There is always a chance that conservative, non-surgical treatment -- the kind David Price is attempting right now -- does not work. Tuesday marks four weeks since Price threw the bullpen that sent him scrambling up to the NFL Combine to see two renowned sports surgeons.
Maybe the Red Sox knew it would easily be a month before Price could step on a mound. But the lack of public specificity about his elbow injury leaves concern about how long the Sox should let Price attempt this rehab before sending him for surgery.
Depending on what potential surgery we're talking about here -- for the elbow ligament or for forearm/elbow muscles -- time is truly of the essence.
Somewhat ominously, Price said he was told that if he were a younger man, 22 or 23 years old, the recommendation would have been surgery.
If he's referring to Tommy John surgery, a replacement of the ulnar collateral ligament in the elbow, the longer the Sox and Price wait, the more they're cutting into Price's potential 2018 season -- if he winds up needing that surgery.
At that point, you can also guarantee Price won't opt out of his contract.
Conversely, if you send him for Tommy John tomorrow if it's indeed needed, he could still have a decent but shortened 2018, and just maybe give him enough reason to test the market.
Dr. Joshua Dines, an orthopedic surgeon at Hospital for Special Surgery in New York, has not examined Price. But Price's commentary about what would happen were he younger suggests to Dines something is amiss related to the UCL.
"If the ligament looks kind of questionable, in a 22-year-old where they're just starting their career and all of a sudden they're going to miss spring training, or now their starts are getting pushed back in the regular season, and it's tenuous, that's one where you [say], let's do a Tommy John surgery," Dines said. "It's a year recovery. But the results are pretty predictable at this point, and 25 percent of major-league baseball pitchers have had it and they're back.
"The problem is, to your point, David Price is not 22 years old. He may have been pitching with a partial tear of the UCL, or whatever it is, for years and maybe it just got slightly incrementally worse. If it's something you can kind of milk him through it, and get him back to where he was, then to subject him to a surgery that takes longer to recover from as you're older, a little less predictable, then I would have said the same thing: let's try to avoid the surgery.
"I haven't examined him. I haven't seen the films. But just based on the history, who would I say that to -- [that] I would fix them as a 22-year-old but not a 30-something-year-old -- that would be maybe a partial tear of the ligament or something like that."
To Dines, age doesn't matter so much if the procedure is a repair of the forearm, the flexor-pronator mass, rather than the UCL.
A repair of the flexor is a shorter recovery time. Short enough that the Red Sox could take most of the regular season to try to get Price back, and if it failed they could send him for surgery with time to be ready for next year's spring training.
"That's less of a recovery," Dines said. "It would be actually more the timing of the surgery (rather than patient age). To recover from that it's quicker, it's probably about four to five months. So I think the timing is the issue there for me, more than the age, if that's what it is. If I saw a patient at . . . the end of February and I said, 'Okay, you need surgery,' they're missing the season.
"Because you're not going to come back in September unless you make a playoff run. But realistically, you're done for the season. [So] I might say, let's try to get this better conservatively. Even if you can get through the season, we can fix it in October and you're still ready for spring training. Or, if you break down at some point during the season, we'll fix it if we have to. That might be the way I could kind of interpret that. But it wouldn't be age as much as [at what] point in the season."
In other words: if you're Price, you hope your worst-case scenario here is surgery for the flexor.
But, if the UCL is worn, pressure on the flexor can start to mount. One can impact the other.
Price said he has a unique arm. What exactly he meant by that is unclear, leaving a lot of possibilities.
There are some pitchers for whom Tommy John isn't a slam dunk. Some don't even have UCLs. Some also don't need them.
"You get an MRI of every professional baseball pitcher 90 percent of them will have some abnormalities in the UCL, when that's a sprain or a partial tear, that's almost again a foregone conclusion from pitching for so many years," Dines said. "And the problem is there are so many things we still don't understand. But there are people with partial tears who can pitch.
"There are people with complete tears who can pitch and don't even know it. There's other variables. The more of a tear there is, the more you need everything else working perfectly to compensate for it. So if you've got a partial tear, but your shoulder motion is great, your elbow motion is great, you're strong, your forearm muscles are strong, your mechanics are flawless, you can probably get away with it. If you have a sprain, but you've got poor shoulder range of motion, poor mechanics, you're probably going to tolerate it even less.
"Unfortunately, that's where it gets a little more difficult when discussing the treatment options for these patients. Because it's not just a a matter of looking at an MRI saying, your UCL is torn X percent, based on our algorithm, you need surgery. There are just simply more variables that factor in."
The real worst-case scenario, though, is if both the UCL and the flexor need repair.
Dines and his HSS colleague Dr. David Altchek did a study looking at people who had flexor tears in addition UCL tears. Older pitchers, in particular, don't have a good outlook.
"They did not do as well as people who just had isolated UCL tears," Dines said. "We've gotten a little more sophisticated at confounding variables that may make it a little more difficult to recover. So, if you have a lot of arthritis in the elbow. If the forearm muscles, the flexor mass, which is one of the things that helps you compensate for it, if there's tearing of that as well, we know that in older patients -- we did a research study of this."
Studies are limited, however.
"Clearly, UCL tears and Tommy John surgery is common, but when I say common, it pales in comparison to everything else we do in orthopedic surgery," Dines said. "At the Hospital for Special Surgery, we'll do 15-20,000 total hip and total knee replacements. We'll do 75-100 Tommy John surgeries, and that's at one of the specialized centers in the world. Any study you're trying to do right out of the gate is basically underpowered when you start asking much more subtle questions."
With Price, the question unanswered publicly is basic: is the UCL significantly compromised, or heading that direction?
If so, a protracted rehab is a dangerous idea because of the possibility that rehab alone doesn't work. With surgery, months waited now add up to years later.