Expert explains Santana's tear

Dr. Jonathan Glashow, an orthopedic surgeon and co-chief of sports medicine at New York’s Mount Sinai Medical Center, who formerly worked as a New York Rangers team doctor, offered his insights on anterior capsule tears. That’s the injury that Johan Santana will require surgery to repair.

Glashow believes Santana may have difficulty going full throttle at the beginning of next season, even under the best-case scenario. And if doctors find rotator cuff damage when they go inside, the prognosis gets significantly worse.

What are the main points to make about anterior capsule tears?

“You can kind of think of the anterior capsule as the front ligaments of the shoulder. The ligaments are just really thickenings of the capsule. And it sounds like from what I’ve just briefly read about this, the ligaments are stretched. I don’t know if he’s got a damaged labrum. 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.’ Or, if it’s more of a cuff issue, that’s a significantly longer problem and less predictable.”

How does this happen?

“It’s not so uncommon in my experience. It’s an overload injury. It’s the repetitive throwing that causes that rip in the capsule as opposed to one dramatic episode like a fall on an outstretched arm that may cause a dislocation and a big labral tear. It’s probably a repetitive thing that happens due to the constant forces on the shoulder -- wear and tear with some accentuations by recent throwing. The distinction whether it’s just capsule, or whether it’s capsule and labrum, I don’t think that makes a big difference. The big difference comes in how much of the cuff is involved. If the cuff is not really involved, quicker rehab, more predictable. If the cuff is involved, slower and less predictable. And then there’s the degrees of that. Age is a little bit against him. He’s been throwing now for how many years at 31? That puts a lot of wear on the cuff and on the labrum. But if he gets it early enough, which it looks like they’re doing and they fix it, it’s not unheard of that he comes back in six months. I think before six months is going to be tough.”

And six months to begin throwing? Or in competitive games?

“Six months to throwing a ball. I think that’s the short side. That’s optimistic. That’s if it’s a minor capsular tear where they can sew it back, it’s a quick rehab and everything goes right -- no glitches. I think six months is very optimistic. I think the likelihood is greater than that. It could be up to two years. Certain shoulders take 18 to 24 months to mature, especially those with larger rotator cuff issues. But that does not seem like the case here. But he’s got a lot of wear and tear on his shoulder. I’m sure. All pitchers at his level have some damage to the cuff. And then when you shut down the shoulder for a little while, rehab is a big deal. For every couple of months it’s shut down, it takes a couple to three months to bring it back. So the rehab is going to be a really important part of his game -- that he’s doing the exact right rehab so he doesn’t let everything else atrophy, so when he starts to go out to throw, things that were not repaired are not shut down and come back quicker. There are a lot of question marks here. But certainly this season he’s out. I wouldn’t count on him being great for the beginning of next season. It could be theoretically nine, 10 months out, which would put him into early to the middle of the season next year. It’s not unreasonable to expect, if it’s a better scenario going inside and he does all the right rehab, that he comes back potentially at the same level. But it’s hard to predict. I’d rather have somebody who is younger and doesn’t have as many miles on his shoulder.”

BIOGRAPHY: Dr. JONATHAN GLASHOW is an orthopedic surgeon and co-chief of sports medicine at New York’s Mount Sinai Medical Center and has been in private practice for 18 years. He specializes exclusively in shoulder and knee injuries including advanced arthroscopic all-inside ACL reconstruction, double-row suture bridge rotator cuff repairs, as well as state of the art techniques to repair labral, meniscal and condral injuries. Dr. Glashow acted as a medical media consultant for ESPN Sports and was a frequent guest on their morning sport commentary “Cold Pizza.” His guest appearances on news broadcasts include CBS World News Tonight and most recently on CNN Evening News with John Roberts for his expertise on the usage of platelet-rich plasma (PRP) injections for expediting the healing process of certain injuries. After receiving his medical degree from Cornell University Medical College, Dr. Glashow completed his residency at Lenox Hill Hospital in Orthopedic Surgery. He went on to earn subspecialty fellowship training in sports medicine and arthroscopic surgery at the Southern California Orthopedic Institute/UCLA in Los Angeles, followed by a traveling Shoulder Fellowship in London, Ontario, Canada, and the University of Texas at San Antonio.