Team doctor works wonders for Schilling
It may go down as one of the most innovative, quick-fix medical procedures in the history of postseason baseball, and it may have been possible only because the doctor who brainstormed the breakthrough first tested his technique on human cadaver legs.
Welcome to the intriguing story behind the Red Sox medical team temporarily repairing a dislocated tendon in Curt Schilling's right ankle so well that he dominated the Yankees Tuesday in Game 6 of the American League Championship Series and helped to force last night's monumental do-or-die finale.
General manager Theo Epstein wasn't kidding after Schilling's injury-shortened start in a Game 1 loss when he said the Sox would explore "every medical technique under the sun to try to get his tendon stabilized."
The sheath surrounding one of Schilling's peroneal tendons, which run across the back of the ankle, had ruptured, allowing the tendon to slip out of its groove and drift above the ankle. When Schilling pitched, the tendon snapped painfully against the bone, badly limiting his effectiveness.
The only permanent fix was reconstructive surgery, which would require three months of rest and rehabilitation. But with their season slipping away after one loss led to another and yet another, sinking them in a 3-0 hole in the best-of-seven ALCS, the Sox needed Schilling more than ever.
In rushed Reebok, Schilling's shoemaker, which designed a high-top cleat it hoped would stabilize the tendon. Schilling tested the cleat in the bullpen at Fenway Park Friday and Sunday, but the Sox remained skeptical about their season rising or falling on the shoe alone and scrambled to find alternatives.
Epstein said, "Everybody was thinking, `Well, is there some way to strap [the tendon] down? Can we just screw that freakin' tendon to bone? What can we do here?' "
Enter Sox medical director Bill Morgan, who recommended a novel approach in concert with the team's training staff. Why not suture the skin around the dislocated tendon down to the deep tissue and effectively create an artificial sheath that would seal the tendon in place?
"We were going to do it as a last-ditch scenario," Epstein said. "Although it seems extreme -- we couldn't find a case of it ever having been done before -- we thought it was almost a conservative approach in that it would be the best way for Curt to have his normal mechanics."
The only problem was, Morgan had never performed such a procedure and was unaware of anyone who had conducted one whom he could consult. So he did what many doctors do to test new medical techniques: He experimented on human cadaver legs.
By the time Morgan finished his test run, Schilling had considered all the available alternatives and agreed to undergo the procedure.
So on Monday, team doctors, laboring in a Fenway Park back room, jury-rigged the stunning and counterintuitive solution. Instead of fixing Schilling's injury, they, in effect, exacerbated it, using a few simple sutures to keep his loose tendon out of place but immobile, thus ending the snapping so bothersome to the pitcher. The makeshift procedure worked. On Tuesday night, Schilling pitched seven innings, giving up only one run, to lead the Sox to victory in Game 6.
And so another chapter in the storied history of the Red Sox was written, with comeback heroics on the diamond -- and a brilliant flash of medical improvisation behind the scenes that made it possible.
Orthopedic experts said no similar cases had ever been recorded in medical literature. In fact, they said, they could not think of another situation where they would recommend such a procedure. However, they agreed that treating a big-time pitcher before a big-time game was that rarest of circumstances warranting it.
Morgan admitted he was treading new ground in devising the idea during the Division Series against the Anaheim Angels two weeks ago, when the extent of Schilling's ankle woes became apparent.
"It was totally unprecedented," said Morgan before last night's Game 7. "It was a reasonable alternative when all else failed. And all else failed."
While improvisation is common in surgery, Morgan had an uncommon goal: simply to get Schilling out on the mound for as many innings as possible.
"Brilliant . . . it worked," said Dr. Tammy Martin, orthopedics chief for the Boston Veterans Affairs health care system and doctor for numerous college athletic teams. "If it hadn't worked, I'd be saying, `He tried what?' " A week ago, Martin and other orthopedics experts interviewed by the Globe were skeptical that Schilling could perform at anywhere near his usual level without season-ending surgery.
The medical drama began in earnest Oct. 5, when Schilling painfully stumbled while fielding a grounder against the Angels in the first game of that series. Morgan said yesterday he quickly suspected a serious tendon injury, though in public Sox officials said Schilling suffered only from an inflammed tendon.
In actuality, his peroneus brevis tendon, in the back of his right foot, had been dislocated, as became clear in Game 1 against the Yankees, when Schilling pitched poorly and blamed a "popping" sensation in his ankle for distracting him.
The popping was his tendon flapping around. The tendon anchors the ankle's muscle and bone, crucial to movement. The tendon is held snug in a groove on the fibula bone by a thin, yet strong sheath. That sheath had ruptured, and the tendon was loose like a limp rubber band. In that state, it was tough for Schilling to fully use his right leg muscles to pitch -- not to mention the pain he experienced every time he pushed off the pitching rubber.
During Game 1 against the Yankees, Morgan's medical team tried the usual approach: using tape and an ankle brace to keep the tendon snug. It failed.
"It was impossible," Morgan said. "We tried splints, high-top shoes, taping, everything possible to keep it in."
Morgan had already devised an alternate plan, and floated it with Schilling after the game.
"Curt understood the concept. He wanted to try it," said Morgan.
On Monday, Morgan and three assistants, working in a sterile back room at Fenway Park, applied a local anesthetic to Schilling's ankle. Then they stitched. A "few" sutures, threaded through skin and the tissue beneath the skin, were placed in between the groove and the loose tendon, according to Morgan. This created a tiny wall of flesh that kept the tendon in place -- about 2 centimeters outside its groove.
"We forced it to stay out of the groove so it wouldn't move around," said Morgan. "It's going to stay out until his [postseason] surgery."
Boston University's Dr. Timothy Foster said: "I've been associate editor of the American Journal of Sports Medicine, the major journal in the field, for 12 years, and this is the first time I've seen this or heard of this.
"There is a lot of improvisation in sports medicine. However, most of the surgery and treatment is based on scientific studies. But this was such an uncommon situation."
The sutures did the job, but the Sox kept the procedure a secret. "It's always nice to have some secrets in October," Epstein said. "Maybe if the Yankees knew there were sutures in there and they saw it start to bleed it would give them some confidence that things were falling apart for Curt."
Epstein said the Sox also "didn't want to cause unnecessary distraction before the game, as if there weren't enough already."
Despite the favorable results in practice Monday, it remained a mystery how well the sutures would hold up under game conditions. Schilling needed to field his position as well as pitch, which meant scrambling to cover first on grounders, including one by Bernie Williams in the fourth inning. There was blood visible near Schilling's ankle during the game.
"After the first pitch, I was pretty happy with his delivery," Epstein said. "But after that, I was pretty nervous through the whole thing, especially when he had to cover first because you never know what kind of force might impact the sutures and the tendon. But it went really well."
It went so well that manager Terry Francona was asked after the game why Schilling only went seven innings (he surrendered only one run on four hits without walking a batter).
"We were actually keeping an eye on him from the fourth inning in case he was starting not to feel real great," Francona said. "He went inning to inning and kept pumping outs, so when if he said he was ready to come out, we weren't going to leave him in."
After the victory, the sutures were removed to prevent infection. In order to pitch again prior to surgery, Schilling would likely have to be sutured again before each game.
The procedure did not heal Schilling: "It probably weakens his ankle . . . he doesn't have the normal fulcrum there, but not in a way that impairs him," said Morgan, explaining that even with the quick fix that enabled Schilling to pitch, he will require surgery. Morgan said the suture fix would not jeopordize Schilling's prospects for full recovery or make the injury worse; other orthopedic experts interviewed agreed.
But on Tuesday, Schilling didn't pitch like a man hobbled. Instead, he threw perhaps the most memorable game of his career, one for Red Sox annals.
"We were sort of on a battlefield with our best warrior," said Morgan. "We were just trying to get him out there."