John Danks injury: Torn shoulder capsule diagnosis makes for a tough road back

John Danks is having a rough spring so far by all accounts. He came into Tuesday's start with an 11.74 ERA, reports have his velocity down, and he didn't assuage concerns about either after another ugly outing. It's bad enough that Danks is finally beginning to concede that he could be somewhere besides Chicago on Opening Day.

No one wonders where this is coming from. Danks clearly wasn't himself last year in the few starts he did make, and rehab following a diagnosis of a subscapularis tear didn't make things better. When he finally did go under the knife, we found out that Danks' subscapularis injury had healed, but that the underlying problem turned out to be a torn shoulder capsule.

I'll be honest and own up to not having paid any attention at all to these details, largely because I'm spoiled as a White Sox fan. Oh, somebody's injured? Well I'm sure they'll come back better than ever. I mean Jake Peavy tore his lat muscle off the bone, and the only thing that got in the way of his return was his bulldoggery. Yeah, it sucks that they're injured, but it's not like it's going to be a problem beyond the time missed due to surgery, right?

This time, unfortunately, might be different. The shoulder capsule problem is a relatively rare diagnosis and gathering details on those who've had the same issue has also been problematic. But the preliminary research is not promising given the names on the list: Johan Santana, Chris Young, Dallas Braden, Chien-Ming Wang, Pedro Feliciano, Tim Byrdak Mark Prior, Robb Nen, John Maine, Tomo Ohka and Rich Harden.

As far as I can tell, none of those guys have come back to be the pitchers they were. To be sure, some of the guys on the list had non-capsule shoulder problems. Prior, of course, had a bunch of things wrong with him. Nen was old, and so were Ohka and Feliciano. Maine had non-capsule problems and Young had labrum surgery back in '09.

Basically, it's very difficult to isolate a pitcher who is only dealing with a shoulder capsule tear. The rigors of playing baseball and, in particular, being a pitcher means that establishing what causes what is difficult. But we should be able to talk about what it's like to rehab from the capsule surgery specifically.

In which case, let's turn it over to Susan Slusser:

Only a handful of pitchers - Johan Santana, Braden, Chris Young, Chien-Ming Wang - have had the surgery ... Most people aren't familiar with this kind of injury, but my impression, from talking to team medical people, is that plenty of pitchers are dealing with this kind of injury and just trying to strengthen the shoulder to avoid surgery. When most orthopedists won't do it, the procedure is relatively new and the results uncertain, it's unfair to blame Harden [for trying to avoid surgery]. He was repeatedly advised not to undergo surgery. You might recall that Braden had to visit several orthopedists last summer before finding one who would do surgery.

That's interesting for a couple reasons. As Slusser notes, "most" orthopedists won't perform the procedure. New York pitchers don't seem to have a problem getting recommendations for the surgery. Braden and Harden don't have NYC connections, but all the others do. As does Tim Byrdak, who had the operation performed after Slusser wrote the post.

For instance, this quote from Dr. Jonathon Glashow suggests that the injury is what matters, not the surgery. Regarding Santana, he says:

The big distinction here, and the important distinction, is whether the rotator cuff is involved. If it’s simply the capsule, plus or minus the labrum to a small degree, his return is much more predictable and quick. If his cuff is damaged more than they think -- and you may say, 'Well, they have an MRI,' but MRIs are less than perfect -- then I think there’s a big question mark whether he comes back at the same level and how long it takes him to come back. Some MRIs are better than others. And even in the best-case scenario, it’s never until you look inside that you know exactly. The question is not going to be fully answered until somebody looks in there and says, ‘Hey, his cuff is fine. Great. It’s maybe five or six months.’

That's five to six months before throwing, for the record. The whole interview is worth a read. In terms of gleaning where the Sox fall in this debate, obviously Danks had the surgery and projected he'd be ready to get going by Spring Training. Moreover: Danks had six months from August through February to get ready to begin throwing.

Glashow is an NYC-based doctor (he was formerly the team doctor for the New York Rangers). I bring up the geographical connection because the guy who pioneered the surgery happens to be the Mets' team doctor, David Altchek, also based in New York. The Slusser list also misses Bret Saberhagen, who seems to be the first big-time MLBer to undergo the procedure.

It's also worth remembering that the Sox were fairly decisive. They gave Danks time to rehab, saw relatively little improvement and chose with Danks' consent to figure out what was wrong via arthroscopy, then fixed him up. One of the surgeons was the same guy who fixed Peavy's detached lat, Anthony Romeo.

Nonetheless, Harden's caution and the relatively few procedures performed, despite the injury being more common than we know, suggests that Slusser's summary isn't wrong. Clearly, there are just a few teams out there who think of this as routine, as Herm and the team docs would seem to. That would be far more damning, but the track record of the White Sox, not to mention Romeo's past success, makes any conclusion hard to reach.

And picking out a prognosis for Danks isn't helped by the fact that almost none of the pitchers in the sample are much like him. Wang, Braden, Harden, and Young all had other shoulder issues. Only Santana seems to have been especially healthy in the shoulder prior to the problem.

What's apparent is that all of the pitchers have struggled to return to pitching consistently, and that the condition seems to cause a substantial dip in both velocity and command. Evidently, the shoulder capsule is a tricky thing. The low profile of the injury and the lack of industry consensus on treatment suggests, even if the anatomy is understood, that the precise condition parameters that enable shoulder capsule function are known with certainty by few, if any.

Given what little we do know, it seems wise to temper our expectations. The old John Danks may not be walking through that door any time soon.