"We're looking into every option, and I have a full-time nurse on staff," said Nathan's agent, Dave Pepe. "She's been great about going through and reviewing all kinds of options. Tommy John [surgery] is obviously the most known and the most common option. Dr. [David] Altchek in Manhattan has developed a technique, it's a modified docking procedure and it's an alternative to Tommy John.
"We're exploring that and we're exploring if he's going to rehab this, what are the best ways to safeguard the rehab and make it most successful? The Twins are doing the same. So we're doing a lot of research in a short period of time to make sure that the decision we make is the right one for Joe, and obviously Joe wants to do what's right for himself and for the Twins."
One place to start might be in one of the rare instances a pitcher was successful in trying to pitch with a similar injury. Two years ago, then-Dodgers reliever Takashi Saito suffered a torn UCL. He was 38 at the time and did manage to return from the injury that season and had a successful 2009 with the Red Sox.
"The way I understand it is that some people have a lot of pain and other people have just a little pain," said Saito, now with the Atlanta Braves. "Sometimes you can cover the scar tissue with the muscle or you have to have surgery. I was thinking about my age when I chose not to get the surgery. I thought it would be too risky. I don't know why, but I am now completely recovered."
Nathan is 35, so there is some similarity in terms of career stage to Saito. And while it might seem counter-intuitive, the fact that Nathan has thrown for so many years, that there's been wear-and-tear on his elbow, could actually work in his favor.
Oddly, so would the fact that Nathan needed surgery this offseason to remove bone spurs. According to Dodgers team doctor Neal ElAttrache, who oversaw Saito's treatment, those kinds of loose bodies or secondary bone changes actually help the elbow to compensate if there is ligament damage.
"If you take an elbow that hasn't been through it, there wouldn't be as good a chance as Joe Nathan's," Dr. ElAttrache said. "If you had to put a number on it, and keep in mind I haven't seen the MRI for him, he probably stands a 20-30 percent chance of coming back without surgery."
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Like Saito, Nathan's injury is likely best described on two levels. The initial issue is a chronic, progressive injury that comes as a result of long-term throwing. Most Major League pitchers have some level of this condition.
On top of that progressive degeneration of the ligament, there can be what Dr. ElAttrache terms an "acute, onchronic injury."
"The extent of that injury can tell you how successful a pitcher might be in [avoiding surgery]," ElAttrache said.
Saito also used what some might consider an alternative type of treatment known as platelet-rich plasma therapy. In this procedure, some of the athlete's blood is taken and the platelet-rich plasma is separated. It's then injected into the injured area, in this case the elbow.
The plasma is said to act as a healing catalyst, speeding up the body repairing muscle, bone and tissue. It seems like it might also help build ligament and tendon fibers, which could help those receiving the treatment avoid surgery. There isn't strong evidence yet about the success rate, or if it works at all, but there doesn't seem to be a down side.
"There's a perception it's a miracle healer, that it's going to work in everybody," ElAttrache said. "The scientific answer to that is not in. It's definitely safe and it doesn't look like it will [cause side-effects].
The one issue might be the timing. In order to see if the PRP injection works, ElAttrache said about six weeks are needed. Then, the pitcher can start throwing again. That's when things could get iffy for Nathan. If he undergoes the treatment, waits the six weeks and still needs to undergo surgery, it pushes back the timetable for his return.
With Saito, it was an easier decision. The injury occurred in July. The Dodgers wanted to try everything they could to get him back for the pennant race. If they opted for surgery right away, he also would've missed at least half of the following season.
The question for Nathan, then, will be one of scheduling. The closer said on Tuesday he would make a decision sooner rather than later. If he has surgery in the near future, the timetable could have him back in time to pitch a complete and healthy 2011 season. The longer he waits, the more he could eat into contributing the following season.
What direction he heads in might also depend on what part of the ligament is damaged. Altchek, an orthopedic surgeon, explained that if a pitcher sustains a tear in the upper part of the UCL, where it's thicker and broader, there is a better chance the muscles can compensate, giving rehabbing and strengthening a chance. If it's at the bottom part of the ligament, which is much thinner, it's unlikely Nathan has a chance to avoid surgery.
"It also depends on what type of pitcher you are," said Altchek, who also knew of some success with PRP injections when the injury was to that upper part of the elbow. "If you can play with arm angles, that can help you."
If attempts to rehab the elbow do not work, the next decision will be which procedure to choose. The traditional Tommy John surgery is the most widely-known procedure and has a fairly high success rate. Then there's Altchek's modified docking procedure. This wouldn't get Nathan back any faster -- the 12 months to get back to full health remains the same because of the biology of allowing the ligament to reform and recover. But the surgery is less traumatic and lessens the chance of a post-surgery injury occurring. Veterans like Billy Wagner and Twins teammate Carl Pavano have undergone Altchek's procedure and have returned to full strength.
"It is a modification of the traditional surgery," Altchek explained. "It's an evolution of technique. We thought, 'How can we do this better?' We think we've done that. It's how the tendon is grafted. We fix it more rigidly.
"We've had good results with pitchers. If [Nathan] fails conservative treatment, this would be one of the surgical options."