Experts: Surgery only effective option

The extent of Red Sox ace Curt Schilling's ankle injury virtually guarantees that he will not be in top form until surgeons repair his damaged right ankle after the season, according to medical experts.

ADVERTISEMENT

The Red Sox yesterday said they would seek to get Schilling into shape to start a possible Game 5 against the Yankees Sunday with the assistance of an ankle brace and painkillers. But orthopedists interviewed by the Globe said a brace could not adequately replace the torn tendon sheath in Schilling's right ankle. And until he gets surgery, they said, the muscle power in his right leg -- the one he pushes off to generate the speed on his pitches -- will be impaired.

Complicating matters, the decision on Schilling's playing status Sunday would also hinge on how much pain he feels on game day. Only he can say, of course, but medical experts said they consider him an unreliable source -- a highly competitive athlete determined to play.

"It may be pretty good by then but it's not going to be 100 percent," said Dr. Tammy Martin, orthopedics chief for the Boston Veterans Affairs health care system and team doctor for numerous local college teams. "You certainly couldn't guarantee the same level of performance. He may do well for a couple of innings. Or not."

Schilling will undergo postseason surgery. Had this occurred during the regular season, the Red Sox would have immediately placed him on the disabled list, said team physician William Morgan.

"The tendon is snapping over the bone," he said yesterday in describing the injury.

The injury is called a peroneal tendon subluxation, a more serious problem than the Red Sox and Schilling first disclosed. For the last three weeks, they have said it was mild tendon inflammation, or peroneal tendonitis.

Schilling's ankle tendon is normally held taut against his ankle by a thin but strong sheath, similar to sausage casing. The sheath keeps the tendon snuggly in a groove along his fibula bone. This tight arrangement allows for ankle movement, balance, and muscle power. The latter is crucial to Schilling, who generates much of his pitching power from his right foot.

This sheath somehow has torn, likely from intense stress during recent pitching outings.

"You can't generate muscle power with this injury," said Martin.

Braces, no matter how sturdy, cannot replicate the sheath, she said.

"It's not something you can brace or tape well enough to tolerate playing," said Martin. "There's nothing externally that holds it as snuggly as that sheath can internally."

The "popping" sensation the pitcher complained about after Game 1 Tuesday night, when he was able to pitch only three innings, was likely the tendon snapping and grinding against bone, doctors said.

Dr. Arun Ramatpa of Beth Israel Deaconess Medical Center's sports medicine division said of the injury: "It can be very painful."

Thus, Schilling's only chance to return to full form is surgery, said experts.

"What's required is to sort of reconstruct that sheath," said Ramatpa.

Schilling has said he first developed the injury during a Sept. 21 game against the Orioles in which he pitched with some discomfort. He said he "tweaked" it again while pitching against the Yankees Sept. 26; he was seen wearing a boot-cast after the game. Finally, a slight stumble during Game 1 of the Division Series against the Angels last week exacerbated it, Schilling has said. Nonetheless, the Red Sox quickly said he would be able to start a Game 5 in that series, though the Red Sox sweep made it unnecessary.

Red Sox manager Terry Francona said at the time: "I don't think it affects him while he is pitching because he's so strong mentally."

Before Tuesday's game, Schilling threw 52 pitches at a Fenway practice session, satisfying the team that he was ready to play at championship level. He used a local anesthetic on his ankle.

"Everything worked great. I'm not planning on it being an issue," said Schilling afterward. Francona said the team's medical staff was "really confident" Schilling could play "without problems."

But practice isn't an exact simulation of competition, especially a championship game, and can be misleading, said experts.

"It can seem OK in practice, but when you're out there on the mound, and pitching as hard as you can, an injury can get to you even more," said Martin.

Schilling took the mound in Game 1 against the Yankees with his ankle heavily taped and with injections of Marcaine, a local anesthetic. Experts said this drug could inadvertently lead to a worsening of an injury, because Schilling would be unaware of additional stress on it.

"It certainly must be used judiciously, and with caution," said New England Baptist Hospital foot and ankle specialist Dr. Mark Slovenkai, who treats the Boston Celtics "It masks pain. You could aggravate an injury more."

Raja Mishra can be reached at rmishra@globe.com.