When the Red Sox announced that Chris Sale's visit to Dr. James Andrews earlier this month resulted in the famed surgeon recommending a treatment of platelet-rich plasma injections for his ailing left elbow, it was seen as a significant victory for the pitcher and the franchise.
After all, whenever a pitcher is linked to the nationally-known orthopedist, the prognosis is generally not positive. Far more often than not, Andrews is in a position of confirming a known diagnosis and Tommy John surgery is frequently the suggested course of action.
When the Red Sox put out a release that made no mention of any such procedure, it came with the proverbial good news/bad news element: Sale wouldn't be available for the rest of this season, thus dimming the team's already faint playoff hopes; on the other hand, the implication was that, with the PRP regiment, rest and rehab, Sale would be good to go in the spring of 2020, just when his five-year, $145-million contract kicked in.
Twice, in a media availability in the Red Sox clubhouse the day after he returned from seeing Andrews in Pensacola, Fla., Sale was asked directly if he had been assured by the surgeon that he hadn't suffered a tear in his ulnar collateral ligament -- the condition which often leads to a Tommy John procedure.
Twice, Sale answered in the affirmative. In other words, Andrews had given him that assurance.
But weeks later, a grimmer reality has surfaced, based on a number of factors.
1. Sale is notoriously controlling when it comes to releasing information about his own health.
Last summer, when Sale was sidelined with a shoulder injury for much of the final two months, the pitcher specifically instructed the organization to offer little in the way of specifics related to the injury.
The Red Sox announced only that Sale was dealing with "shoulder inflammation.'' When reporters asked for a more detailed diagnosis -- bursitis? rotator cuff impingement? -- the Sox countered by saying that they couldn't provide any additional information because of federal HIPPA (Health Insurance Portability and Accountability Act) laws which safeguard medical information if the patient requests.
A Red Sox source later confirmed that Sale had specifically asked the team to withhold an official diagnosis, and as they must under federal law, the organization complied.
Sale's penchant for secrecy surfaced again in the postseason when he was hospitalized with an intestinal infection. When he was released, Sale, straight-faced, insisted that the condition had come about because a belly ring had become infected. It was a humorous bit of misdirection, but again, telling: rare among modern pro athletes, Sale zealously guards any details about any injury or personal setback.
(A baseball source later confirmed, as many suspected, that Sale had developed an intestinal reaction to anti-inflammatory medication, prescribed for his ailing shoulder).
This month, it's been more of the same. When I emailed president of baseball operations Dave Dombrowski to confirm what Sale twice said to be true -- namely, that Andrews had assured him that he was not suffering from a sprain or tear of the ulnar collateral ligament -- Dombrowski responded thusly:
"Due to HIPPA laws, I can only release what you've been given. You have to ask Chris if you have additional questions.''
On the face of it, that would sound ominous. If Sale indeed got a clean bill of health in terms of the structural soundness of the UCL, you would think he and the Red Sox would highlight that.
2. The very nature of PRP treatment is to sometimes treat small tendon and ligament tears.
According to the U.S Health and Human Service's web site: "Platelet-rich plasma (PRP) therapy uses injections of a concentrate on of a patient’s own platelets to accelerate the healing of injured tendons, ligaments, muscles and joints. In this way, PRP injections use each individual patient's own healing system to improve musculoskeletal problems.''
That would seem to indicate that Sale could be suffering from some sort of tear, slight or not, with the team and Sale hoping -- perhaps against hope -- that the PRP treatment could forestall a surgical procedure that could sideline him into the 2021 season.
Indeed, often, PRP treatments are viewed as something of a last resort, a last-ditch effort to avoid surgery. Sale's teammate Brandon Workman hoped that PRP therapy would do that for him in mid-April of 2015. But when the treatment didn't alleviate the issue, he underwent Tommy John surgery two months later. He didn't pitch again in the majors until 2017.
Dr. Thomas Gill, who served as the Red Sox medical director and is currently the director of Boston Sports Medicine, said recently that PRP treatment only occasionally works well enough to forego Tommy John surgery.
"Generally speaking,'' said Gill, "when you're treating an elbow with PRP, there are three scenarios: One, the ligament is intact, but it hurts. Two, there's a partial tear. Depending on the severity of the tear, you can sometimes continue to pitch effectively. Or three, there's a complete tear that has to be repaired.''
The exact scenario facing Sale likely won't be known until the end of September or early October when he's again examined by Andrews.
3. Precedent isn't encouraging.
While the evidence suggests that Sale is suffering from some form of a tear, we don't know that with certainty.
However, if indeed there is a tear -- regardless of the degree -- it would seem as though it's only a matter of time before the ligament gives way completely.
"It's like a piece of rope,'' explained Gill, "and eventually, it becomes more and more frayed.''
There are some exceptions to this case. Soon after he signed with the New York Yankees, Masahiro Tanaka was found to have a slight tear in his UCL. Somewhat miraculously, Tanaka has remained durable and effective in spite of the tear. As Joel Sherman of the New York Post noted recently, Tanaka is 22nd in the number of starts made since 2015 and 20th in innings.
But, Sherman also pointed out that while Tanaka has remained largely healthy and durable, he's never again reached the level of dominance he displayed in the first half of his first season with the Yankees (12-4, 2.51).
Or, it may well be that Sale experiences the same path followed by former Red Sox starter John Lackey. When Lackey was signed to a five-year deal, Gill cautioned then-GM Theo Epstein that Lackey's elbow was suspect and could well eventually need Tommy John.
Epstein structured a deal whereby Lackey effectively gave the Red Sox an "extra'' year, at the major league minimum, if he were to miss a season with Tommy John surgery. Indeed, after two seasons in Boston, Lackey underwent the procedure.
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