Season of controversy for Red Sox docs

In light of the controversy raised by medical issues swirling around the Boston Red Sox, perhaps the most notable aspect of Mike Cameron's season-ending surgery Friday was the doctor who performed it.

Cameron elected to have Red Sox team medical director Thomas Gill repair his abdominal tear as well as perform a procedure to alleviate pain in his groin, even though Cameron's agent, Mike Nicotera, had suggested to him that he might want to solicit a second opinion.

Cameron's confidence in Gill stands in marked contrast to some of the criticism received by the Red Sox front office from players and their agents directed toward the team's medical staff, most notably in the case of Red Sox outfielder Jacoby Ellsbury, who has missed most of the season with fractured ribs predicted to need just a matter of weeks to heal.

The Red Sox medical staff received further affirmation last weekend when the foot specialist who reviewed Dustin Pedroia's medical records was cited by manager Terry Francona as saying he would have cleared Pedroia to play just as the Sox medical staff had done. Pedroia went on the disabled list two days after returning to the lineup after an absence of seven weeks, leading to questions whether he had been rushed back.

Multiple sources told ESPNBoston.com that Pedroia and his representatives had voiced their concerns to club officials.

"I hope they cleared me [to play] and I should have been cleared,'' Pedroia said Friday, even as he insisted he wouldn't second-guess his treatment. "If they [let me play before I was to cleared], then we're going to have problems.''

But Robert Anderson, the Carolina Panthers' team doctor and foot specialist who reviewed Pedroia's case at Gill's request, said Pedroia's return was in keeping with established medical protocol, according to Francona. The expectation now is for surgery to insert a pin into the foot to ensure proper healing.

"That was one of the questions we all had, because we don't want to make a mistake," Francona said. "[Anderson] said, 'If I was the attending [doctor] I would have done it the exact same way. With the amount of healing that took place, I would have cleared him to play, also.'"

Sox confident in medical staff despite 'plague of injuries'

The Red Sox have placed 19 players on the disabled list, which they have used 24 times. By the end of the season, they will have lost close to 1,000 games -- or more -- to the DL, the equivalent of over six seasons. Six Opening Day starters have wound up on the DL, as well as nine former or current All-Stars.

The last time Francona used the same starting lineup, including DH, in back-to-back games was April 12 and 14. His lineup Tuesday night against the Baltimore Orioles was the 95th he has used this season.

Red Sox CEO Larry Lucchino on Friday acknowledged "the plague of injuries" endured by the Sox this season.

"It's obviously an area we have to examine,'' he said.

Lucchino said the team intends to review its medical staff after the season but insisted such a review comes under the heading of "due diligence.'' He also expressed confidence in the team's partnership with Massachusetts General Hospital.

He refused to be drawn into a discussion of specifics, however, saying, "I'm not going to address it. It's a distraction at a critical time of the season. I don't have anything further to say other than the fact we feel fortunate to have an institution such as Massachusetts General Hospital as our medical partner.''

Red Sox general manager Theo Epstein also said he intended to keep any discussion of the medical staff in-house, because to do otherwise would hurt the organization. And while one club source said some changes might result after a review that will also include trainer Mike Reinold -- who is in his first year as head trainer after Paul Lessard's contract was not renewed -- another said Gill has received assurances from ownership and Epstein that the club is satisfied with the quality of care.

Gill would not comment for this story.

Errors in diagnosis, or a problem of perception?

Club sources acknowledged communication issues have contributed to the perception of problems with the team's medical care.

Cameron's case is illustrative. The Sox had maintained that Cameron would be able to play with his injury this season and that surgery could be postponed until after the season. Instead, Cameron was limited to 48 games, was never healthy and finally had the operation Friday.

The team believed Cameron would be able to contribute more than he did and conveyed as much publicly. But according to a club source, the Red Sox were fully informed that Cameron would not be able to play on a daily basis, that his availability would be symptom-based, and that essentially, as with other athletes who have had a similar injury, like NFL quarterback Donovan McNabb, you play until you can't.

The source said the team planned to shut down Cameron much earlier than it did and elected to have him keep playing in part because Ellsbury was sidelined longer than anyone expected. Cameron was willing to endure the pain for weeks in an attempt to help the team before finally shutting it down on Gill's recommendation.

Cameron had been signed as a free agent last December to upgrade the outfield defensively, with Ellsbury shifting from center to left. Instead, Ellsbury wound up playing just 18 games after fracturing ribs in an April 11 collision with third baseman Adrian Beltre.

Ellsbury's diagnosis and treatment have created the most controversy, with the player insisting the team medical staff did not take scans of his back and thus did not detect the presence of a fifth fractured rib.

That was not discovered, the player said, until he attempted to come back in late May, complained of pain, and at his agent's insistence went to see Dr. Lewis Yocum for a second opinion. That's when an MRI revealed the additional fracture, as well as nerve damage and a strained back muscle, according to the player.

Ellsbury's version of events, supported by agent Scott Boras, is vigorously disputed by the club, which arranged for Gill to conduct a conference call to offer a detailed explanation of Ellsbury's diagnosis and treatment. A club source said that initially Ellsbury was sent to a thoracic surgeon and a radiologist, and the original scans did not detect the fractures.

What was not fully understood, a club source said, is that before Ellsbury went to see Yocum, Gill called Yocum and asked him to do both a CT scan and MRI. Gill continues to insist the medical evidence does not support Ellsbury's contention that a fifth rib fracture went undetected. The club's position remains that Ellsbury most likely fractured the rib in the back while diving for a ball in Philadelphia on May 22, just as he sustained an additional fracture in a collision with Texas pitcher Tommy Hunter on Aug. 13.

When Gill discussed Ellsbury's treatment with Epstein, the source said, Gill told the general manager he would do "zero" differently in hindsight.

One prominent Red Sox player who did not have a problem with his care was Kevin Youkilis, according to his agent, Joe Bick. Youkilis had surgery three weeks ago to repair a torn adductor muscle in his right thumb, a season-ending procedure. That operation was performed not by a Red Sox doctor but by Thomas Graham at the Cleveland Clinic, who had been recommended to Youkilis by Gill.

Graham was also the doctor the Boston Bruins called upon to perform surgery on center David Krejci's dislocated right wrist in early May.

"The bottom line is Kevin decided to have Dr. Graham do his surgery just because we felt he was one of the best hand guys in the country, and it was a very unusual injury,'' Bick said. "That combination was the only reason for his decision."

Youkilis had felt pain in the area for several days before he experienced so much discomfort during an at-bat Aug. 2 that he came out of the lineup and went on the DL the next day.

Youkilis tried to play, Bick said, because of the type of player he is. "It had nothing to do with anybody discounting the severity of the injury at all,'' he said. "No. 1, you can't tell exactly when it happened. It was a very strange series of circumstances.''

Graham predicted a full recovery for Youkilis, who has held out hope for a possible return if the Sox make it to the playoffs.

"I think they're going to be cautious,'' Bick said. "If it's Oct. 10 and Kevin says he can play and the Red Sox are playing that day, I don't know that that will happen. I think they'll err on the side of caution.''

Curious cases date to last year

There are other medical issues that predate this season.

Infielder Jed Lowrie injured his left wrist just before his callup to the big leagues in 2008. He played 81 games that season for the Red Sox, despite experiencing intense pain. It wasn't until after the season doctors discovered the wrist was fractured, but he did not have surgery until the following April 21, which essentially made his 2009 season a washout.

The club's position is that it knew of the fracture from the outset and Lowrie was sent to five hand specialists around the country, all of whom recommended against surgery. Lowrie consulted a sixth specialist, who recommended surgery, but even after having surgery, there are indications the wrist is not fully healed, the source said.

This season, Lowrie was sidelined nearly five months with mononucleosis, with one source contending the team was slow in making a diagnosis. The club disputes that, and according to another source is still uncertain why it took Lowrie months to recover.

In Mike Lowell's case, his hip condition, not the torn ligament in his thumb, led to Texas calling off the trade that would have made the infielder a Ranger last December. But because he did not have surgery on the thumb until Dec. 30, Lowell was not able to play enough in spring training to persuade another team to look at him.

The Yankees did have interest at the July trading deadline, but they, too, backed off because of Lowell's hip, according to a source. Lowell has acknowledged the probability that he will need hip replacement surgery, but with Youkilis sidelined, he is playing regularly after seeing little action for most of the season. His mobility is clearly impaired, however, which supports the Red Sox correctly assessed his availability when they elected to sign Beltre to play third.

Risky business

Part of the role of the team's medical director is to act as risk assessor when the team is considering signing a free agent or trading for a player. That placed Gill in the center of another controversy last year, when concerns he raised about the condition of outfielder Jason Bay's shoulder and knee led the Red Sox to pull back on the verge of giving Bay a four-year, $60 million deal.

Bay insists his shoulder and knee were healthy. What Gill told Epstein, according to a source, is that while neither the shoulder nor knee had been an issue in the year-plus that Bay played with the Red Sox, they could surface as a problem in the future. "It was like, 'There may be no problem for X number of years, a medium risk in Y number of years, and a serious problem in Z number of years,''' the source said, citing Bay's age (31).

Bay and his agents were furious, claiming the injury issue was spurious. He ultimately signed a four-year, $66 million deal with the Mets, where he performed far under expectations and now is sidelined with postconcussive syndrome.

The Red Sox inserted an unusual clause in the contract of free-agent signee John Lackey, who in each of the previous two seasons had elbow problems that had sidelined him. The contract calls for Lackey to be paid $82.5 million over the next five seasons, but if Lackey required surgery that would cause him to miss significant time over the life of the contract, the club would have the option of bringing him back for a sixth season at the major league minimum. The clause was Gill's idea, according to a club source.

It comes as no surprise to Sox officials, nor to the medical staff, that in a season in which players have been injured at such a remarkable rate, fingers would be pointed and there would be a public perception of turmoil. The medical staff, the club source contended, remains confident that it has not lost the confidence of management or the players. But there is little doubt the scrutiny will continue.

Gordon Edes covers the Red Sox for ESPNBoston.com. Follow him on Twitter.