Nick Lodolo’s injury is worse than you think

Nick Lodolo’s injury is worse than you think

The medical news hit hard today as Nick Lodolo was placed on the injury list and we learned his diagnosis of “left calf tendinosis.”

First things first. “Calf tendinosis” isn’t a thing. If you Google “calf tendinosis” you get results from today talking about Nick Lodolo and nothing else. No other references. No other baseball players. No pro athletes, college athletes or even guys Springsteen wrote about in “Glory Days.”

More likely, Lodolo suffers from Achillies tendinosis. Your Achilles tendon connects your calf muscle to your heel bone and causes ankle movement.

Beyond the minor question of calf vs. Achilles, there’s the not-so-minor matter of the second medical term in Lodolo’s diagnosis.

At first glance, most of us skimmed past it and thought “tendinitis,” a condition many of us have had. Common symptoms are pain, burning and decreased strength. Basic treatment is rest and ibuprofen. A bout of tendinitis is generally short and temporary.

But tendinitis is not what afflicts the 25-year-old Lodolo. No, the young left-hander has the wicked evil cousin of tendinitis, tendinosis. To explain the difference we need to do a bit of anatomy.

Basic Anatomy Tendons are strong, rope-like tissues made from collagen fibers that connect muscle to bone. When your muscles tighten and then relax, your tendons and bones move. Ligaments are something different. They attach bone-to-bone and generate stability not flexibility.

We also have to talk collagen. As the most common protein in your body, collagen is the building block of the human form. Collagen provides connective structure, strength and support throughout your body. Tendons are largely made up of collagen. Collagen helps tendons endure high-impact stress and resistance. It plays a vital role in tendon health and preventing sports injuries.

Tendinitis vs. Tendinosis Tendinitis is the painful inflammation of a tendon resulting from micro-tears due to overloading. Whereas tendinosis is the breakdown (degradation) of the tendon’s collagen in response to overuse with insufficient time to recover. With tendinosis, the collagen fibers are no longer aligned and become disorganized. The difference: inflammation vs. degradation, the latter being far more serious. Here’s a helpful but scary graphic from the Cleveland Clinic:

Diagnosis is made with a simple ultrasound exam that can detect the degrading (often described as “disorganized”) collagen.

As an example that many people are familiar with, the plantar fascia is a flat tendon on the bottom of your foot that attaches to the heel bone. Plantar Fasciitis, which affects many people, is degenerative tendinosis, not an inflammation. Other examples of repetitive tasks that can cause tendinosis include gardening, painting, typing and throwing an unhittable breaking ball.

You might think the distinction between tendinitis and tendinosis isn’t important. But it turns out the two conditions have different treatments and timelines. For tendinitis, the goal is to reduce the inflammation through rest and ibuprofen. The healing time for tendinitis is several days to six weeks.

Tendinosis Timeline (I’m going to issue a Reds fan trigger warning for the next paragraph.)

Treatment for tendinosis that is caught early can be as brief as 6-10 weeks but can take 3 to 6 months. Three to six months and may take up to nine months. Tendons need 60 to 100+ days to make new collagen. Treating tendinosis for just a few weeks would provide little long-term repair or solution. Around 80 percent of people with tendinosis make a full recovery in 3 to 6 months, depending on whether their condition is chronic or not. Tendons are slow to heal because of poor blood supply.

Implications I’m not a doctor (although I see many). We’re trying to analyze Nick Lodolo’s condition based on the limited information that he has a condition the Reds have incorrectly termed “calf tendinosis.” Given that an ultrasound can readily distinguish between tendinitis and tendinosis, we have to assume the Reds are at least right about that part.

Did the Reds catch it early? It doesn’t sound like it. Reporting indicates Lodolo had been pitching through soreness all season. Manager David Bell said that Lodolo wasn’t feeling pain as he pitched (that’s not unusual with tendinosis), but Lodolo also wasn’t improving.

As for that timeline, Bell told reporters today they’re looking at a minimum of four weeks before Nick Lodolo returns. My guess is that means they’ll re-evaluate in four weeks. We’ve learned in recent years that Reds estimates of player return dates tend to be optimistic, sometimes extremely so.

Three to six months, sigh. Three months would be the middle of August, a month after the All-Star break. Six months would be season-ending.

We’d just published an analysis of Nick Lodolo’s start to the 2023 season, including his struggles. The Reds entered the season with three reliable starting pitchers. Each lacks experience, but that’s what is left here. Luke Weaver had an excellent start today and showing tentative signs of being a solid starter. It’s worth noting Weaver hasn’t started more than 12 games in a season since 2018. Losing Nick Lodolo for months will put a severe strain on the organization to put a capable rotation on the field.

Featured image: Reds Twitter

Steve Mancuso

Steve Mancuso is a lifelong Reds fan who grew up during the Big Red Machine era. He’s been writing about the Reds for more than ten years. Steve’s fondest memories about the Reds include attending a couple 1975 World Series games, being at Homer Bailey’s second no-hitter and going nuts for Jay Bruce at Clinchmas. Steve was also at all three games of the 2012 NLDS, but it’s too soon to talk about that.

6 Responses

  1. Brian Van Hook says:

    Thanks for this.

    Reds have no depth as it is. What comes after “no depth” ??

  2. Mike Bittenbender, MD says:

    I suspect they will try protein-rich plasma injections to stimulate healing, and try to shorten the recovery, but they have to be careful, here, as a rupture would be a year recovery, MINIMUM. I am a doctor, Family Medicine but have cared for high school athletes for years and have done sideline medicine also. He is young and should heal, but the further you get from the heart, the worse the blood flow, and the slower the healing. Better to shut him down than to have him try to pitch through it, alter his mechanics and hurt his elbow, or God-forbid, his shoulder. That would be far worse. Might want to revisit Chase Anderson or they could look at Abbott, but based on what I saw in Louisville the other night, he still needs work on command, but I do think he is close.

    • Steve Mancuso says:

      Always good to hear from experts. Thanks, Mike. I ran across examples of PRP treatments in my research. My overall sense was consistent with yours — they need to be careful and patient. They may have already let it go on longer than was prudent.

  3. Pinson343 says:

    My (desperate) hope is that the description of the diagnosis has been completely botched although, as Steve said, “an ultrasound can readily distinguish between tendinitis and tendinosis.” Lodolo will be examined in Cincinnati this week, which will hopefully provide better news. But it’s ominous that Bell, who always provides ridiculously optimistic recovery estimates, did not say that he is expected to be throwing again in about 4 weeks.

    • Steve Mancuso says:

      Agree about the foreboding in Bell’s statement. I think they called it “calf tendinosis” instead of “Achilles tendinosis” to manage public fears.