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Friday, March 7, 2008

A User’s Guide to Pujols’ Elbow

The question looming over the most important and precarious ligament in the Cardinals’ franchise is whether or not Albert Pujols can play out the rest of his already illustrious career without repairing a shredded ligament in his right elbow.

His answer is yes now and check back with him later.

The team doctor agrees.

“Probably. Possibly,” Dr. George Paletta told three of us reporters Wednesday here in Jupiter, Fla. “This is not a curable problem without reconstruction. What we hope is this is a manageable problem. We’ve been managing this problem since 2003. … But there may come a time when it’s not manageable anymore. And if it’s not manageable, the best answer for Albert, long-term, is having reconstruction done.”

And therein lies the rub.

The Cardinals and Pujols will manage the elbow injury until they cannot.

As Pujols said: It blows when it blows.

There are continuous questions about the former MVP’s elbow — and sporadic bursts of intensive coverage, as we’ve seen the last couple days — and this is an attempt to pool all of the information for a one-stop reference. Below is both a history of the injury, a current situation report on the injury and some additional references. These details have all been discussed an reported before, but over a span of the last couple months and the breadth of several articles, at the P-D and elsewhere.

It started in April 2003.


– On April 19, 2003, an article appears in the P-D reporting how Pujols has strained the ulnar collateral ligament (UCL) in his right elbow and the doctor recommends Pujols takes three weeks off from throwing.

– Manager Tony La Russa makes the call, in concert with Pujols, to continuing playing the invaluable hitter in the outfield with strict orders not to throw. Pujols complies, but this move prompts columnist Bernie Miklasz to write in May 2003:

When the baseball travels in the general vicinity of Albert Pujols, manager Tony La Russa offers a prayer to the baseball gods, hoping that Pujols resists the temptation to do what fielders are supposed to do: make a throw when challenged.

Because if Pujols lets one rip, and guns a speedball to cut down a runner, his right elbow may unravel and come apart. So, too, would La Russa’s reputation.

– According to Pujols this spring the fact the Cardinals did not make the playoffs in 2003 helped his elbow recover, because he did not have any problems with it in 2004. It felt as good then as it has in any seasons since.

– The elbow flared this past season, forcing Pujols to play in pain.

– Shortly after the end of the season Pujols consults with Cardinals’ team doctors and is also sent to Dr. James Andrews for an exam and a discussion on his possibilities. It is at that time that Andrews and Paletta lay out three options for Pujols:

1. Reconstructive surgery, a/k/a Tommy John surgery (here is a tremendous graphic from USA Today on the procedure).
2. A scope, similar to the one done on Chris Carpenter’s elbow early last season — which will clean the elbow and remove bone spurs.
3. Managing the injury by treating the inflammation and cautious use.

– Pujols rejects No. 2 when told that surgery could, like Carpenter, lead ultimately to No. 1 anyways, and he chooses No. 3. He said in February:

“Because it didn’t make sense when we were talking about doing it. Me having the surgery and just clean it up, when cleaning it up it wasn’t going to make it good. I had to do something in the ligament. If it wasn’t going to make sense why are we going to do surgery for it? Just leave it like that and when I do need the surgery and then we do it.”

– No. 1 is briefly discussed as the only solution that assures long-term health, but as one Cardinals source said this winter: “It is a real difficult call when you are talking about taking a hunk of playing time away from a player of this magnitude and a career that could accomplish amazing things.”

– Reconstruction prescribes a 7- to 8-month rehab process for a position player.

– At the Winter Warm-up Pujols says the rest has done him good and his elbow is fine, but then, after the cameras have stopped rolling, he shows a few reporters how he cannot entirely straighten his right arm. It stops short because of the elbow.

– Pujols reiterates at Winter Warm-up and in his first day at spring training that he can manage the elbow, that it won’t be a problem, but that he also will not play again through the pain he went through last season.


– Paletta classified Pujols’ injury as a “high-grade” tear of the UCL.

Diagram showing the location of the UCL

– He went on to say that Pujols’ injury is worse than the tear in Carpenter’s elbow last year, the tear that sent Carpenter in for Tommy John surgery. “Albert’s tear is farther along than Carpenter’s ever was,” Paletta said.

– In addition to the tear in the ligament, Pujols has developed what Paletta called early onset arthritis and bone spurs.

– It’s possible, Paletta said, that the bone spurs and arthritis have developed in response to the torn ligament and may actually be helping to provide stability and protection in the elbow for its continued usage. The severity of the tear has not changed since 2003, but the ailments surrounding it have. One reason a scope was so unattractive as an option is for the same reason it became problematic for Carpenter a year ago. Any work in the elbow could disrupt the environment created, however gnarly. And that could aggravate the injury just as easily as it addresses it.


– First, a couple things to get out of the way, without qualification:

* If Pujols were a pitcher, this would be a different news story. We’d be tracking the play-by-play of his recovery from surgery already. Done deal.
* Perhaps now you have a clear understanding why for several months now I’ve been adamant in here and elsewhere that Pujols would not play third base.

– Paletta called it a “wise decision” to try the non-surgical route of treatment. That will include attacking the inflammation in the joint with medication when needed and vigilance on Pujols part to pull back when the elbow barks or stick to treatment to brace the elbow for use.

– Pujols is a big believer that having a full offseason to rest the elbow will be the sure cure. It worked after 2003. Should work in 2008.

“Coming into spring it never bothered me,” he said. “It gets irritated during the year. Never has bothered me coming down to spring training and it doesn’t bother me at all during the offseason. It’s during the year when I’m hitting and throwing and doing more baseball stuff and not resting.”

– The Cardinals and Pujols point out that the plan this season isn’t all that different from the seasons past — more diligence; perhaps more conservative — and he’s played nearly five seasons with the same tear.

– La Russa said he spoke with Pujols about an elbow-friendly schedule this spring, and that the two may discuss how to build in days off for the regular season. Pujols has said he was open to such a discussion, but also dismisses the need for one. He has been on a limited throwing program this spring. In the regular season, La Russa could see giving Pujols a Sunday off before a Monday off day to steal the first baseman a couple days off. Pujols believes that one day or two day is not going to diminish any soreness and that any rest would have to be lengthier, so “go with the flow.”

– The manager said what Pujols did in 2003 — playing “under control” with the zapped ligament — and with his foot trouble and chronic hamstring issues has earned him the trust to decide when he’s playable and when he’s pushing. Said La Russa earlier this spring:

“There is a category of guys that deal with feeling less than their best and just play through it. And other guys it takes something away from them, either mentally or physically. Albert is one of the guys — the word that is most usually used to describe them is toughness.”

– Team officials have said that if he can manage the injury this season and not irritate it — or, as La Russa has said, “tweak it” — he could go a career without it needing a repair. Though, each swing is a chance.

“He’s just been really careful with it,” La Russa said Thursday. “Watch everyday. Being smart with the swinging and the throwing. Don’t make crazy throws. Not trying to hit the ball 500 feet. Don’t chase a pitch. … (All he has to do is) do something funny and tweak it.”

– It’s early March. At last check, Pujols said the elbow is tweak-free. Last time he was asked about he responded sharply: “It’s fine.” Paletta said on Friday (March 7) that the elbow is “completely asymptomatic”.

– Though it won’t be articulated there has been some sentiment internally that if Pujols’ elbow squawks this season or is even an annoyance and the team slips out of contention, he could have the reconstructive surgery and prep for 2009. There will be some resistance to doing that, for many reasons, his history-making stats just the most superficial. But the elbow is already at a point of no return.

“If he said he can’t continue playing like this, my recommendation would be to probably have the whole thing reconstructed,” Paletta said. “If the elbow condition cannot be (successfully) managed and it gives him significant problems again, then I think the horse is out of the barn. He should consider having the whole thing done.”

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