It has been an unusual string of events for the Red Sox medical team.
For years, the Sox have felt that their medical infrastructure has given them an edge over other clubs. The comprehensive operation that is overseen by medical director Dr. Thomas Gill, who supervises the training staff’s efforts to provide both care for injuries and injury-prevention programs, has typically received strong reviews for its ability to keep players on the field.
Players, particularly pitchers, have said that the team’s reputation for top-notch care helped to convince them to sign with the Sox. “I definitely did my homework,” said pitcher John Lackey of the factors that influenced his decision to sign with the Sox this winter. “[The team’s medical staff] was a positive, for sure.”
And yet there have been recent instances of controversy that have threatened to cast a different light on the team’s medical program.
At the end of the 2009 regular season, Mike Lowell suffered a sprained radial collateral ligament of his thumb. But in mid-December, at a time when the Sox and Rangers had agreed on a trade that would ship Lowell to Texas, examinations revealed that the corner infielder would require surgery to repair the ligament. The trade with the Rangers was called off due to Texas’ medical concerns about the 2007 World Series MVP, and Lowell admits to having been “very frustrated” that the need for the surgery was not discovered sooner.
Most recently and prominently, the injuries to outfielder Jacoby Ellsbury’s ribs have brought scrutiny to the team’s medical operations. He has landed on the disabled list twice, missing all but nine games of the season, due to hairline fractures of his ribs that had the outfielder suggesting that his condition was “misdiagnosed.”
Ellsbury’s health led to something with little precedent in Gill’s six-year tenure as the head of Sox medical operations. Not once but twice the respected orthopedist (the chief of Mass. General's Sports Medicine Service) conducted conference calls to explain his diagnosis of the outfielder.
He did so only reluctantly.
“Up until recently, when I was asked to comment on some of these things, I’ve never talked to the press. I’m not interested in being in the paper. I’m just interested in taking care of the guys and doing the job here,” Gill said at Fenway Park on Sunday. “Even when I’ve heard or seen things reported that are not true, the player knows they’re not true. The team knows they’re not true. It’s not about me. It’s about the players.
“No one’s a stronger critic of my results than me,” Gill, who has also served as the team physician for the Patriots, Bruins and Revolution, added. “I feel like that’s why my results are pretty good.”
Gill remains confident that he has the trust of the Sox clubhouse, something that he has worked hard to earn over his tenure as the team’s medical director. He also insists that the Sox did not make any missteps in their medical assessments of Lowell or Ellsbury.
All three claims bear further examination.
A FRACTIOUS SITUATION WITH ELLSBURY?
Ellsbury suffered a pair of injuries to his ribs. The first, in which the outfielder collided with Adrian Beltre on April 11, was called a left chest contusion after X-rays did not reveal a fracture.
Yet Ellsbury progressed slowly from the injury, and landed on the disabled list. A subsequent CT-scan revealed that there were hairline fractures of four ribs, leading Ellsbury to question his diagnosis, and to suggest that the pace of his rehab had to change to reflect his new medical situation.
“I don’t think [the recovery has] really dragged on,” Ellsbury said at the beginning of May. “I was just misdiagnosed. We didn’t know it was four broken bones.”
Then, after returning from the D.L. in late-May, Ellsbury suffered another rib injury, this one in a different part of the chest. The injury, the Sox believe, was most likely incurred when he made a diving catch in Philadelphia.
After a period of rest for a few days, Ellsbury tried to resume baseball activities. But his continued discomfort in trying to return from that injury led him and agent Scott Boras to schedule the outfielder to seek a second opinion from Dr. Lew Yocum (a colleague and mentor to Gill) in California last week.
A subsequent CT scan (one that was performed in California, but that Gill says the Sox were already going to request in Boston prior to learning of Ellsbury’s scheduled meeting with Yocum) revealed a hairline fracture of a different rib. The Sox announced that Ellsbury would be rehabbing at Athletes’ Performance in Arizona, rather than with the club in Boston.
The scenario would suggest a player who was uncomfortable with the team’s diagnosis and its treatment path. Yet Gill remains adamant that the Sox did not misdiagnose the injury, and that he would not alter anything about the club’s response.
While the hairline fractures were only diagnosed when Ellsbury received an MRI and CT-scan (in the case of his second injury, the hairline fracture was diagnosed only after multiple scans in different cities), Gill says that those scans were unnecessary to establish the right diagnosis or treatments. He points out that it is almost unheard of for a player to get an MRI or CT-scan for a chest injury if the X-ray does not reveal a potentially dangerous fracture.
“[The idea that there is a controversy] is a creation. It’s much ado about nothing is what it really is. It’s a perception,” said Gill. “In the exact same situation we’d do things exactly the same way. In 12 years of taking care of the Patriots and the Bruins, never have we ever gotten an MRI or CT if we have a negative X-ray.
“The X-ray is the safety test. You want to make 100 percent sure there’s no injury to the lungs or the abdomen,” Gill added. “If you have a displaced rib fracture on the X-ray, then I would think about getting a CT scan to make sure that rib isn’t puncturing any other soft tissue. But when you have absolutely perfect X-rays, there’s no medical indication to do that.”
While Ellsbury was clearly concerned that he had suffered hairline fractures rather than a contusion, Gill said that from an orthopedist’s perspective, there was no difference between those two terms. The diagnosis is the same, as is the prescribed cure of rest, helping to explain why NFL teams would not request imaging scans on a chest injury if the X-ray did not reveal an unstable fracture.
“When I think of a fracture, I think of a broken tibia, a bone’s kind of dangling. I think of Joe Theisman,” said Gill. “[Ellsbury’s injury was] completely stable. It’s basically a deep bone bruise. They call it something different. Not just the treatment, but diagnostically [a deep bone bruise and hairline fracture] are the same, as far as I’m concerned. It’s exactly the same thing.”
THUMB'S DOWN: MIKE LOWELL'S SURGERY
Mike Lowell does not pretend to be a doctor (even of the Holiday Inn-inspired variety). Even so, it remains unclear to him why he did not receive an MRI or surgery on the damaged ligament in his right thumb until the middle of the offseason.
“Medically, baseball-wise, I think you err on the side of caution,” said Lowell. “If this test will give you all the answers, then you get that test.”
The need for surgery was confirmed at the time he was undergoing his physical with the Rangers. Lowell did not have the ligament repaired until January, a fact that limited his activities at the start of spring training, and prevented him from playing in Grapefruit League contests until midway through the exhibition slate.
During the spring, multiple major league sources said that their clubs could not consider exploring deals for Lowell because they would not be able to get enough of an opportunity to evaluate him on the field during the early spring. Given that a trade was his only avenue to anything more than a bench role in Boston, Lowell believes that his season may have been altered by the timing of his treatment.
“They’re the experts. That’s why they went to school. We’ve got to rely on them,” said Lowell. “It can definitely be very frustrating. I think [the course of treatment for the thumb] transformed my whole preparation for spring training. … I think things might have been significantly different.”
Yet Gill disputes that characterization. An MRI would not have been helpful at the time of Lowell’s season-ending exit physical because the club had already diagnosed a sprain (or tear) of the radial collateral ligament on the outside of his right thumb.
Typically, Gill said, that ligament is one that heals through immobilization and treatment -- and without surgery -- 90 to 95 percent of the time. As such, an MRI would not have altered the initial course of offseason treatment.
Later in the offseason, however, when it appeared that the injury had been unresponsive to treatment, an MRI was requested to see if there was evidence of healing. Only then, suggested Gill, did surgery present a reasonable course.
“If I say you’ve got a sprained radial collateral ligament in your thumb, and 90-95 percent of people who have this, with immobilization and treatment for six weeks, it’s going to get better without surgery,” said Gill. “If you want, we can get an MRI now, but I can already tell you what it’s going to show. It’s going to show a tear, a sprain injury.
“We can either operate on you right now, or we can give you the six weeks to see if it heals, and if not, then we can operate. Which one would you choose? It’s a no-brainer.”
Gill suggested that there is now a “misconception” that any sports injury will and should receive an immediate MRI. The reality, he suggested, is otherwise. An MRI represents a data point, rather than a definitive blueprint for treatment.
Physical exams, Gill said, remain a key indicator of a patient’s health once an X-ray rules out the largest potential dangers from fractures. He notes that Canadian health care professionals typically wait a year to see if an injury heals on its own before conducting an MRI in explaining why the course taken with Lowell did not represent a misstep.
“People say, ‘Why do you wait to get the MRI?’ It’s because the MRI has nothing to do with the treatment,” said Gill. “With any of my patients, if a treatment doesn’t go [as hoped] -- whether surgical or non-surgical -- of course I say, ‘I wish they’d gotten better.’ That doesn’t mean I’d do anything different.”
THE TRUST FACTOR
Gill discusses with pride the trust that he and his operation have built with Sox players.
“Baseball is a sport based on trust,” said Gill. “Trust is something that has to be built. You can’t come in and demand it. It doesn’t matter what your resume says. It’s earned. I think that we’ve earned it.”
He believes that his medical operation is unique. It does not merely seek to treat athletic injuries, but also offers comprehensive medical care for athletes (whose nomadic movements from team to team often mean that they do not have a primary care physician) and their families.
“[Players] know we’re their advocate and we’re here for them,” said Gill. “The second you do something different as a team physician than you would do for your regular patient, that’s when you lose the locker room. They’ll never trust you again.
“That’s why I think we have such great relationships and great trust within the major teams we take care of. They know we’ll go the extra mile for them, whether it’s midnight phone calls for a family problem or whether it’s a problem about a physical ailment they have.”
Yet given that Ellsbury has gone elsewhere for his rehab Lowell’s sense that his season was altered by his course of treatment, it is impossible not to wonder whether some of that trust has eroded. Gill, however, harbors no such concerns.
He remains confident that any perception of his recent medical decisions has done nothing to undermine what he has spent years building. Nor will he allow scrutiny of his treatment decisions to alter his professional decision-making.
“I’m never worried about perception. I would never change what I do because of perception,” Gill said. “Whether it’s my results with my regular patients or not, across the country, if you say who are the doctors who get results and who people rely on for good second opinions, I’m one of those people. When I go home at the end of the day, I know that I’ve done everything I can do to help that patient or help that player.”
Gill points to the family care that he’s provided to players as point of pride, and he also notes the on-field successes that permit him to pass his own self-assessments. Examples include: The ability of Josh Beckett to produce 200 innings in three of his first four years with the Sox; the strength program that helped Jon Lester go from cancer survivor to a pillar of strength; the suggestions by players such as Lackey and Brad Penny that their decisions to come to Boston were influenced heavily by the team’s medical staff; and the behind-the-scenes suggestions of some players that the Sox medical staff added years to their careers.
Those measures all instill Gill with confidence in the work that he has done and is doing.
“Ultimately, over the past six years or more that we’ve been doing this, if you look at the success of this program and look at players – especially pitchers – who have had up and down health in their careers before they came here, by and large they’ve prospered and excelled here,” said Gill.
“Hopefully the medical staff gives a competitive advantage to this team, as the front office has stated. … We’re a part of this team. We feel that we have huge value-added.”
Yet ultimately, Gill says, the measure of his work must be taken not by the notion of value added to the club, but instead by the quality of care provided to his individual patients, whom he wants to treat as people rather than athletic specimens.
“Fortunately, we have a great relationship with the vast majority of the guys,” said Gill. “I want them to feel like at the end of the day, they know I’m going to help them perform their best, add time to their career and be value-added for them or their families, rather than perception.
“They know I’ll always have their back and I’ll always do what’s best for them regardless of its affect on baseball or the team. It’s always going to be about the player first and foremost.”