The scandalous photos!
So there are a few biology things to put out there, up front, for anyone that is interested in what happened but not real informed on the physical makeup of a pitchers shoulder. I emphasize pitcher because there are parts of this that are relevant to me being a throwing athlete.
The first piece to this is regardless of what anyone in the medical profession has ever told you about MRI’s, even Gadolinium MRI’s (which is an MRI where they inject a fluid into your shoulder to give the images much better contrast, hopefully giving the experts reading the images more information on the condition of the joint being examined) it’s as inexact a science as there is. MRI’s are a very nice way to get an idea of a potential problem, but at best they are very obscure and inexact.
The MRI’s I have had over the past 5 years were reported as “unchanged” all the way up to my arm actually being opened. That’s not to say “healthy” or “in great shape” but rather nothing had medically changed from a diagnosis standpoint on the MRI’s, in anyone’s mind, with the exception of Dr Morgan.
The MRI taken early this year, as he read it, showed the bicep as ‘striated’. Think of how a thick piece of rope is made. The hemp is small strings wound together to create a thick rope. The bicep tendon is very similar in makeup, and a ‘striated bicep’ means that the ‘hemp’ that is wound together to create the bicep, was unraveling. This I was told is a sign of latter stages of deterioration of the bicep and is not a common thing, even in throwing athletes. It’s generally seen in older people who do manual labor, carpenters and such, and people that tend to use their arms over their shoulder height quite often, as well as tennis players at times.
So Dr Morgan diagnosed a striated bicep tendon and there was disagreement as anyone familiar with the situation might remember, but most everyone involved was in some sort of agreement that beyond that there was no real change.
Everyone that is but Dr Altcheck. Dr Altcheck was brought in as an independent 3rd opinion after the initial disagreements and as per the collective bargaining agreement stipulates. In Dr Altchecks opinion there was agreement that there were significant issues with the bicep tendon, but beyond that there was an opinion that I had ‘significant’ damage to my rotator cuff, career ending damage to be exact. That led to the belief that while a bicep tenodesis at that time might cure the pain I was receiving, the larger issues were of such significance that short of a major rotator cuff repair I would never pitch again.
This led to a lot of discussion about the completely unexplored area of doing a bicep teno-desis in a Major League pitcher. The opinion was that it had never been done and therefore was not a realistic option. Unfortunately we came to find out that it had actually been done and the few it had been done on, some as far back as the late 1970s, some threw in the major leagues afterwards. The more recent example(s) were in players much younger than I am.
The age and mileage factor was the wild card piece to any discussion about surgery, and rightly so. We knew, even if the MRI read pristine, opening my shoulder would reveal at least some semblance of damage, given that an MRI would most likely show the bare minimum in the way of injury.
The physical aspects of this are somewhat relevant too. The bicep tendon runs up the middle of your arm and enters into the shoulder joint along a narrow shallow canal at the end of your humerus bone. It enters at the lower end of the ‘knob’ of the humerus, and when it does it then is under a small bony sheath to the point it exits at the top, and is attached to your shoulder at the labrum.
The second important part to this is the labrum. Think of the labrum as an oval. A thick rubbery ‘buffer’ that is between your humerus and your shoulder socket, and is there to act as a buffer between the bones and the joint. Also think in terms of a clock, with 12 at the top and 6 at the bottom. In 1995 I had a labral tear from 11 o’clock to 1 o’clock of my labrum that Dr Morgan repaired with what was then cutting edge technology, tools and procedures. Now the bicep tendon exits this small canal and attaches to the labrum in two places. It splits just before attaching and is anchored to the labrum in two locations.
This first picture is my labrum. This actually looks rather innocent until you realize this. That white wispy cotton looking material is my labrum and that solid bone thing to the right is my bone at the joint. The white wispy thing is supposed to be adhered to the bone and NOT all frayed and floating. Basically I had a torn labrum from about 10 o’clock to 3 o’clock. Far more significant tear than I had 13 years ago. Also if you peek behind into the background you can see my bicep tendon hanging out back there, all shiny and white and healthy. That’s the bicep tendon as it exited the small canal near the top of my shoulder, looking pretty sexy I might add.
The second photo is the repair in action. The labral tear is “debride” which in addition to likely being spelled wrong is when they shave away the peripheral tissue to clear it out and insure what’s left is strong enough to handle being re-attached. They also start the bone healing process by making it ‘bleed’, at which time the body reacts by starting the healing process even before it’s truly fixed.
The picture above is the labrum repaired. Anchored to the bone with 3 sutures of ridiculous strength. Also note the bicep tendon is now absent, it’s been removed.
Another major factor in the process was that by removing the bicep tendon you could argue that the labral repair becomes unnecessary because the bicep causes all of the pulling and tension on the labrum in the first place. With the bicep taken out of the equation that part of the pain puzzle is removed. I would argue that would not be the smart thing since having a torn labrum to this degree would provide ample opportunity for that tissue to get ‘caught’ or wedged in the joint, and I don’t think that would feel too good. I am guessing that if there was no repair they would remove the labral tissue altogether? Not sure but I wasn’t real interested in finding out.
These last two pictures are the evidence I honestly never felt I needed (and if you’re squeamish I’d recommend not scrolling down). I knew there were issues and I knew they were not all connected to my labrum. Not only was my bicep ‘rotting’ and ‘diseased’ (which you can see by looking at the ends of the muscle which are whiter, and thicker than the middle portion, but notice that split? Ya, that’s not supposed to be there. The bicep is, until it exits the canal, one long continuous muscle, at least in normal cases it is. Mine is not. Mine is actually split in two as you can see. That’s not good but that is a definitive set of reasons why I had the pain I had, the way I had it.
Oh one more piece. In the picture below you can see an arthroscopic tool touching some tissue. That’s the undersurface of my rotator cuff. In layman’s terms the cuff is basically 4 ‘muscles’ that anchor your shoulder joint and keep it stabilized. They are rather small and fragile but they tend to be the lynch pin in that were they absent your humerus bone would bounce around inside your shoulder joint and you’d be done, fast. I did NOT have a rotator cuff tear in the traditional sense, not even close. I had what’s called a ‘partial thickness undersurface tear’ and if you look close enough you can see it. Partial thickness is one of the few medical terms I have heard that means what it says. It’s partially torn and not torn all the way through the muscle. I’ve been told that pretty much any pitcher on the planet that’s thrown even a few innings at this level can show this exact thing. The career ending piece is when you have a ‘full thickness tear’, that means your tear goes all the way through the cuff muscle and there is detachment from the bone. I had none of that. In fact other than that small partial tear my cuff was 100% intact.
Off of this I had to make some assumptions when all was said and done. That labral tear is not a gradual hard to figure out piece here. That’s a major injury and in thinking back there is only one set of dates and times that make even remote sense to any of this piece of the puzzle. Last year I came one out away from a no hitter in Oakland on June 7th. Six days later I was atrocious and struggling in getting battered by Colorado and 5 days after that I was throwing 83mph in my last start before going on the DL. I think I tore my labrum sometime between the last pitch of the Oakland game the last pitch of the Atlanta game. In all honesty I think it was prior to the Atlanta game since those symptoms spread out over that 11 day period match the symptoms exactly that I experience over 1 inning in 1995 in Colorado when I tore my labrum. No real pain while doing it, but a sudden immense drop in velocity. Only when I cooled down and stiffened up did pain enter into the picture.
What I am curious to know is just how they kept me alive and breathing the rest of the season. I can’t deny the cortisone had to have an immense impact since my first three rehab starts in Pawtucket that next month were the best I had thrown in 3 years. I also know that everyone involved knew that every day after coming back was on a path of diminishing returns since there was no real time to rest anything.
I think I got fooled into believing a little longer rest period over the winter would cure all ills for that simple reason. I managed to get by the entire year because I could ingest Vicodin when needed for pain, and in between starts when it wasn’t that bad and my ankle wasn’t screaming we could manage to get some work in. The magic John Ferrell worked is now even more amazing to me looking back.
What we didn’t say at seasons end was that long layoff I had before the post season was due to a second cortisone injection and complete rest. I had immense discomfort between starts and really could not manage to throw much, if at all, in between games. My biggest fear going into Anaheim was rust, I literally DID NOT touch a ball for I think 7 of those days and as someone who lives for that little touch and feel work between starts it killed me. I will add that it was the first time I ever committed myself to visualization and I may have even gone overboard working with Don Kalkstein, another guy who without him I’d have folded the tents far sooner than I did.
I do remember heading out for game 3 and until I was on the mound pitching I had no clue how it was going to turn out. I certainly wasn’t physically locked in, not even close, but I think the ‘brain work’ and the complete and unflinching confidence in ‘Tek back there allowed me to get settled and get after it a bit sooner than I otherwise might have. I remember a lot of loud outs early but I also remember feeling like I was improving as the game went on.
Conspiracy theorists and ‘experts’ can speculate on ulterior motives about so much of this but the fact of the matter is I was strong enough to pass a physical and my MRI didn’t show anything anyone had not seen before. I was sure the rest would fix it all, but it didn’t. The bicep issue is not a spur of the moment thing, that’s been a long time coming and I guess given my age and mileage shouldn’t end up being a shock. Dr Morgans analogy back in January when everyone was looking for answers to why and how I just suddenly had pain, before we knew of the labrum damage, was that sometimes it’s just ‘the straw that broke the camels back’ with regards to my bicep.
So there it is, in all it’s gory splendor.
What next? I really don’t know. I am moving the shoulder passively and nearing that stage of the process when some decisions are going to need to be made. I have access to the right people should I decide to take the long road and rehab back to pitch one last time. If I did that it would be no sooner than the 2nd half of next season and even then there is a lot to ponder if that’s the path I choose.