over the place.

There are many variations in how the labrum can tear and exactly what happens structurally, and they are named for the involvement of the bicep tendon and the location of the tear using the numbers on a clock. One of the most common ways to tear the labrum is to have a large force pull abruptly on the bicep tendon, effectively yanking the part where the labrum attaches right off (this is usually called a SLAP tear [Superior Labrum Anterior to Posterior]).    Labral tears are fairly common sports injuries overall and downright ubiquitous in Major League Baseball pitchers (in fact, many pitchers without any symptoms at all have labral tears).  In basketball and football players, they are less common but typically happen when there is some sort of impact to the shoulder or arm while the arm is in a bit of an awkward position.

It appears that Anthony had his worst aggravation of the injury when Kevin Garnett gave his arm a little tug during game 5 of last year’s opening round of the NBA playoffs: as the arm is pulled, the bicep pulls back and a force is applied to the labrum itself.  In Anthony’s case, his labrum was probably a little damaged at that point and responded poorly.

As for Sanchez, he suffered a fall on his arm while it was in an awkward position.  This causes a simultaneous grinding, twisting, and pulling forces on the labrum.  Needless to say, it doesn’t like that.

Anthony avoided surgery because the severity of his tear was probably significantly less than that of Sanchez’s.  Hopefully, Anthony’s shoulder will hold up all year:  labral tears usually don’t heal.  Cartilage in general has very poor blood supply, meaning that all of the goodies needed for tissue healing don’t make it there (this is why people are going to Europe to have stem cell based treatments on their worn down knees, as cartilage damage is a factor with that too).  Anthony will have to hope the tear was small enough and in a good location (towards the outer rim of the labrum).

As for Sanchez, Dr. Andrews anchored the torn part of the labrum back to the rim of the socket of the joint, cleaned any debris from other tissues, and sewed him back up.  He’ll be in a sling for a few weeks and have restricted motion to make sure he doesn’t undo the repair.  He’ll progress to full motion and work on regaining strength.  He should be back to start next year.

Unfortunately, he’ll probably still be holding a clipboard. He’ll just be in another uniform and without a sling.

With just over 5 minutes remaining in the third quarter of Tuesday’s game 3 of the NBA Finals, Tony Parker left the game with an injury.  After getting an MRI, Parker was diagnosed with a grade I strain of his hamstring.  As he is certainly integral to the Spurs’ success, we must know: can Parker play? If so, can he be effective? What the hell is a strain, anyway?

First, a quick overview of muscle anatomy.  Muscles are essentially bundles of fibers grouped together in parallel that are surrounded by connective tissue called fascia (think sausage casing).  These fibers are comprised mainly of proteins (actin and myosin) that are able to contract.  In other words, the muscle can shorten, pull on a bone, and provide movement.  Nerves that connect to muscles give them the input from the brain and spinal cord to do what we want them to do.  Muscles have lots of blood – as they need tons of oxygen to provide the energy to move.

See, we’re just made up of pomegranates!

(Please note that it is EXCEPTIONALLY more complicated than that.  But don’t sweat it right now)

Often, muscles get injured.  We call them “pulls” much of the time, but what we’re really referring to is various degrees of tearing withing the belly of the muscle.  This is called a “strain” in fancy pants talk.  Strains typically occur when a muscle is trying to elongate and fire at the same time very quickly (I spoke about this in the Kobe Bryant Achilles article; similar principles apply to tendon and muscle belly).  Strains are classified by how much the muscle is torn.  Grade I means there is either over stretching of the muscle or minor tearing, no more than 25%.  Grade II refers to a larger tear, about 25-50%.  This tear is a lot more debilitating and usually results in a pretty black and blue up and down the back of the leg in the hamstring’s case. Grade III is even more severe, with the majority of the fibers being torn. Sometimes even a complete rupture will occur, usually requiring surgery.

That probably hurt.

So Parker is lucky in that the strain is merely a grade I.  Unfortunately, hamstring strains are quite annoying.  If you’ve ever had one, you know that the pain and tightness can linger for weeks on end, especially without appropriate rest.  You’ll see players hobbled on the court or field for months sometimes, as they play through the pain but it never fully disappears.  Such rest is very difficult as the hamstrings are used with every step we take.  It’s main function during walking and running is to decelerate the leg while it is propelled forward.  The hamstring lengthens as it slows your leg down so your foot can hit the ground.  So as the muscle is trying to mend, simple walking can repeat the same type of movement that got it hurt in the first place.  In addition, your hamstring stabilizes your hip when your leg is on the ground.  Basically, unless you lie around in bed or learn to levitate, your irritating the injury.  It’s like trying to glue two things together and pulling them apart every 5 seconds saying “Is this dry yet? No, ok I’ll check again.”

I fully anticipate Parker to play in game 4, and if the strain is really minor he might be ok (last I heard it was only stretched, not torn at all).  But don’t be shocked if he’s a little ginger on that leg.  Trainers are going to be controlling inflammation, keeping soft tissue flexible, and making sure the muscle doesn’t tighten up.  He’ll probably be on a stationary bike of stretching every single second he’s not in the game.  This will keep blood and neural output flowing and the muscle will stay flexible.

Time will tell if Tony Parker will be his dynamic self the rest of the series.  But if not, we all know Danny Green and Gary Neal can just shoot the lights out every night, right?

I apologize in advance for this, but: ya gotta have heart.

Let’s take a quick look at the heart as it functions normally.  Without getting too technical, remember the following few things:

1. The main function of blood is to deliver oxygen and other nutrients to the tissues of the body.  Without that happening, we are like a car without gasoline.

2. The heart has four “chambers” – the right atrium, right ventricle, left atrium, and left ventricle. The atria receive blood, the ventricles pump it out.

3. The path of blood goes like this: body, right atrium, right ventricle, lungs (gets oxygen), left atrium, left ventricle, body.

4. The left ventricle pumps blood to the entire body (including the heart itself) via the aorta.

An aneurysm is an abnormal distention (widening) in a vessel that prevents it from working properly.  It represents a thinning and breakdown of the smooth muscular wall that makes up the vessel.  The muscles that compose a blood vessel cannot contract and move blood when they are stretched, thin, and weak. Aneurysms are exceptionally dangerous in the brain (leading to strokes) and in the aorta.  A distended aorta can’t pump blood to the whole body.  This is a problem.

Imagine Jeff Green’s shock finding out that his aorta was defective.  Fortunately, cardiac surgeons do fantastic, miraculous work to help people like Green.  They perform was is called an aortic root reconstruction: they rebuild the non-working part of the aorta with synthetic material like foam rubber, creating a functioning vessel.  I was fortunate enough to observe this surgery up close when I was in school.  It is beyond amazing.  The surgeon essentially cuts out what is defective and stitches fabric in its place. Only its someones heart. In their chest.

Taken form the Boston Globe, who took it from the Cleveland Clinic. Pretty crazy stuff.

Green’s surgery took about 5 and a half hours.  His heart was stopped completely for an hour and a half while the most important work was done.  Amazingly, Dr. Lars Svensson, who performed the surgery at the Cleveland Clinic, said the surgery was a fairly simple procedure.  Recovery time varies for this surgery, but the goals of rehab in all cases are to retrain the cardiovascular system. It is expected, especially for someone Green’s age, to return to pre-condition status.

Its truly great to watch a young guy like Green recover from such a terrifying and stressful thing. Here he talks about the experience:

Green’s story is a great one for a city that needs all the positivity it can get right now.

The Achilles tendon is the attachment point for the calf muscles – the soleus and the gastrocnemius.  The soleus is the smaller muscle that is closer to the ankle, and its job is to work for a long period of time – ie while walking or running a long distance. The gastrocnemius is the larger muscle that attaches across the knee joint – its role is in explosive movements like sprinting and jumping. Both muscles combine to allow the foot to push off during all standing activities.

Now imagine taking a pair of garden shears to that.

Achilles ruptures are most common in males in their late 20′s to mid 30′s.  The reasons for this are that a) flexibility slowly decreases at this age and b) blood supply becomes slightly compromised in the distal (farthest away from the center of the body) extremities. These factors, combined with high activity level, make for greater susceptibility to injury.

Take a look at what happened:

Any experienced trainer or physical therapist can tell right away what happened.  He plants his foot and…nothing happens.  Down goes Kobe.  The foot tries to push off and the Achilles tears.  It usually happens during the eccentric phase of motion -the muscles tries to contract while it is elongating at the same time (think doing a “negative” at the gym”).  It’s like jumping off a diving board and having it snap before it propels you up.

Skip to 1:00 for instant fun.

There is some debate as to whether Kobe playing a massive amount of minutes as of late combined with a minor ankle injury earlier in that same game caused the injury.  I say no as this injury happens fairly often to people like Kobe all the time.  It’s not linked to fatigue, or breaking down, or anything like that. More importantly – in win-or-die mode, do you think Kobe is going to listen to “hey, you’re getting on in years, maybe we should sit you down and let Steve Blake take over for a while, you might tear your Achilles later” even if it was true? In addition, there’s no way to prove that there is any causal relationship between the injury earlier in the game and the big one later on.  Blame Mike D’Antoni for the disjointed Laker’s offense and poor effort on defense, not this.

The surgery itself will consist of one of three procedures.  First – if there are some fibers still attached, the surgeon will simply sew it back together.  Second – if the tear is truly complete, they will use part of the plantaris muscle (a vestigial muscle – it has very little use in the modern evolved human body).  Third – a wire mesh may be used over the graft to further bolster the repair.

There’s lots of chatter that Kobe’s career may be over.  Let me help explain in a few words – there is literally no chance that this is ending Kobe’s career. None.  Chauncey Billups came back.  Elton Brand came back.  Dominique Wilkins is the poster child for Achilles rupture rehab – he returned in 9 months and made 2 all-star teams afterward.  There is no reason – and this is irrespective of Kobe’s “heart” and “drive” and all of that – that Kobe cannot recover from this.  His heart will only help him, but he’s a 34 year old man with the best available care on earth and a pro-athlete undergoing a relatively routine surgery.  That’s why he’s going to come back.  The fact that he has a pathological desire to prove doubters wrong and win is the icing on the cake.

If he makes this face at his Achilles, it’ll probably repair itself.

The only two questions remaining are when will he come back and how good will he be.  Achilles ruptures are not like ACL ruptures in that the surgery often robs the athlete of some explosiveness no matter what.  This is where smarts and desire come in but cannot conflict with each other.  Kobe cannot afford to rush back as you know he will probably want to (a la Derek Jeter, who is of similar mindset).  All things considered, I think he’ll be back in 6-8 months and will still play at a pretty high level.  He’ll have to modify his game a bit – look for him to be shooting threes at an all time high rate next year

Whoever is coaching the Lakers will have to deal with that.

The tibia is a very important bone, as it is the primary weight bearing bone in the lower leg (its your shin).  The fibula, the thinner bone adjacent to it, is a much easier fracture to handle as it mainly serves as an attachement point for muscles and has much less responsibility in holding us upright.  Tibia fractures are more painful and harder to rehabilitate.  Moreover, Ware had a compound fracture, meaning that the bone broke through the skin.  This invites the possibility of an infection entering the fracture site and, more concerning, the bone itself.  A bone infection is called osteomyelitis and lead to a host of complications. As if that weren’t enough, Ware also has to worry about nerve and blood vessel damage in the lower leg as a result of the fracture.  A compartment syndrome can occur, during which blood accumulate in the leg, choking off nerves and causing permanent damage. In the worst case scenario with poor emergency management, this combined with blood vessel damage can lead to losing a limb.

Here is roughly what the before and after surgery will look like.

Immediately after Ware’s injury, trainers and doctors have 3 main goals: to prevent infection, to ensure the integrity of the nerves and vasculature, and reduce (put back in place) the fracture.  From all reports, they were quite successful at accomplishing this and Ware has already had surgery that went very smoothly. Kudos to the medical staff on hand for a fantastic job. The surgery involved cleaning the site, reducing the bone, and placement of an intermedullary rod, which is a fancy term for using a large nail thorough the shaft of the tibia in order to hold it in place.  Ware will be able to put weight on his leg very soon.

Where my people come in is the rehabilitation, which will be tough but doable.  Ware will have a hard time as a tibia fracture can affect the knee and ankle joint simultaneously.  Fortunately, from what I saw it did not appear to do much damage to the joint surfaces of the bone.  That would only cause even more problems.  Like just about any other surgery in the leg, he will work on range of motion, swelling, strength, balance, agility, endurance, and returning to his sport. I anticipate Ware will try to return for his senior year at Louisville (he is currently a sophomore).

Our prayers go out to Kevin Ware because, quite frankly, that injury sucks.  However, I think eventually he will be OK.  From what it seems, he has a great medical staff to get him through it.

Having these guys around won’t hurt either.

Johan Santana, in his prime, was one of the premier pitchers in Major League Baseball.  With the Minnesota Twins, he won 2 Cy Young awards and had 3 consecutive years with a WHIP under 1(!) and was the only guy who remotely intimidated Yankee fans during their yearly playoff win over Minnesota.  After signing a 6 year, $137 million deal with the Mets, he pitched the first no-hitter in franchise history.  He’s a force to be reckoned with.

Unfortunately, injuries have plagued his tenure with the Mets.  He had back to back season ending injuries in 2009 and 2010, and now we hear he is about to have his 3rd.  His shoulder surgery it 2010 was due to a tear in the anterior capsule of the shoulder, and now it appears he has retorn it.  He is traveling to New York, I’m assuming to see Dave Altchek, one of the premier shoulder surgeons in the world.  The news, since already confirmed with an MRI, will probably not be good.

So what the hell is a capsule? Why does he need it? Why does it get torn?

You and I need this intact to scratch out head. Imagine Johan Santana?

The capsule of the shoulder is essentially a thick, fibrous covering of the ball-and-socket joint that blends in with ligaments.  Most of our joints have capsules; they provide stability and hold fluid within the joint that helps keep the structures within happy with nutrients and lubrication. In the shoulder, the capsule is especially important because, along with muscles, it makes up for the fact that the ball doesn’t fit well in the socket (this provides the shoulder with a lot of movement, but makes it prone to dislocate).  The capsule is EXTREMELY important in pitchers, because what they do with their arm thousands of times a year. You don’t want a loose or torn capsule.  Unless you want to do this:

First, pitchers move their arm faster than any other recorded movement in human history in order to throw a baseball.  They move their arm 1700 degrees/sec (or, the same speed it takes for the Mets to fall from first to last place in the division) (EDITOR’S NOTE: We apologize for that vicious and gratuitous assault on the unsuspecting Mets fans reading this.) (2nd EDITOR’s NOTE: No we don’t) In other words, fast.  You need all the help you can get stabilizing a joint that moves that fast.  Second, as the pitcher cocks his arm back all the way and accelerates the arm forward, they achieve what we call maximum external rotation (MER) of the shoulder.  What that means is that the arm is rotated as far back as humanly possible, stretching the ever-loving-shit out of the capsule that is designed to prevent that exact thing from happening.  Normal people have 90 degrees of external rotation.  Pitchers occasionally approach 180 degrees.  In sum, pitchers do things with their arm that it was never intended to do. They move faster than anything else and have excessive motion in the joint at the same time.

Yikes.

So Johan Santana tore and had surgically repaired one of the essential components to keeping his arm stable.  And now he tore it again.  In my opinion, his career may be in serious jeopardy at this point.  It’s a shame, because Santana is a phenomenal talent and a nice guy.  We’ll wait and see what happens, but this looks like another disappointment for the Mets and their fan base.  Good thing they have a Shake Shack.

We certainly won’t question this man’s toughness.

In a word: yes.  To understand why, first lets take a look at what happened initially.

I truly cannot comment on the details of Jeter’s injury, as this information was never released.  What we do know is that Jeter’s fracture was significant enough to require surgery.  This probably means that he had what is called a “bimalleolar” fracture. The malleoli are what people often call their “ankle bones” that protrude medially (inside) and laterally (outside) from the ankle (there’s sort of a third malleoli, but we won’t worry about that right now).

There they are.

When someone fractures one of the malleoli, they can often get away without surgery (as originally thought with Jeter) but when both or all three fracture, surgery is required.  This extends the typical rehab by about 6-8 weeks and provides more opportunity for crap to happen down the road. The surgery, called an Open (surgically open) Reduction (set the bones in place) Internal (inside the body) Fixation (held together by hardware) is performed and rehab is initiated.

Pretty intense.

The problem is that while the hardware holds everything together, it can become irritated for some people, giving them prolonged symptoms that eventually require its removal.  For Jeter, we are also unsure of any soft tissue damage that may have occurred to the ligaments, cartilage, or tendons in the region. From what we’ve been hearing, it would appear that the fracture is the primary issue.  At any rate, today we see that Jeter’s ankle is still not responding perfectly to getting back to play.  What gives?

There are a few things to consider.  Its funny that Joe Girardi used the word “cranky” because its a word many physical therapists use to describe a joint that becomes irritated for whatever reason during rehab.  I use the term all the time and it is a normal part of the process.  Any time someone reaches a new level in function, the joint often gets cranky.  It represents a small amount of irritation or inflammation in the tissues affected by the injury.  In addition, anyone who has has a significant orthopedic surgery will tell you that the joint often gets pissed off for any number of silly reasons for the first year or so (and beyond).  Things like weather changes, or getting dehydrated (ie, hungover) can do it. It’s not a huge deal.

So why am I a little worried about Jeter? Two primary reasons.  First, when a patient tells me that their joint is cranky, we don’t run and do an MRI.  It takes significant or prolonged signs and symptoms to make us do this.  So, I am a little concerned that the Yankees medical staff ran out and ordered imaging right away.  Jeter doesn’t seem like the type to bitch a lot, so he must have said something that raised a flag for someone.  If this was July, I’d say fine.  But now? I’m not at ease.  Secondly, the MRI revealed mild inflammation.  Now I know “mild” sounds reassuring but that title is misleading.  When inflammation actually is visible on an MRI, it is usually associated with more troublesome symptoms.  With truly mild symptoms and mild inflammation, the MRI signal does not change enough to pick it up; everything just looks gray.  In this case, the signal intensity was increased, meaning something came up white on the MRI.  This is usually indicative of something a little more annoying.

I’m not saying Jeter is done or going to miss a huge chunk of time.  As Wallace Matthews pointed out:

@afr_sports could be they were just playing it safe. Pro teams MRI jock itch. they can afford it

— wallace matthews (@ESPNNYYankees) March 20, 2013

He’s right in that with the face of Major League Baseball, they’ll MRI at the drop of a hat.  Jimmy the plumber has to wait.  Plus, Jeet’s a tough cat, as we all know.  But be aware, Yankees fans, that his injury is probably going to haunt Jeter all year.  Get ready for some games off and DHing for him in the near future.  I think he’ll be ok, but that’s it.  Just ok.

UPDATE: So here we are on opening day and, for the first time in 12 years and only the second in 18, there will be no Derek Jeter.  He will be retroactively placed on the DL, making him available on April 6.  If he’s ready, of course.  The MLB.com reports that the Yankees will not play Jeter unless he can play 9 innings of shortstop on consecutive days.  The most he’s gotten so far is 5 innings.  This is a major bummer, but if Jeet comes back too fast he’ll only prolong the setback.  Let’s hope the healing process continues well and he’ll be on the field soon.  Unfortunately, there are no guarantees as to when that will be or how long it will last.

These flareups are common when there is a major functional progression in rehab (any of you who has had an orthopedic surgery of any kind knows this). Derek Jeter is no different.  His ankle will settle down soon enough and he’ll be back out there.  But he’ll have to be very carefully managed throughout the season to ensure that he won’t be feeling too banged up during the home stretch.  If the Yanks make it to October, they’ll need the Captain at full strength.