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Under The Knife: Kemp, Tulowitzki find the limits of playing in pain

Is there luck in baseball? Few would disagree with that premise, or at least they would say there are elements of the game that can't be modeled, predicted or simulated with any degree of accuracy. Is there luck in injuries? This is a more dangerous fork in the road, especially for me. There are clearly some injuries that cannot be prevented, such as the freak fracture suffered by Jonathan Lucroy when his wife dropped a suitcase on his hand. Unless the Brewers hire 23 more athletic trainers to follow players into their bedrooms ... umm, no, that's just weird. Let's take a look at some facts to try to find luck, something that's much more intangible. Comparing 2011 to 2012 as of June 1, there's a pattern of an increase in lost days per DL stint:

Total DL Stints: 264 v. 246Catchers: 20 v. 19Pitchers: 145 v. 125DL Stints before Opening Day: 90 v. 103Days lost as of 6/1: 7572 v. 8067Avg Days Lost per Stint: 28.6 v. 32.7

Dan Wade (who does amazing work maintaining the IDB) notes that the major difference is the injuries that occurred in spring training. Of the 103, 74 (72% percent) are still on the DL today. Every season, someone is lost like an Adam Wainwright, but it seems there's a higher percentage who were injured this year with no discernible reason or pattern. I'm wary of using the ADL since some DL stints are 15-day minimums and some are year-long Tommy John rehabs. Saying that it's often somewhere in the middle doesn't seem that instructive. Dan and I will keep digging and working on this data set. Not to be a tease, but we're hoping to debut something new within the next month that will help with fatigue analysis on pitchers.

Powered by vision, on to the injuries:

There's nothing worse than a recurrence. Just as Kemp was coming back from his hamstring injury, one hard run around the bases appears to have put him right back on the shelf. Kemp was visibly angry in the dugout just after running first to home on a double. It's not clear from the video exactly what happened, but Kemp's reaction sure indicates that it's in a similar, if not identical location as the last strain. He'll head out for an MRI on the leg in order to determine exactly where the muscle defect is, but these are easy enough to find. The term "palpable defect" is just that -- a spot in the muscle that can be found by touch. Kemp hits the DL, but it's unclear just yet how long he'll be out. We have to assume that it will be longer than the minimum.

Tulowitzki has been playing through a groin strain for at least a few weeks. The Rockies are selling that he's had this since the beginning of the season. If so, it's worth about 50 points of OPS, some range and a good bit of pain for the Rockies SS. Tulowitzki tried everything, including a couple days of rest, and the groin is, at best, not improving, and, at worst, re-straining with each wrong step or stretch. He left Wednesday's game with the latest exacerbation and has finally admitted that he'll likely need a DL stint to rest and rehab the strain. My guess is that the team will elect to protect Tulo from himself and shelve him for now, which is exactly what happened just before Thursday's game. I doubt he'll be out much beyond the minimum.

Cliff Floyd corrected me about Pedroia's best comp. I had forgotten that Kevin Youkilis' thumb injury in '10 was a similar adductor strain, though more severe. Then again, I should know to take Floyd's word on injuries! (Kidding aside, Cliff does a great job on Sirius' Fantasy Channel.) Pedroia's strain will keep him out through the weekend, but there are indications that the Red Sox think they've found a way to keep Pedroia in the lineup. I don't have the slightest clue what it is -- perhaps trainer Mike Reinold has found some taping technique deep in the bowels of his research library. Pedroia fought to stay in the lineup through his foot injury, ending up on the DL after taking grounders from his knees. As with Kemp (and many others), he has to be protected from his own desire at times. It's not an easy job, but it is an important one. Sources indicate that he could be back as quickly as Monday, but I'm more wary than the ERD shows.

The Angels decided to be conservative with Weaver, in part because of his brother. Jered is 29, the same age when Jeff Weaver's career was essentially done due to shoulder issues. Jeff came back after a couple seasons in the minors, but Jered is signed long-term and is a better pitcher than his brother. That makes him more valuable, and for a team expecting a playoff run, having him rest now, miss a couple starts, and be ready for the second half just makes more sense. Weaver insists that if this was September or October, he could pitch through it, but the look on his face, the description of stabbing pain and indications that there could be disc involvement beyond the spasms makes me wonder if he's correct. I wouldn't be surprised to see this stretch further than the couple starts that have been mentioned, and if so, the All-Star break could get involved. If Weaver hits July without throwing, the Angels could wait a bit longer and let him come back after the break. The record of the team and the distance from both the Rangers and the Wild Card slots will also be major factors in the timing.

One of the things that keeps coming up in discussion of injuries are MRIs and delays. Dr. Jeremy Szymanowski is a musculoskeletal radiologist at Orange Coast Memorial Medical Center in Fountain Valley, Calif., was kind enough to explain to me whether or not a delay after trauma is necessary to get a good MRI. "In most cases, swelling (or edema), at an acutely-injured area does not significantly affect MRI interpretation. In certain instances it can actually enhance visualization of normal or damaged structures, such as intrinsic ligaments. Alternatively, edema from blunt force trauma to a structure such as a collateral ligament of the knee can have an imaging appearance similar to a low-grade ligament sprain. There are other instances; to the trained eye this is usually a non-issue." The key here is "trained eye" and there's some difference of opinion on this, part of the art of sports medicine rather than the science. So why then do some teams wait? Szymanowski said, "Not all injuries require immediate advanced imaging. Imaging in the acute setting relies on a doctor's clinical impression. If a low-grade injury is suspected, a clinician may choose to treat conservatively and only image as necessary. However, if a higher grade injury with possible surgical ramifications is suspect, then earlier imaging is preferred. Not only does this establish a diagnosis but will likely prevent further injury." This, plus the holiday weekend, help explain why the Phillies waited a couple days. The result didn't change. It also didn't change when Halladay went to see Dr. David Altchek, though full results of the exam weren't available at deadline.

Kemp wasn't the only one with a recurrent muscle strain. Fister heads back to the DL after re-injuring his side. The Tigers aren't saying this is the same muscle or same location, but they're not correcting that assumption either. Most recurrences happen almost immediately, indicating that the player came back too soon or his state was misread. Fister had five starts and showed no problem with his core until he was injured. Rather than being a typical re-injury, this appears that Fister either has a specific muscular weakness, a mechanical flaw that's overtaxing a specific area, or a combination of both. The Tigers' medical staff and Fister will have to address those during this second rehab, which means he could be out longer than the month it took him last time. So why "strained core?" There has been a lot of discussion on the differences between the obliques, abdominals, intracostals and costochondrals. All four are in the muscle group popularly called the core and all four have similar timelines for rehab depending on the grade of strain. If there's only an anatomical difference, the rest is just semantics. What I believe you care about is what happened and what we can expect.

The Cardinals aren't saying what's wrong with Garcia's elbow, but they are saying what isn't wrong. It's not a problem with his repaired UCL. It's not a problem with the flexor. It's not a nerve issue. With those three off the board, the most likely suspect for something like this that could clear up quickly is some sort of bone chip. Most think of chips as the sort of large embedded piece of stray calcium like what's kept Drew Storen out, but they can also be very small, like grit. If you've ever left the beach with sand in your shorts, it's that kind of irritation that can be problematic for a pitcher. The bigger worry here is that Garcia's can't do what he's doing and stay healthy in the long term. Is he putting too much force on the elbow or slamming the bones together rather than pronating? A quick biomechanical analysis could tell the Cardinals all of that and more, but I'm growing tired of trying to lead horses to water. For now, Garcia will miss one start with the Cardinals re-assessing in a week.

It looked a lot like the comebacker that broke Halladay's leg. Brandon Morrow was a bit luckier, taking a hit on the muscle rather than the bone. He just has a bruise. We'll see whether or not he makes his next start ... Adam Jones got a bit lucky, taking a Morrow pitch off the wrist. X-rays were negative and he shouldn't miss much time ... Nick Markakis wasn't so lucky. A similar pitch broke his hamate bone. He'll have surgery and miss at least a month. Dan Wade found that the quickest someone came back from this type of injury is 25 days, so the Orioles are being very optimistic with their timeline ... Joe Strauss has details about Skip Schumaker's strained hamstring and more interesting stuff about maintenance on Carlos Beltran's knees ... Pablo Sandoval will have his wrist checked this weekend. If all checks out well as expected, he'll start a rehab assignment early next week ... Travis Hafner will miss a month after minor knee surgery ... As expected, Mike Morse could be back Friday for the Nats. He's scheduled to play Thursday night in one last rehab game ... Ruben Amaro says that he doesn't expect Ryan Howard back before July 1. That surprises me, given what he's been able to do so far, but apparently the atrophy in the leg is far more significant than we knew ... Josh Thole will return Friday for the Mets. He was cleared The Rangers will start Roy Oswalt at Round Rock (AAA) on Saturday. He's already in very good pitching condition according to sources and may need less than the four starts the Rangers have discussed ... Jesus Flores should be back in the Nats lineup on Friday. They'll ease him back in ... I'm taking a break from Twitter because of two things -- I respect my work and I respect my readers. I think my work has value and think that you coming to SI.com to read it has value for you. You don't have to jump through hoops or do anything other than read SI, like you probably would anyway. I think you deserve the best of my time and resources, as does SI, who are the people that pay me. You, the reader, are who I do this for and I'm determined to do it better than anyone else.

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