The Miami Marlins keep suffering more and more blows in what has turned into a disastrous season. However, the news of "right shoulder tightness" in Jose Fernandez after his last start versus the Atlanta Braves was one of the scariest bits of news yet. Fernandez is just seven starts into his recovering from Tommy John surgery for a torn UCL, an injury that kept him out for 13 months. The prospect of another potentially dangerous throwing arm injury could have been crippling.
After examination from team doctor Dr. Lee Kaplan, it turns out Fernandez has a right biceps strain. The Fish are expecting to put him on the disabled list, but relative to more dangerous shoulder injuries or tears, this seems relatively benign. But what is the spectrum of injury to the biceps, and what can we expect for Fernandez?
Biceps and Biceps Strain Anatomy
The biceps is one of the two muscles that acts on the elbow joint that originates from the upper arm. The biceps is two-headed muscle that controls both flexion and supination (turning the forearm to face upwards, like holding a cup of soup) motions, and it is the primary muscle that handles both activities. The two heads are comprised of a long head and a short head, both of which attach to the bottom part of the humerus and the first part of the radius.
The attachments at the top, or the origins of the muscle, are more likely to be problematic in a pitcher than the bottom attachments. The long head of the biceps originates from a part of the scapula, which is the shoulder blade, in what is called the supraglenoid tubercle. The tendon runs down and becomes muscle as it runs in the front part of the humerus, the long bone of the arm. The most common site of biceps tendon inflammation is in this area, with 30 percent of these injuries originating from there.
The lower attachments are more likely to be the source of an acute injury rather than overuse or wear-and-tear problems. Usually, however, these occur in older patients in which the distal attachment has been worn down over time and snapped against some force while the arm is flexed. This sounds like less of a situation than what Fernandez is going through, especially since Fernandez had initially described "shoulder tightness." That sounds more like a patient who has tendinitis and inflammation and may have gotten a small strain in an aggravated area.
How could we tell the difference? Depending on the scale of the tear, Fernandez may have a visible bulge in a certain location of his arm. The bulge is from the head of the muscle de-attaching from the original site and bunching up close to it. It is likely, given his initial complaints, that Fernandez if anything has some bunching of muscle near the top of his arm rather than the bottom.
Biceps Injury Diagnosis and Treatment
This is mostly a diagnosis by examination, but the Marlins did indeed get an MRI that showed a small tear with no structural damage. Likely, this sounds a lot like a tendinitis with maybe small-grade tearing. It would make sense for the Marlins to want to see an MRI in order to make sure that there were no further injuries or worse causes, given Fernandez's recent severe injury history.
As for treatment, the descriptions that have been released do not sound like a surgical problem. Had any tendon been seriously been torn, surgical management would probably be necessary, so these injuries must have been relatively minor. If that is the case, the mainstay of treatment is pain control and possibly physical therapy. Treatment with Motrin or Advil is a reasonable choice to help reduce inflammation and pain, which are the limiting factors for early return. Steroid joint injections are also an option, but repeated injections can risk future tearing of the tendon because steroids can decrease the healing process.
For just tendinitis, rehab would not be necessary, but in the case of a partial tear, it most likely be required. Simple exercises can be used in mild disease, but I imagine Fernandez will undergo a more rigorous program to get him back into shape once his pain is well under control.
The tentative plan should be for patients to return to competitive play around three weeks after pain is completely under control, which could take three to four weeks of treatment with medication. All told, the injury, if mild, could take something like six weeks from which to recover, though it can be done earlier because many of these steps are not required if pain is managed properly. Fernandez does not need to be immobilized or kept from doing normal motions, only competitive activity-type work.
If it does take something like six weeks, it will pull Fernandez close to the end of the season. There is a possibility he could be back by early September, in which case Miami will have a tough decision ahead about whether shutting him down entirely would be the better call. However, given the lack of severity of this condition versus the more concerning shoulder or elbow problems, Marlins fans have to consider themselves lucky.