Taking another look at Betemit's injury and slow recovery

The news that Cuban defector Henry Urrutia was joining the Orioles in Texas this weekend came as little surprise for three reasons. He's putting up numbers deserving of a promotion, executive vice president Dan Duquette and manager Buck Showalter hinted at it during the last homestand, and Wilson Betemit is a long way from serving as the Orioles' left-handed designated hitter. The Orioles haven't given up on Betemit this season, but his goal of returning immediately after the break has been destroyed. He's performing baseball activities in Sarasota when his right knee allows it, when he feels up to it. That's it. Betemit tore the PCL (posterior cruciate ligament) in his knee while running to second base during an exhibition game. I walked down from the press box at Ed Smith Stadium to grab an interview outside the clubhouse, watched the flight of a ball to left field, turned and saw Betemit writhing in pain in the infield dirt. I had no idea what happened to him. There was no contact, which usually causes such an injury. It's much more common in football. It doesn't usually happen to a baseball player who's simply running the bases. "First of all, it's not as commonly reported as an ACL (anterior cruciate ligament)," said Gene Shirokobrod, a doctor of physical therapy and certified orthopaedic manual therapist based in Clarksville. "The ACL is the one that gets most of the attention because in most sports you pivot, and that's when you tear the ACL. You have two main ligaments in the knee, the ACL and PCL. The reason why it's uncommon for the PCL to get injured is because it's a lot thicker and a lot stronger than the ACL. And you hardly ever see it in baseball because you need to have a force hit the lower leg bone, the shin bone, and the force needs be strong enough to slide it back into the knee and tear the PCL. As I recall, Betemit was running and tried to stop and hyperextended his knee. No trauma. "When I saw Grade 2/3, there's no such thing. There's three grades to ligament damage - 1, 2 or 3. When you work out and you're really sore the next day, that's a Grade 1. Microscopic tears in the muscles. Grade 2 is a partial tear, half to more than half. Grade 3 is completely severed. There's no more connection. It's either severed in the middle of the ligament or the connection between the ligament and the bone. "Chances are it probably created a severe Grade 2. He tore a lot of it, but it's still holding onto itself a little bit. It's right on the border. But sometimes with a Grade 3, you can get away without having surgery. Pro athletes usually don't do that. They have surgery and get it fixed. But the fact that it's taken this long, in my mind, something else is going on." It's got to be a mental strain on Betemit, who immediately feared that his career had ended on that sunny afternoon in Sarasota. And the injury was severe enough to warrant those concerns. "It's very common when you have a high-level PCL injury to have damage to other structures, as well," Shirokobrod said. "When you get a Grade 3 tear in your PCL, in most instances there's usually damage to one of the other ligaments. The most common is the MCL (medial collateral ligament). He might have had secondary damage there and it's just taking a while to heal up. And so much depends on his motivation, his rehab, how much he's working, how hard he's working. If you don't put the work into it, essentially waiting for the body to heal itself, which could take nine months depending on the severity, if you're not putting in the work, you're not getting the muscles to do what they're supposed to do. You can have atrophy because you're not using the muscles that function around it. They start to get smaller and weaker." So what are the chances that Betemit could return the same player he was before the injury? "Pretty high," Shirokobrod said. "Plenty of studies show it. I think the numbers are as high as 80 percent that's it's like it never happened. It's such a strong ligament, short and thick and very, very strong, but especially because in baseball, the majority of game action is forward motions. You're not doing a lot of backward motions and you're not hitting it. He's just got to get more comfortable with sliding and the pivot. "He'll definitely have a harder time being a switch-hitter. Probably batting from the right side, he's going to have a little bit harder time initially because that will be his pivot leg and where he has to load up. But he should be able to bounce back. It just depends on how much damage he had in the knee." It works in Betemit's favor that he's pretty much restricted to batting from the left side because of his splits. And he's not being asked to play in the field. What he's being asked to do is clear a psychological hurdle. "One of the biggest issues with athletes is pain apprehension," Shirokobrod said. "It's a very, very real and significant thing. There's a fear of reinjury. Athletes are so hyper in tune with their bodies, and if they have a little instability and don't feel the same, it alters their game significantly. "It's like, on that first slide, do I go leg first? Will I hurt the bone? I'm sure the medical team is trying to explain all these things to him. To us, it seems like a simple thing. You heal up and get back to it and you're fine. But it's a really, really hard thing for an athlete to process." Betemit will have to make another adjustment after the season. His $3.2 million vesting option for 2014 becomes guaranteed if he has a combined 700 plate appearances in 2012 and 2013. That's not going to happen, and the Orioles won't attempt to re-sign him.