Joey Votto is Perfect

Votto’s injury, adding insult

With a quarter of the season remaining, the Cincinnati Reds face an increasingly tenuous situation. And one of the largest variables in their success or failure is the healthy, productive return of Joey Votto in September.

The Reds first baseman has been sidelined or limited most of the season by an injury to his left quadricep. To some, Votto’s condition has been shrouded in mystery amidst innuendo concerning the slugger’s commitment. For those interested in paying attention though, the situation has been relatively straight-forward.

Timeline

It’s hard, but I think important, to remember that Joey Votto hit well at the start of the season. On April 25 he was batting .309/.452/.506 with an wRC+ of 171. Compare those numbers to .324/.424/.600 and wRC+ of 172 in his 2010 MVP season.

But by mid-May, concerns had arisen about the health of Votto’s left leg. Then on May 16, Ken Rosenthal of Fox Sports, reported that Joey Votto didn’t make the Reds road trip to Philadelphia. Instead, Votto had remained in Cincinnati to undergo MRI testing on a sore, weak knee.

Suspicions justifiably ran rampant that Votto had re-injured his left knee — the same joint that needed two surgeries to fix during the 2012 season. Later on May 16, the Reds reported the good news that the MRI had revealed there was no structural damage to the knee. Instead, Votto had a left distal quadriceps strain.

Up to that point, Votto had hit .257/.410/.449 with a wRC+ of 145.

The Reds initially hoped that Votto’s injury was mild and that he might return in a few days. On May 21, they placed him on the disabled list retroactive to May 15. By May 29, Votto was fielding ground balls at first and by June 5, taking batting practice. He returned to the Reds lineup on June 10, missing 23 games.

From June 10 to July 5, Votto plainly struggled through the next 23 games. Over 99 plate appearances he hit just .250/.354/.345, with no home runs and eight doubles. His wRC+ over that time was a mere mortal’s, 97. Joey Votto returned to the DL on July 8, where he remains today.

Left Distal Quadriceps Strain

Let’s break that down. Left means left leg. Distal means near the knee. A quadriceps strain is a tear in one of the quadriceps muscles at the front of the thigh. They can be mild or severe. It’s an injury that is frequently seen in kicking and running sports like soccer.

That doesn’t mean it is rare among professional baseball players. Edwin Encarnacion has been out since July 6 with a quad strain. When he returns, possibly next week, he’s not expected to be 100 percent and will largely DH for the Blue Jays. In 2008, Troy Tulowitzki missed two months with the injury.

Votto’s quad strain being near his knee likely involves the patella (knee) tendon. Will Carroll, who writes extensively on athletic injuries, explains that “down there, the muscle kind of becomes the tendon. There’s this transition zone. … damage to both of them is going to be called a strain.” (John Fay)

Reds trainer Paul Lessard implicated Votto’s knee tendon. “In the distal quad, all the muscles verge into the tendon,” Lessard said. “The tendon is basically beat up. We did a strength test on him as well as MRI. The strength was down quite a bit compared to the other leg.” (Fay)

Patella Tendonosis

Tendons are fibers that connect muscle to the bone, in this case the quadriceps to the knee.  Tendons are the strongest soft tissues in the human body. This strength comes from the tendon’s structure, which is mostly made up of collagen fibers aligned parallel to each other.

A tendon injury like Votto’s is usually the result of many tiny tears that have happened over time. Tendonitis is inflammation of the tendon caused by tears in the tissue in and around the tendon. It mainly manifests as irritation and swelling. Elbow tendonitis is common in tennis players and pitchers. Let me say again, it manifests in irritation and swelling.

Tendonosis is a more severe injury and refers to the degeneration of the tendon’s collagen to the point where the fibers are no longer aligned and fail to link up for load-bearing. It manifests as soreness and weakness. Again, weakness. Now, recall a certain left-handed batter’s leg collapsing underneath while he was swinging. Hello, tendonosis.

Tendonosis goes beyond irritation and swelling. “There’s actually cellular change,” explained Carroll. “Basically, the cells explode.” The cellular damage is thought to be caused by micro-tears in the connective tissue. A sports medicine expert I spoke with described it as the muscle “turning to mush” and becoming extremely weak.

Both tendonitis and tendonosis are generally caused by overuse. By the time you feel the soreness from tendonosis, the injury has been gradually building for many weeks.

Unfortunately, the same quality that makes tendons capable of enormous weight bearing – low blood flow – also makes them slow and difficult to repair. It often takes months, maybe half a year for an athlete to recover fully. Experts estimate tendons require over 100 days to make new collagen. Initial recovery is usually within 2-3 months and full recovery is within 3-6 months. Exactly what we’ve seen with Votto.

80 percent of patients fully recover. Getting Votto into that 80 percent — back to normal — brings us to PRP.

Platelet Rich Plasma Injections

In his second DL stint, Votto has received two platelet rich plasma (PRP) injections. PRP injections are a low risk procedure that has been shown to restore the healing process and provide significant improvement in both pain and performance. The goal of the procedure is to replace unhealthy tissue with healthy tissue.

A recent literature review by Drs. Ricardo Colberg and Kenneth Mautner concluded: “The overwhelming majority of studies in the literature report favorable outcomes after treatment of lower extremity tendinopathies with PRP injections, whereas only a few articles have reported adverse effects or no significant added benefit of the treatment.”

That’s the good news about PRP, the odds are high that it will work. The bad news is that PRP takes time to work. That’s why players in all sports are usually hesitant to have injections during the season. The Beacon Orthopedic website notes: “This can take weeks or months, but when successful, the effect is lasting. Most patients need 2-3 treatments spaced about 4 weeks apart. Most patients will not feel relief until a few weeks after the second treatment and that relief is gradual.”

Votto did not try PRP in his first trip to the DL. But after that didn’t work, he decided to undergo the procedure the second time around in hopes of permanent improvement. Votto’s last PRP treatment was July 21.

The Reds Have Been Clear from the Start

I’ve been plenty critical of the way the Reds have managed other injuries, especially Joey Votto’s meniscus tear in 2012. But this time, there hasn’t been anything mysterious or inappropriate about the way Votto has been treated, other than the inherent uncertainties in dealing with the healing of the human body.

As early as May 25, the Reds knew and said the healing process for Votto would take months. Bryan Price has indicated repeatedly that Votto may not be at 100 percent again this year. They clearly knew and indicated early on that Votto’s injury was on the severe end of the quad strain spectrum.

Every indication from the Reds front office, manager and training staff has been that this is a muscle/tendon injury, not structural damage to the knee. The treatment regimen – PRP – also definitively indicates it’s the tendon, not the knee.

Dr. Tim Kremchek, the Reds’ Medical Director and Chief Orthopaedic Surgeon, said on July 12 the plan was to get Votto back for the “stretch run” which John Fay interpreted to mean the last “four or five weeks” of the season (the first week of September).

Bryan Price said Tuesday (August 12) that it’s “reasonable” to think that Votto would return to baseball activity in the “next week-and-a-half to two weeks.” That’s late August.

It’s reasonable to be skeptical of the estimates. But you can’t say the Reds haven’t provided information or a timeline, all along the way. And so far, it has proven reasonably accurate.

Adding Insult to Injury

It’s plain to see for anyone of good will, that plenty of information is readily available discussing quad strains, tendon injuries and PFP treatments in general, and concerning Joey Votto’s injury in particular. The beat reporters covering the Reds, John Fay, C. Trent Rosecrans and Mark Sheldon, have kept their readers informed on the topic. John Fay, in particular, has written several articles that have brought important knowledge and understanding to the topic.

But that hasn’t stopped others in the media and broadcast booths from using the legitimate and expected uncertainty about Votto’s recovery to darkly insinuate that either something mysterious is going on or that Votto isn’t eager to return.

Paul Daugherty recently (again) questioned Votto’s commitment to returning. He wrote on Wednesday: “And while Phillips is busting it to get back in time for what the naïve believe will be a September run, we are told that there is no timetable for Votto to return to what Bryan Price calls ‘baseball-related activities.’ The only thing that’s clear about Votto’s strained distal quadriceps is that Votto will return when Votto believes Votto is ready, and not an inning before.”

Comparing Phillips and Votto’s recovery is lazy and unfair. Phillips had a clear cut injury that was fixed with surgery and has a well-established recovery regimen and timetable. Votto’s injury, by it’s nature, is immersed in uncertainty and risk of backsliding. Also, is it really that surprising, given their respective personalities, that Brandon Phillips has been highly public in his rehabilitation efforts and that Joey Votto has been private?

No serious commentator could question Joey Votto’s desire to play baseball. He’s often spoken of the immense importance of playing every day. And Votto has backed up those words with deeds. He played 161 games in 2011 and all 162 games in 2013. This season, Votto played on his weak knee until the team made him stop. When he returned from the DL the first time Votto tried to compete on one leg. A source who is around the team regularly said: “You can’t question Votto’s desire to be the best player he can.”

Of course not. He’s the last person who should suffer the insult of character assassination.

But as my high school debate coach used to advise, consider the source.

When you realize that it’s exactly – and I mean precisely – the same people who criticized Joey Votto’s approach to hitting who are also questioning his injury recovery process, well that’s really all you need to know.

The Long Term

Many Reds fans are rightly concerned that this episode, combined with Joey Votto’s previous meniscus injury, means that the Reds first baseman will fight knee issues the rest of his career.

That’s possible. But certainly not inevitable. People do return to complete health from tendonosis. PFP treatment has increased the odds.

I asked Jordana Bieze Foster, the editor of Lower Extremity Review and a medical journalist specializing in sports medicine, if a player with tendonosis who received PRP and returned to healthy was at a greater risk of recurrence of tendonosis.

Her reply: “I don’t think anyone knows. There aren’t many long-term PRP studies. But increased risk seems unlikely.”

Going Forward

Let’s not pretend that Votto’s recovery time-table was devised independent of the Reds remaining schedule. In May, you give a short rest period a shot, cross your fingers and hope against odds that’s enough because the alternative is daunting. When that doesn’t work, you regroup. You take out the calendar, find September 1 and count backward. That accommodates two PRP treatments and a stretch run. If it all works.

We’ll know soon. If and when Votto returns to baseball practice in late August, his knee will either feel healthy or it won’t. It might and it might not. There’s no way to know that now and no reason to speculate.

At that point, the Reds will face a tough decision, either to bring Votto back or let him continue to rest and rehab the quad strain, maybe take another PRP treatment or two.

The pros and cons are obvious. Returning too early carries risk. We’ve already watched Votto try to come back too soon earlier this year. How did that work out? And there’s a chance of reinjury if the tendon isn’t ready.

On the other hand, the entire point of PRP and taking two months off was to change the approach. The sports medicine expert I spoke with this week said that while there is always a risk of relapse, the chance that Votto’s condition would revert all the way back to zero was remote. Remember the literature review of studies indicates that PRP works.

It would make the Reds decision easy if the team were either clearly out of the race (Votto sits) or clearly in it (Votto returns). Pulling Votto back would raise the white flag in front of his teammates and fans who are expected to continue to fill Great American Ball Park and watch on FSO.

But the Reds position won’t be clear-cut. Absent a sudden collapse or unlikely winning streak, the Reds will bang along around .500, a handful of games from the second Wild Card spot. Don’t be surprised to see Joey Votto back under that circumstance.

50 thoughts on “Votto’s injury, adding insult

  1. Bringing Votto back in 2014 is risky and short sighted. Gear up for next season with as much of the team’s health concerns behind you as possible.

    • If the doctors say he can play, he should play. I say that even if the Reds completely fall from the race. As the article says, the chances of him doing any permanent damage by playing a few weeks in September is remote. I think the Reds need to see if he is fully healthy now or whether intensive treatment will be needed throughout the off-season. There’s no way to tell that unless Joey plays.

      • “If the doctors say he can play, he should play.” Same was said just before Votto’s latest DL stint. One thing we know, he’ll be stronger next spring than he is right now. Why do anything to compromise your $200MM investment?

  2. I’m pro-Votto when I say this, but my gut tells me that he will not be playing baseball in 5-7 years. Just an opinion.

    • I’ve wondered all summer at how far or soon into the future he might pull a “Jim Brown” and just walk away (sorry if my age is showing. Google it for the details).

      There is an insane amounts of money involved and the MLB/ MLBPA CBA makes it difficult to reach partial payment settlements but one has to wonder what Votto will decide to do if he is no better come next year.

  3. From what I understand, Votto’s injury may be partly (at least) attributed to working too hard during the offseason and spring training. It is simply laughable to assert that he does not want to be on the field or is otherwise avoiding a timely return.

    • I think that’s reasonable speculation. Underline speculation. He said in interviews that his power might have been down in 2013 because of lingering effects of his injury. I think he even said the surgery in late 2012 prevented him from working out in the 2013 offseason like he usually did. Seems like he might have worked extra hard in the 2014 offseason to keep the knee strong. My sports medicine guy said he’s worked with numerous athletes who have developed tendonitis and tendonosis from working out too much.

  4. I have heard reports that he would have to do an off-season of re-strengthening his knee through tedious and slow strength building tasks.

    Yeah but throw in the towel in 2014, we know a lot better what we will get in 2015, and just put all in on next year.

  5. This is a very well written article which concisely details the situation. I haven’t followed this season as closely as I have past ones, so it makes chasing down the facts challenging. Not sure if I should feel encouraged or discouraged, but I guess that’s the nature of both the injury and our season.

    • That’s kind of how I felt as I was researching the article. Some encouragement, some discouragement. Felt it was important to try to get the facts out there (they already were, really) but didn’t feel confident enough in the situation to recommend anything more than qualified encouragement.

  6. Don’t see much merit to bringing Votto back (assuming his knee is healthy) if there are <=15 games left and Redlegs are behind the 2nd wild card by 5 or more games. It may be unrealistic to expect JV to start producing near his level immediately.

  7. Looking forward to reading this when I have time later. Daugherty didn’t stop at the above statement, when a reader questioned his statement, another reader ridiculed that one, saying that “Paul has sources he can’t reveal.” To which Daugherty himself replied: “A number of them.” I challenged him on that, with sarcasm, as to why do they have such different “information” from John Fay’s sources.

    I know, I know, as CP replied to me yesterday, don’t click on his articles. But his weird agenda against Votto is sick, reminds me of the alcoholic Red Sox writer who came up with false and negative stories about Ted Williams for many years.

    • Daugherty is definitely a jerk but I don’t think he’s sick. It’s possible that he doesn’t really even believe the junk he’s writing and he just recognized that there is a fairly large, vocal contingent in reds fandom that wants to hear this crap about votto and he is providing it. I don’t think he’s actually changing any minds about votto. He’s just pandering to the morons in the fan base. It’s embarrassing that there is that much demand for ridiculous criticism of the best player the franchise has had since Barry Larkin, but hate sells and business is good. Ignore him by all means if you want to but the sad truth is that he wouldn’t be writing this if nobody wanted to hear it.

      • Last week, I had a conversation with a fan at the game and he was talking about Votto and all the walks and not swinging at pitches that look good because he’s looking for the walk. The talk then went to how Bruce is struggling and he’s Adam Dunn Jr. Then there was some talk about BP and how he’s too flashy and how the fan really didn’t like him but at least he was a clutch RBI guy… So I asked was there anyone on the roster that he really, really liked. He said “Skip Schumaker” and then discussed why Schumaker should be starting every day in RF over Bruce.

  8. If the Reds knew this could sideline Votto most of the season, WHY didn’t they go find legit help instead of letting the weak offense get worse and worse??? Alot of wasted good starting pitching. If this team got lucky to get a wild card game on the road. -they would loose 1-0 with cueto pitching. Thanks Walt for telling me a reds fan you had no desire go help this team. And saving me from wasting my time and money this Aug and Sept.

    • The legit help you ( and I) want would have cost some of the starting pitching, in all likelihood. It would take more than one good bat to give the Reds a serious shot at winning the WS with the pitching they have, and subtracting some of the pitching to get the bats would leave them where they are now, or worse, and looking bad for next year.

      • At the trading deadline, the Reds had a hole at 1B, 2B, RF, and LF. Seems like a great opportunity to go all in and trade away some of the pitching that the club has taken a decade to acquire.

  9. “But this time, there really hasn’t been anything mysterious or inappropriate about the way Votto has been treated….”

    I’d say that them letting Votto go out there and basically fall every time he swung the bat was inappropriate. They should have shelved him long before they did. The guy couldn’t run, couldn’t swing, heck, couldn’t even keep his balance… yet they kept sending him out there and made us keep watching that sad sad display. Until they finally did the right thing. Kind of like how everyone on the planet other than the Reds knew Marshall was not okay to keep sending out there.

    • That’s fair. I think you can make an argument they shouldn’t have tried the June experiment at all. But I can understand them wanting to try. I didn’t have the heart to do this, but I was tempted to compare Votto’s wRC+ of 97 during that period to how the replacements for him in the lineup have hit. Is it really possible the offense would have been better with Votto almost literally on one leg? (Of course, Votto wouldn’t have been better off … )

    • Todd aren’t we watching the same thing with Bruce but not as dramatic as it was with Joey? Jay is a young ball player yet this season has been a disaster at the plate along with some unusual fielding while going to his right. All things being equal have the Reds had Jay go through a complete physical including his eyesight. While he is the “slugger” type his performance has been abysmal. IMHO there is something wrong and the Reds are reluctant to pursue that avenue.

  10. Excellent, well researched article. I think the Reds should only play Votto this season if it is in his best interest either as a form of rehab or as an evaluation to see if further treatment is needed. Bottom line is that what is best for Votto’s recovery is also best for the Reds, long term. I have always felt that Griffey’s injury was mishandled by the Reds because they wanted to see an immediate return on their investment and to a lesser extent by Griffey himself because he just wanted to play ball. Had he went through a longer and better treatment regimen initially when he was first injured, even if he had to miss almost a whole season that year, he would have had a more productive career with the Reds. Griffey also received a lot of unwarranted criticism, much like Votto is, now.

  11. Excellent story. I fall into the category of those who are concerned about Votto’s production long term. Hope he’s able to return to form because this team needs him to be the driving force in the lineup. I’ve met Joey & would never question his heart or desire. Not the first time Doc misrepresented the truth just to incite readers. Beware of columnists who don’t follow the team every day kids.

  12. Wish Votto a quick recovery. Reds need to use some long term wisdom and start developing a legit first basemen to provide backup to Joey. Cut down his games played from the 160’s down to the 130’s and have someone else play first whenever we play scrub teams. We have to much invested in a player at first base. The least we can do is get him a backup to protect his health more so than we did this year. Maybe if we had a legit backup he would not have been so compelled to play through an injury?

  13. Demeanor, personality, emotions and work ethnic say that Joey Votto’s dour persona is one of depression brought on by his inability to be on the field. If he never plays another game he is one of the greats to wear a Red uniform.

  14. I have always been a skeptic of management that operates in a very small circle, only those we know and have dealt with, when it comes to money (contracts) or information. I really feel that the Reds need to open the medical circle to gather more diverse information. I know most feel that Kremchek is a God in sports medicine and that the trainer is considered a league great. No one person is that good or without pimples. If it is my money, my clients, or the companies, I gather as much information as possible, it is called due diligence.. At this point I have no reason to doubt any information that Steve presents or has presented as he doesn’t have a dog in the fight, but in reviewing it in total and I am Bob C., I would be calling Joey and pay him a visit and have a long discussion with him about the future and move him to the 60 DL and tell Walt that until Joey can be evaluated on the field (live action) get us a temporary/relief 1b player and move on to 2015. I have previously posted that to trust the team paid medical staff and the player about medical decisions while dealing with a players agent when it comes to contracts (money) are the owners saying that the player is to uninformed to make money choices but is adequately intelligent to make medical choices. Really.
    May Joey be Joey, independent and resolute, this is his future not ours.

  15. All in all this is a very strong and well written article with which I pretty much agree, particularly that the team has been up front about the situation this year; and that the player should not be held responsible for the injury and amount of time required for treatment and recovery.

    What I would add is that this injury has already been career altering; and, unfortunately it could well turn out to be career ending in the long run. There is no guarantee that Votto will be in the 80% who recover or to what degree of his previous abilities he will recover if he is in the 80%.

    While there is general agreement the PRP injections will do no further harm, there is no clinically established level of efficacy for these PRP injections. To my mind this makes these treatments a course of last resort which simply underscores the seriousness of this injury and the uncertain prognosis of recovery from this injury.
    Here is a link from the America Association of Orthopedic Sugereons which discusses the treatments: http://orthoinfo.aaos.org/topic.cfm?topic=A00648

    Hopefully the Reds are not going to sit on their hands this off season in blind faith that all will be well with Votto come late February/ early March of 2015.

  16. I would think it would be difficult for a thoughtful professional athlete playing on a team with millions and millions of dollars at stake to overwork his muscles to that point. You’d think it would be a recognized risk–an ultra competitive guy trying desperately to overcome the lack of workouts that came with his previous injury–and the player and the medical team/training staff would discuss the risk and the warning signs, develop a workout plan, monitor the muscle, etc. I don’t blame Votto, but I’m not sure we should let the team off the hook; it’s not like this is a freak or sudden injury.

    Depressing. But thanks for writing this, and for taking pundits to task who question Votto’s commitment and competitive fire.

  17. After fumbling coming out of the break, the odds for getting in the playoff really dropped and at this point, Reds really just need to concentrate on getting better for 2015 and being a pain to the rest of the division down the stretch. Even ‘if’ Votto could get back, how much production are you going to get at less than perfect health and laying off for two months. Joey Votto is signed for nine more seasons, this one is done for him.

  18. Saying “Votto has no desire to come back” vs “Votto is, rightfully, being overly cautious about coming back” may be completely different things in both meaning and context, but the end result is the same. And that end result is all most people see and/or focus on.

  19. Thanks for the in-depth medical info, Steve. Sounds like there’s more of a chance of Votto fully recovering than I originally thought.

    That said, it’s his left leg – his back leg – and weak tendons tend to continue to get weaker with wear and tear and various tweaks and pulls over time. And he’s a back leg hitter, so either he needs to be 100% to continue to hit this way, or he’ll need to make some major adjustments to how he generates his power.

    Wonder if they could try Tommy John Surgery on his leg, replace the tendon, and call it Joey Votto Surgery…

  20. Well, Marty, what did Votto do three or four years ago (2010-2011)? He averaged 100 walks, and had an OBP of .424 and .416 for those two years. Looks like he was “concerned” about walks and on-base percentage then, too. The difference? Power. And the loss in power happened after his knee injury in 2012. Marty might remember, since he mentioned it more than once that season, that Votto was on pace to shatter the Major League record in doubles prior to his knee injury. Barring another setback and with a full recovery, the only piece missing to the “old Votto” will be his confidence. His confidence was noticably absent in 2014, and when you’re hampered by an injury, your confidence suffers. If Votto returns healthy in 2015, and with each at-bat, slowly lowers his bat to touch the plate and then points it toward the pitcher, he and his confidence will be back, along with the line drive power that earned him the respect of National League pitchers.

    • Very well written article and majority of comments right on the button. After seeing Joey struggling at plate and his balance after swinging, my hear broke. That was humiliating for him. Shame on REDS management. Would you put your son out there in that physical condition? Paul Daugherty has it in for Votto. Is he jealous of Joey’s obviously freakin good looks and talent? That’s my conclusion. I wish someone would stick his head in a bucket of water.

  21. May I add that Marty is as annoying as his son. I turn the volume down when Tom’s commentating the game. Talk about a voice like nails on chalkboard. Wow I have wanted to say that for so many years. GO REDS!!! Votto will be back and the game is not the same without him.

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