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The grades of a Carlos Carrasco hamstring

The Cleveland Indians' Carlos Carrasco left Sunday afternoon's game with the early diagnosis of a "hamstring" injury. According to Indians' manager Terry Francona, the ace has been sent back to Cleveland for an MRI on Monday, and will be placed on the DL regardless of the outcome.

Most fans breathed a sigh of relief, thankful that Carrasco didn't tear his ACL, which had been quickly speculated on social media because of the clear debilitating pain that Carrasco was in as he writhed on the ground. While hamstring strains usually have a shorter timetable than ACL injuries, how long Carrasco is ultimately out really will be an unknown, even after the MRI. The need for Carrasco's legs to be sound as a starting pitcher is clear and obvious, so it will be really interesting to see what's said publicly.

On a sidenote, I'm in no way trying to predict the injury of Carlos Carrasco. I'm certainly not a doctor, and I'm certainly not going to be taking a look at a cross section of injuries that's significant enough to definitively nail down Carrasco's timeline for healing. A "hamstring" injury is usually a graded strain, but the location on the hamstring, and type of "tear" can vary significantly. This piece is simply to give a broad spectrum of baseball injuries, so we can guide our thinking once Carrasco's MRI is complete.

Carrasco injured his left hamstring, which is on his landing leg when he pitches. According to a pitcher I've talked to, as well as a pitcher on twitter (@drewshish), this is better than the push off leg, although I think the degree is minor in that the length of time is probably measured in days, not weeks. The mental piece may be different though.

He felt pain behind the knee (which is fairly common with hamstring injuries, and where I have felt the pain the two times I've strained my hamstring), and it was clearly a tremendous amount of pain. It's also worth noting that people deal with pain differently, so it's hard to gauge an injury by how a player reacts. When you deal with the emotion of "how long is this going to take to heal" in the moment of competition, sometimes the pain is multiplied.

The Injury

Hamstring strains have three grades, and all three strains generally don't require surgery. However, surgery is required if the hamstring is pulled off the bone.  For a baseball player, or anyone really, the fix is generally time, which is monstrously difficult for a player that's competitive, and wants to get back to playing. Remember, Michael Brantley played in his first spring training game three weeks ago, before realizing it was too early. "Resting" isn't an easy thing when you're a professional athlete.

Again, I want to preface all of this with the simple fact that I'm not a doctor, nor have a slept in a Holiday Inn Express recently. This is all based on some quick internet research:

The Grade 1 strain 

The Grade 1 is a mild muscle injury that is measured in days, rather than weeks. There could be some torn tissue, but it's usually minuscule in nature. The key to this injury is that there's no discernable loss of strength. A player can rest for a few days, and with stretching and strength building, can be back on the field after a short time. This isn't to say that players recovery time is always measure in days, as like anything, it really depends on the player and situation.

The Grade 2 strain

The Grade 2 is a clear tear in the muscle tissue, but it's not a complete tear. This is an injury that is measured in weeks, and sometimes months, depending on the player. When you get into Grade 2 territory, you really have to grab ahold of the diagnosis and hold on. For a pitcher, my thoughts are that you immediately thing four weeks, especially when considering the drive and landing that a starter like Carrasco does with his legs on every throw.

The Grade 3 strain

This is the complete tear of the muscle tissue, and immediately means you're talking about months. This is the injury that athletes have to be on lockdown. Rest is needed to allow mending to take place, and if athletic activity is resumed too early, a big injury could turn bigger.

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Recovery from any strain really depends on the severity, but there's also a mental piece to it as well. Obviously, in a sport in which you use your legs as much as you do in baseball, getting past thoughts that you are going to reinjure yourself are part of the process. With Carrasco, every pitch requires him to land on the leg that he injured.

That takes time.

It's also important to notate that there is a high-risk for re-injury. If the hamstring isn't 100% healed, there's a 25% chance for re-injury, which obviously prolongs the healing process.

The Players


Grade 1 strains

Last year, The New York Yankees' starting pitcher Masahiro Tanaka was diagnosed with a Grade 1 hamstring strain when he felt his hammy "grab" after an attempted bunt. Tanaka's injury occurred during his September 18th start, and during a playoff run. He missed his next start, but was able to pitch five innings on the September 30th, then again during the October 5th Wild Card card, which the Yankees lost to the Astros. Tanaka pitched well in that last game.

The perennially injured Yankees' first baseman Mark Teixeira had a Grade 1 strain in early April while fielding a foul ball. He was put on the disabled list, and returned on April 20th, 2 1/2 weeks after the injury occurred. He resumed normal duties, and sustained them after the injury. He played the rest of the season without missing significant time.

The San Francisco Giants' starting pitcher, Matt Cain, was diagnosed with a grade 1 hamstring strain on May 21 in 2014, when he felt discomfort. He returned 2 1/2 weeks later and resumed his normal spot in the rotation, pitching six innings or more in five-of-seven of his remaining starts. He eventually returned to the DL because of an elbow injury, that would cost him the rest of his season.

San Francisco starter Mike Leake suffered a Grade 1 strain on August 2. He missed three weeks, returning to a full-time schedule on August 22nd. He looked more irritated than in pain after his injury, and while he was clearly hurt, was able to walk off the field. He wanted to keep pitching. Leake also resumed to normal duties once he was healthy, and pitched well, going 7+ in multiple starts over the last month. He closed the season with a complete game.

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This is a small sample size, but you can see that the general time period for this injury would coincide with a stint on the 15-day DL. In other words, 10-days to two weeks is the norm, give or take a few days. All the players mentioned above seemed to come back 100% healthy, and were able to resume their performances.

The catch to the appearance and description of their injuries certainly don't mesh with Carrasco's in that they felt a "pull," and were able to walk of the field. Carrasco, clearly, could not. That's certainly not a diagnosis, just an observance.

Grade 2 strains

In 2013, Giancarlo Stanton suffered a Grade 2 hamstring strain in the 10th inning, trying to leg out a single. As he passed first base, he pulled up lame, before collapsing past the bag in clear pain. He was able to get up, and lumber off with limited help, but was immediately put on the 15-day DL. The Marlins were very non-committal on his return, and he ended up missing almost six weeks, before returning full time.

A month later, Phillies catcher Carlos Ruiz strained his hamstring rounding second base. He pulled up in clear pain, limping to third in clear pain. He was able to limp off, and was clearly not in the same type of pain that Carrasco was in during Sunday's game. The 35-year old catcher, who clearly needs the hamstrings to play the position, especially at 35, returned exactly a month later, and had hits in six of seven games.

In 2015, oft-injured Josh Hamilton went on the DL with a Grade 2 hamstring. Like Stanton and Ruiz, he was running the bases before pulling up lame. He was able to walk off the field, tentatively. He was placed on the 15-day DL, and missed exactly a month.

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Again, all the players hurt hear looked like they were in more pain the the players with a Grade 1 strain, but again, that shouldn't be a diagnosis. Stanton fell down and struggled getting up, while Ruiz and Hamilton were clearly struggling to stand up, and had a hard time walking. While this certainly falls in line with Carrasco, his injury "appeared" worse. He needed help, and a lot of it.

Grade 3 strains

In 2014, Oakland A's top prospect Addison Russell suffered a Grade 3 strain of his hamstring, after suffering the same injury in spring training. The injury occurred during his second minor league game, and left because his leg was cramping. It got tight, and he ultimately missed two months. I mention Russell, because after he was dealt to the Cubs, he eventually injured his other hamstring, forcing him to miss the NLCS.

Ryan Zimmerman of the Washington Nationals suffered a Grade 3 strain, then missed 55 games and two months of baseball while recovering. He was nowhere near the pain of Carlos Carrasco, but nearly missed the rest of the 2014 season, before returning with two weeks left in the season.

Even with the small sample size, you can see that a Grade 3 is immediately looking at a long term healing process. It wasn't easy locating starting pitchers with Grade 2 or 3 strains in my quick perusal, as clubs tend to just diagnose severe strains, as strains.

Surgery

As I mentioned before, sometimes players are required to have surgery because the muscle detaches from the bone, or they prefer the surgery rather than "waiting it out." Obviously, each case differs from player to player, and injury to injury.

The Milwaukee Brewers Rickie Weeks tore his hamstring on August 7th of 2013 running to first base. If you click that link, and watch the video of the injury, it will look eerily similar to Carrasco's, perhaps not initially, but certainly how he's taken off the field. Weeks hamstring detached from the bone, and he missed the rest of the season. The recovery time was 4-to-6 months. He returned, healthy and ready to play when the 2014 season started.

San Francisco Giants' outfielder Angel Pagan tore his hamstring in May of 2013, and required surgery to repair it. He missed three months. What's interesting in Pagan's case is that he rehabbed the injury for a month, and in his rehab assignment, reinjured his hamstring. After the surgery in late June, he was able to return in two months.

In 2007, the Indians David Dellucci (thanks @thisguyhereisdead) had a "high grade tear" in his hamstring, and required surgery. He missed 3 1/2 months, and made it back a couple games before the season ended. Obviously, that was eight years ago, and the procedures a slightly advanced, but again, it does set in stone that if you have surgery, much of your season is gone, if not all of it.

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If Carrasco requires surgery, it's easy to believe that much of his season will be lost, but the injury is early enough that he could return in the middle of a stretch run. That's a worse case scenario, and again, speculation.

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There's not much to gather here regarding the appearance of the injury, as opposed to a Grade 2 tear. While certainly the reaction seemed to be slightly more severe, I can honestly say that Carrasco's reaction was vastly different than every action I looked at.

What does that mean? Probably nothing. If you've ever seen ten players stub a toe, you'll get what I mean. All have pain, regardless of the severity of the stubbing. People just handle it differently.

What concerns me, is that Carrasco clearly couldn't walk. Unless the trainers forced him not to walk to the dugout, which is possible, Carrasco appeared to be in an amount of pain that kept him from putting any pressure on his left leg.

What will the Indians do?

Carrasco's injury

Carrasco was charging to first base, covering the bag on a slow-rolling ground ball from Andrew Romine. Carlos Santana fielded the ball and tossed it to Carrasco, who grabbed the ball, stepped on the bag, and immediately collapsed to the ground in intense pain. He tried to get up, but continued to grab the back of his left leg, and sat back down...grimacing.

Carrasco needed Mickey Callaway and ultimately two trainers to walk him off the field. Carrasco wasn't walking.

While the injury was diagnosed as a hamstring injury, just in description, it looked a lot more severe than the several videos of other players I've watched over the past two hours. No, this isn't an official diagnosis. I'm just trying to predicate what I saw today, compared to what I've seen in the past.

There's one important piece of information to note. Hamstring injuries can domino off of each other. Last week, Carrasco seemed to tweak something when he stepped on the heel of the Seattle Mariners' Robinson Cano covering first base on a similar play. Carrasco made some practice pitches, but stayed in the game. It looked like the ankle was tweaked, but you never know.

The only reason I mention this is that other injuries, as slight as they may be, can predicate a hamstring injury. Perhaps it's something as subtle as pulling up a little bit because of a mental memory, or perhaps you are moving slightly different, because of a the previous injury. Did Carrasco's jaunt to first base against the Mariners have something to do with his injury against the Tigers?

Probably not, but just another piece to the puzzle, for those of us trying to figure this thing out.

That said, it's hard to be presumptuous. All things being equal, he has a hamstring injury. All things being equal, it can only then be a Grade 1, 2 or 3 strain. If it's a Grade 1 strain, he'll miss a start or two. Since he's already going on the DL, I'd say that's not likely. If it's a Grade 2, he'll miss the 15 days, and likely a few more. If it's a Grade 3, he'll likely not be back until the start of summer, or later.

On average, hamstring injuries force a player to miss 24 games, according to a report published by PubMed online. While that's not optimal, it certainly would be better than the rest of the season.
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