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Under The Knife: Utley's return takes a turn for an uncertain future

Two big name pitchers -- well, big name to fantasy players and hardcore baseball fans, a group with a very overlapped Venn diagram -- will have to contend with more than just hitters this season. Stephen Strasburg and Matt Moore also will have to contend with innings limits. The Nationals have talked about keeping Strasburg at 160, while the Rays have been more circumspect about their expectations. The problem is that neither of these limits is based on science. Strasburg's limit appears to be plucked from thin air, perhaps using the count that worked for Jordan Zimmermann, though that number also had no basis in research.

I've taken a look at possible scenarios, from adding an extra day of rest to Strasburg's schedule, to pitching him only at home, to using him as part of a tandem as possible solutions. Any could work -- or not. The fact is that the Nats are guessing. They don't know what caused Strasburg's original traumatic UCL sprain and they're not sure what, if anything, has changed. It's a multimillion-dollar gamble.

In a similar vein, the the Rays, known as one of the most advanced teams both sabermetrically and medically, are guessing, too. Until baseball gets serious about figuring out how to properly assess innings limits, a lot of teams are going to guess wrong and I'll have a lot to write about.

It appears that this spring trouble comes in pairs. Powered by Verve Coffee, let's get to it:

Last year at this time, doom and gloom surrounded Utley and his knees. The Phillies did a great job rehabbing and maintaining him. He lost some time but once back, he produced at his normal levels. This spring, things haven't gone so well. In fact, it's nearly a worst-case scenario. Utley's knees have degenerated further, to a point where almost any activity is causing pain, swelling and likely more damage. Utley is headed to the DL to start the season and headed out of Clearwater. There's also been talk that Utley may need microfracture surgery, as well as considering considering other options. (Listen to see if Utley ends up with someone like Dick Steadman in Aspen or Walt Lowe in Houston; that could mean something as simple as injections or as advanced as a meniscal transplant or implant.) The information I have doesn't suggest that Utley's career is over, but there's definitely cause for significant concern. He's not just out for Opening Day; there's a chance he's out until midseason or longer. The June ERD I have set for him is a midpoint, not a prediction.

Howard's progress has been at a standstill as doctors focus on the infection and wound from his surgery. This is a common complication of Achilles surgery, but doesn't help Howard or the Phillies. The fact that the infection and/or wound is holding on this long certainly is problematic, but it's difficult to get a good read. The fact that the tendon graft isn't compromised is the key. The rehab worked well, and I continue to believe that once Howard's wound is cleared, it won't take him long to come back. Some extra healing won't hurt that and may prevent some of the setbacks that came with his very quick recovery. Phillies fans will be watching for the expected return to the field before the end of spring training, but the conservative Phillies medical staff may blow past that and take this rehab behind the curtains as they did with Utley last season.

The Mets have some new minority owners, less legal concerns, but are they healthy? After Terry Collins had a wrongheaded meltdown, complaining that players need to "get out of the training room," we have to wonder if the medical staff will be able to deal with small things and do the preventive work they need to do to really keep people out of the training room.

Santana's return has gone well. He's made his starts and shown good stuff, but more important for the medheads, he's missed no work at all. He's done his side sessions, his long tossed, his running and all of his off-field conditioning work. Santana's as close as he's ever going to be to 100 percent.

The news is less clear on Wright. That his injury is to an abdominal muscle rather than an oblique doesn't really change anything. It's on the border between the oblique and the abdominals, so giving a Latin name is just a game for those more concerned with appearances rather than function. The injection he had* seemed to help and he's doing everything but swinging a bat. That could come later this week, which would have him back on or near opening day.

(* Many doctors aren't using the now-standard "corti-caine" injection as a matter of course. The injection we normally refer to as "cortisone" is often a mixture of cortisone and a local anesthetic, such as lidocaine or Xylocaine; hence the name. Some doctors have mixed in stronger anti-inflammatories, but more are moving to toradol. It's less damaging to tissue and has solid results, but it does have some consequences that are problematic. Doctors insist that the problem is not the drug, but how it's used in football. While I may slip and call an injection cortisone out of habit, it's not always the old school substance any more.)

When an exam comes "a couple days" later and is done by Lewis Yocum (or any of the supersurgeons), it's not a good sign. The usual reason is that there's swelling, which makes getting a clear image on an MRI tough, even using advanced magnets and contrast dye. (Late Monday the Royals released news that Soria had an MRI done that showed some uptake in the UCL.) Soria had his UCL reconstructed in 2003 and the "honeymoon period," during which the ligamentization process appears to be protective, is gone. A significant tear would cost Soria the season and another run through Tommy John rehab. Jonathan Broxton likely would be first in line to close if he can stay healthy. Of course, who he and the rest of the staff will be throwing to is also a major question. Perez got a big, new contract and almost immediately tore up his knee. It's not a major concern; it's a simple torn lateral meniscus. The Royals did handle this a bit differently than the norm, repairing rather than removing the meniscus. This should help Perez in the long term, but has a longer recovery period. It's a long-view decision that should be applauded. That all said, Perez won't be back before late May at the earliest.

Morales has had a long trip back to playing baseball, but he's made great progress this spring. After his freak ankle fracture while celebrating a home run, Morales needed several surgeries to fixate and then just plain fix an ankle that went necrotic. It's a fluke injury, pure and simple, and one that couldn't have been "handled differently" as some suggest.

Medicine is as much art as science and there's far more we don't know. I've been reading a book called "The End of Illness" lately, about a systemic approach to medicine. It's enlightening in a case like this, where things went in a different direction than anyone could have expected and we simply don't know why. Morales has lost some mobility, but appears to have enough left to play DH. There are some comparisons here to Edgar Martinez, which would be a pretty good one.

The Angels had another scare last week when Santana took a comebacker off his arm. He came away with a nasty bruise, but nothing more. He was back throwing the next day, and it makes me wonder how close he came to a more serious injury. There's very little that's been done to protect pitchers, even after several scary incidents. I won't soapbox it, but until some player is smart enough to start wearing protection on his own, no one will. I wonder who that will be.

Giancarlo Stanton's knee is sore, but he should be able to play through it. The downside is that the rehab is going slowly. They're past the point where he could have surgery and be ready for Opening Day ... Chris Carpenter will begin throwing this week. While the Cards won't rule out the Opening Day start, it's more likely that they'll skip his first turn through. That assumes the medical staff can keep his neck healthy ... Miguel Cabrera took a bad hop to the face. It hurt, he bled, but he'll be fine. One key is that several people I spoke with focused on it being nothing more than a bad hop, not indicative of his play at 3B ... As I expected, AJ Burnett is well ahead of the Pirates' very conservative rehab schedule. He's going to throw a side session this week and could miss as little as one or two starts, rather than one or two months ... Skip Schumaker won't be ready for Opening Day. He has a Grade II oblique strain ... Corey Hart is doing very well with his rehab after having his knee scoped. He could be ready for opening day ... A lat strain could keep Mike Morse off the field for a week and put his Opening Day in jeopardy if it goes longer ... Freddy Sanchez's post-surgical shoulder is still weak. The Giants are worried he made need extra rehab time, starting the season on the DL ... The Nats are shutting Chien-Ming Wang down for a couple weeks, but not DLing him yet. The Nats don't need a fifth starter the first week. ... Brett Anderson is making progress after his July elbow reconstruction. He could be back in May or June, assuming things continue to go well in rehab, making him a bit of a sleeper in drafts ... The Orioles are being conservative with Zach Britton as they try to keep him off the operating table. His shoulder is still weak, so he won't make the opening day rotation ... We should start seeing the first DL moves late this week. There's no roster relief in spring training, so the moves aren't necessary yet.

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