Pitching in Stitches

How did Curt Schilling help the Red Sox win the 2004 World Series with a ruptured tendon in his ankle? And what did his postseason surgery and rehab entail? Itís all here.

By R.J. Anderson

R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at rja@MomentumMedia.com.

Training & Conditioning, 15.3, April 2005, http://www.momentummedia.com/articles/tc/tc1503/pitching.htm

For many baseball fans, the lasting image of the 2004 season is of Curt Schilling, grimacing and grinding as he and the Boston Red Sox defeated the New York Yankees in Game 6 of the American League Championship Series. And the focal point of that image is Schillingís bloody sock, which covered a ruptured tendon sheath and six sutures, and is now on display in the Baseball Hall of Fame.

After Schillingís performance helped even the series, Boston won Game 7 and made baseball history as the first team to dig out of a 3-0 hole in the playoffs. The Red Sox would go on to dispatch the St. Louis Cardinals in four straight games, winning their first World Series title in 86 years, boosted by Schillingís six stellar innings in Game 2.

But for the sports-medicine community, the story that rose above all others was the medical ingenuity that allowed Schilling to take the mound for his final two starts. With that in mind, T&C takes a look at the ground-breaking procedure that extended Schillingís season, his postseason surgery, and the rehab plan responsible for getting Bostonís ace ready for the 2005 season.

MAKING HISTORY
Down three games to two against their rivals from New York, and facing elimination from the ALCS, the fate of the Boston Red Sox was about to be decided by a surgeon in a back room at Bostonís Fenway Park. Sitting on an athletic training table, Schilling, Bostonís only rested starting pitcher, looked on as 2004 Red Sox Team Physician Bill Morgan, MD, performed a medical first.

Earlier MRIs revealed that Schilling had ruptured the retinaculum in his right ankle. Without that sheath of tissue functioning properly, whenever he pushed off the mound during his pitching delivery or fielded his position, the untethered peroneal tendons running along the distal portion of the fibula were snapping over his lateral malleolus.

"His ankle was under so much tension because of his size and pitching motion that his peroneal tendons would spring back behind the groove in his fibula like guitar strings," says Morgan, an Orthopedic Surgeon at St. Elizabethís Medical Center in Boston. "After examining him and talking to him extensively, it became apparent that the real problem wasnít even the tendons being out of the sheath, it was when they self-reducedówhen they popped back into that groove. It was painful, but more than anything, it was very distracting when they popped back in."

Schilling had endured season-long pain in his right ankle caused by an osteochondral deficit in his talus, basically a deep bone bruise, but Morgan believes the retinaculum rupture was an acute injury. He says it probably happened during Game 5 of the American League Divisional Series against the Anaheim Angels, when Schilling pivoted off the mound to field a slow rolling hit and pulled up lame after throwing the ball errantly toward first base.

Schillingís next start was to be Game 1 of the ALCS versus the Yankees, and in the days leading up to it, Morgan racked his brain trying to come up with a bracing solution to allow Schilling to take the moundóas did others. "One day it was like a dog and pony show. Every brace manufacturer in the world was there," says Morgan. "I also probably got 3,000 e-mails from people telling me how to deal with the injuryóeverything from soaking it in ice for four hours at a time to one guy mailing me his Army boots.

"We finally fabricated a brace on our own and attempted to stabilize his fibula in hopes of keeping those tendons reduced," Morgan continues. "As you could see from the results of his first outing in New York, it failed significantly."

Schilling left that game after three ineffective innings in which the Yankees roughed him up for six runs off of six hits. "He was failing in his location, everything was way off," says Morgan, "and he couldnít push off his right leg at all."

It was clear that a brace was not the answer, so Schilling, Morgan, and Red Sox General Manager Theo Epstein sat down and brainstormed about their options. "We asked ourselves, ĎDo we perform the surgery to repair it, which would end the season for him? Or is there something else we can do?í" says Morgan.
They decided they werenít ready to call it a season, and Morgan began kicking around an idea. "After looking at a couple of MRIs, I felt that maybe we could build a dermal wall by suturing his skin to the periosteal layer of his fibula," he explains. "The hope was that a wall between the tendon and the groove wouldnít allow the tendon to slip."

It didnít take much to get Schilling on board with the idea. "I pulled Schill aside and spoke to him privately," says Morgan. "Iíd never say anything in front of management that may sound like a solution if the patient doesnít first agree to the idea of an invasive procedure. Curt is a very thoughtful individualóhe did a lot of research and understood the anatomy and the options, and for him it was a no-brainer. He said, ĎLetís go!í"

"When [Dr. Morgan] came to me, I mean we were out of options," Schilling said in an interview with the Associated Press after Game 6. "I was not going to be able to pitch in Game 6. That was clear. I was also not going to go out there feeling like I did in Game 1. When he explained [the procedure] to me, it made total sense. Whether it had ever been done or not was not really relevant to me at that point."

Before attempting the procedure on Schilling, Morgan practiced a couple of times on a cadaver. "I wanted to look at the anatomy, mostly to see where the cutaneous nerves are located," says Morgan. "I also wanted to get an idea as to the thickness of the periosteum and a general idea of where all the sutures would go."

The night before his ALCS Game 6 start, Schilling was given a local anesthetic, and Morgan went to work. Assisted by two of the teamís athletic trainers, he inserted six sutures that ran from the tip of Schillingís fibula to the area where the tendon began to subluxate out of its groove. Before inserting the sutures, Morgan reduced the tension in the tendon by holding it anterior to the fibula. The procedure took around 15 minutes.

"Essentially we numbed it up, took some pretty strong sutures and percutaneously sewed the skin to the periosteal layer covering the bone, which, luckily for him, was a pretty good anchor," says Morgan describing the breakthrough procedure. "For some people, the periosteal layer is very thin and you canít get a good bite, so you would just end up on bone. But because he had some inflammation and scarring, we were able to latch onto some tissue.

"We did it the night before the game because I wanted to make sure he could at least walk with the sutures in," continues Morgan. "He was a little sore the next day, but he was getting around, and the tendon wasnít subluxating back. We augmented the repair with Marcaine to numb it and let him take the mound."

As Schilling took his warm-up pitches Morgan held his breathósomething he did for the entire game. "I wasnít sure if it would work. No one can measure the magnitude of the force of that tendon trying to get back into that groove," he says. "So I wasnít sure whether or not he would rip all of the sutures out of the skin on his first pitch. Thankfully, they stayed in place."

With the sutures secure, Schilling was back to his old self, throwing 99 pitches in seven strong innings, defeating the Yankees, and setting the stage for the historic Game 7. And his efforts were not lost on teammates or the national viewing audience as Fox network cameras continually focused on Schillingís right sock, which was stained with blood. "He had a little seepage of blood from the sutures," says Morgan, "but it really wasnít as dramatic as the cameras made it look. The sock absorbed most of the blood."

Still, it inspired his teammates. "When I saw blood dripping through the sock and heís giving us seven innings in Yankee Stadium, that was storybook," said Red Sox first baseman Kevin Millar in postgame interviews.

After the game, Morgan removed the sutures to avoid infection. He says that almost immediately, the tendon started snapping around again when Schilling moved or walked on the ankle.

GAME TWO
Having eliminated the Yankees in Game 7, the Red Sox began preparing to face the St. Louis Cardinals in the World Series. Schilling would start Game 2. Plans were already in place to repeat the technique, but meanwhile the medical staff did all they could to get him ready. Schilling wore a cam walker to limit range of motion and was under orders to stay off his feet as much as possible. The athletic trainers performed a lot of deep tissue massage on his ankle, attempting to milk the edema out of the injured area.

With the Red Sox winning the first game of the series, Schilling readied for his start in Game 2 much the way he did for Game 6 of the ALCS. Only this time the shadows of doubt had shrunk considerably. Until the next morning.

The night before Game 2, Morgan, again in a back room in the Fenway clubhouse, inserted the sutures. This time he was assisted by George Theodore, MD, an Orthopedic Surgeon at Massachusetts General Hospital who specializes in foot and ankle injuries. "I tried to skew the sutures a little so that we werenít going through the same holes because they were still a little inflamed from his first time out," says Morgan. "And we put one more suture in than before. It was a little more proximal because I really wanted to make sure that the top of the tendon didnít subluxate back. I put the sutures in, and Dr. Theodore held the tendon in place.

"That night he was feeling pretty good, but he was still numbed up from the Marcaine," Morgan adds. The next morning, though, Schilling woke up in a lot of pain.

"I woke up at seven that morning," said Schilling at a postgame press conference. "Thatís a tip-off right there because I never wake up at seven in the morning. I couldnít walk."

Morgan remembers a limping Schilling seeking him out in the clubhouse. "I looked at him, and saw that the pain was clearly at the most proximal suture," says Morgan. "Thereís a lot of little sub-cutaneous branches of nerves in that area, so I figured that we might have caught one. I removed that top suture and a good 60 to 70 percent of his pain disappeared immediately.

"Since the other sutures were fine, we again augmented the whole thing with Marcaine. Once that kicked in, he felt pretty good and was ready to go," Morgan adds. "To be honest, when he first limped into the clubhouse, it didnít look like he was going to pitch. Derek Lowe was out there getting warmed up in case Curt couldnít go."

Once again Schilling pitched, and pitched well, going six innings, allowing no runs and only four hits. And again, the Red Sox were victorious. But the suturing was taking a toll.

"When Curt came out of Game 2, he was in a lot of pain and told me, ĎDoc, I donít think I can do this again,í" says Morgan. "The tissue was getting pretty beat up from the sutures and there was a lot of edema around that area. I was also worried about infection, and even possibly rupturing the tendon.

"Would he have been able to go a third time if the series was on the line? I donít know for sure, but I think he would have probably given it a shot," Morgan adds. "Luckily we won the next two games and he didnít have to make that decision."

TIME FOR SURGERY
Despite pitching successfully with the sutures in place, they caused some minor infection and irritation. As a result, the surgery to repair his retinaculum had to be delayed until 16 days after his final game.

The three-hour procedure, which is rarely performed on baseball players because of the uncommon nature of the injury, was led by Theodore with Morgan assisting. The major work involved pushing the peroneal tendons into their proper position and reconstructing the retinaculum.

"After we opened up his skin, we saw that the tendons were clearly dislocated anteriorly," says Morgan. "Also, the peroneus brevis tendon had a little longitudinal split, so we had to fix that as well, but thatís not too unusual considering the chronic trauma it had been through. The retinaculum was in pretty good shape, it was just torn, so we were able to do a primary repair. Once we repaired that retinaculum, and saw that it was pretty strong, we took a little window of periosteum from his fibula and used it to reinforce the repair."

The surgery was considered a success and Schilling was fitted for a cast, which he wore for the next five weeks. Then it was on to an intensive rehab protocol, designed to allow Schilling to return pain-free for the teamís 2005 World Series title defense.

BACK ON TRACK
The rehab stage of Schillingís return actually began while he was under the surgeonís scalpel. An Arizona native who maintains a home outside of Phoenix, Schilling planned to do his ankle rehab and his offseason conditioning work at Athletesí Performance in Tempe, Ariz., a facility where he trained the previous winter. In anticipation of this, Schilling asked Sue Falsone, PT, MS, SCS, ATC, CSCS, Director of Performance Physical Therapy at Athletesí Performance, to attend the surgery.

"It really helped set up communication between me and the Red Sox, and made sure I had a good understanding of exactly how the procedure was done," says Falsone. "It always helps to see the surgery so that if your athlete or patient has any questions, itís easier to answer them."

The communication between Falsone and the Red Sox continued for the rest of the offseason. "Even though we were across the country, I talked to Chris Corenti, the Red Sox Rehabilitation Coordinator and Assistant Athletic Trainer, almost daily. It was the same way with Dr. Morgan and Dr. Theodore," says Falsone. "They knew exactly where he was throughout the entire process. Chris and Dr. Theodore also came to Arizona just before spring training to see how he was doing."

Schilling began working out at Athletesí Performance in mid-December after his cast was removed and he was in a walking boot. He worked with Falsone and the staff at Athletesí Performance five days a week. "He was probably here for half the day," she says. "And once he started to throw he was here even longer."

Falsone says Schillingís rehab program involved a total-body approach that focused on both rehab and performance enhancement. "Itís hard to say what I did specifically for his ankle rehab versus making sure that he got back out on the field in great shape," she says. "Itís a very blurry line. Itís not like, Ďthis was rehab and this was performance.í The entire process was centered on getting him back to playing."

To facilitate the approach, Falsone and her staff used massage, strength and stability exercises, hydrotherapy, and video evaluation. "He would start by meeting with our massage therapist for 30 minutes to an hour just to help with the scar control," says Falsone. "We did a lot of soft tissue work throughout his right leg and in his hips and used augmented soft tissue mobilization tools from Performance Dynamics called the ASTYM System about three days a week. By introducing microtrauma into the tissue, the ASTYM System helped break down collagen and scar formation. Those tools helped Curt to not feel stiff and decreased some of the fibrosis that developed when he was immobilized.

Next, he would train with a strength coach doing upper-body strengthening and core-stability exercises for about an hour. "After that, he would meet with me for more specific ankle therapy for another hour," says Falsone, "then with our metabolic specialist for anywhere from 30 minutes to an hour.

"When I started working with Curt, we werenít allowed to do any active eversion or inversion movements because the doctor didnít want to put too much stress on the repaired tendon or his retinaculum, so we only did dorsi flexion and plantar flexion movements," she continues. "During that time we also initiated strength training for his gastroc-soleus muscle, activated foot intrinsics, and progressed with some minor weight-bearing exercises."

Falsone says one tool that made a big difference in Schillingís rehab is the Power Plate. "Itís basically a total body vibration unit that you can do different things on, like stand and balance," she says. "He did some specific ankle joint mobilization and stretching on it every day. That really helped to loosen him up and get him going."

When Schillingís scar had fully healed, Falsone threw hydrotherapy into the mix. While in the pool she initiated gait training and some low-level ankle strengthening and slowly increased Schillingís weight bearing ability. Once his mobility began to improve, he started working on his throwing motion in the pool, eventually moving out of the water, graduating to soft- and long-toss programs while standing on level ground. Schilling wouldnít throw from a mound until the second week of spring training.

Once Schilling was able to perform his throwing routine outside, Falsone began videotaping him. Using Dartfish software that allows multiple videos to appear side-by-side on one screen, Schilling and Falsone broke down every throw and compared them in order to monitor his mechanics from one throw to the next. "His arm slot, stride length, and trunk rotation were exactly the same every time," says Falsone. "If he was favoring that ankle at all, he would not have had that consistency. And he was just so consistent from throw to throw."

Falsone found Schilling an eager patient and a dedicated student of his rehab. "He wanted to know everything: what was going on, why he felt a certain way," says Falsone. "We actually pulled out the anatomy books a few times to show him how it all works."

SPRING TRAINING TRANSITION
On Feb. 15, Schilling reported to spring training along with the rest of the Red Sox pitchers and catchers. At that point he was a little ahead of schedule, according to Morgan, who still consults with his star patient even though he is no longer the teamís physician. "Heís doing better than I anticipated," says Morgan. "I think heíll be back in time for Opening Day. Itís going to be close, but I think heíll be ready."

As this issue goes to press, Schilling is working hard in spring training, but has yet to feel completely comfortable pitching off the mound. He also battled through a bout of the flu. Those factors have left some doubts as to whether Schilling will be ready for Bostonís Opening Day game at Yankee Stadium. But true to form, Schilling hasnít ruled out making that start.

Falsone, who visited Schilling at the Red Sox spring training facility, says that constant communication between Athletesí Performance and the Red Sox is the reason Schillingís transitions from surgery, to rehab, to spring training have been so smooth. "Itís a really neat relationship that flows nicely between both parties," she says. "And Curt really feels like he benefits a great deal from that."