With a quarter of the season remaining, the Cincinnati Reds face an increasingly tenuous situation. And one of the largest variables in their success or failure is the healthy, productive return of Joey Votto in September.

The Reds first baseman has been sidelined or limited most of the season by an injury to his left quadricep. To some, Votto’s condition has been shrouded in mystery amidst innuendo concerning the slugger’s commitment. For those interested in paying attention though, the situation has been relatively straight-forward.


It’s hard, but I think important, to remember that Joey Votto hit well at the start of the season. On April 25 he was batting .309/.452/.506 with an wRC+ of 171. Compare those numbers to .324/.424/.600 and wRC+ of 172 in his 2010 MVP season.

But by mid-May, concerns had arisen about the health of Votto’s left leg. Then on May 16, Ken Rosenthal of Fox Sports, reported that Joey Votto didn’t make the Reds road trip to Philadelphia. Instead, Votto had remained in Cincinnati to undergo MRI testing on a sore, weak knee.

Suspicions justifiably ran rampant that Votto had re-injured his left knee — the same joint that needed two surgeries to fix during the 2012 season. Later on May 16, the Reds reported the good news that the MRI had revealed there was no structural damage to the knee. Instead, Votto had a left distal quadriceps strain.

Up to that point, Votto had hit .257/.410/.449 with a wRC+ of 145.

The Reds initially hoped that Votto’s injury was mild and that he might return in a few days. On May 21, they placed him on the disabled list retroactive to May 15. By May 29, Votto was fielding ground balls at first and by June 5, taking batting practice. He returned to the Reds lineup on June 10, missing 23 games.

From June 10 to July 5, Votto plainly struggled through the next 23 games. Over 99 plate appearances he hit just .250/.354/.345, with no home runs and eight doubles. His wRC+ over that time was a mere mortal’s, 97. Joey Votto returned to the DL on July 8, where he remains today.

Left Distal Quadriceps Strain

Let’s break that down. Left means left leg. Distal means near the knee. A quadriceps strain is a tear in one of the quadriceps muscles at the front of the thigh. They can be mild or severe. It’s an injury that is frequently seen in kicking and running sports like soccer.

That doesn’t mean it is rare among professional baseball players. Edwin Encarnacion has been out since July 6 with a quad strain. When he returns, possibly next week, he’s not expected to be 100 percent and will largely DH for the Blue Jays. In 2008, Troy Tulowitzki missed two months with the injury.

Votto’s quad strain being near his knee likely involves the patella (knee) tendon. Will Carroll, who writes extensively on athletic injuries, explains that “down there, the muscle kind of becomes the tendon. There’s this transition zone. … damage to both of them is going to be called a strain.” (John Fay)

Reds trainer Paul Lessard implicated Votto’s knee tendon. “In the distal quad, all the muscles verge into the tendon,” Lessard said. “The tendon is basically beat up. We did a strength test on him as well as MRI. The strength was down quite a bit compared to the other leg.” (Fay)

Patella Tendonosis

Tendons are fibers that connect muscle to the bone, in this case the quadriceps to the knee.  Tendons are the strongest soft tissues in the human body. This strength comes from the tendon’s structure, which is mostly made up of collagen fibers aligned parallel to each other.

A tendon injury like Votto’s is usually the result of many tiny tears that have happened over time. Tendonitis is inflammation of the tendon caused by tears in the tissue in and around the tendon. It mainly manifests as irritation and swelling. Elbow tendonitis is common in tennis players and pitchers. Let me say again, it manifests in irritation and swelling.

Tendonosis is a more severe injury and refers to the degeneration of the tendon’s collagen to the point where the fibers are no longer aligned and fail to link up for load-bearing. It manifests as soreness and weakness. Again, weakness. Now, recall a certain left-handed batter’s leg collapsing underneath while he was swinging. Hello, tendonosis.

Tendonosis goes beyond irritation and swelling. “There’s actually cellular change,” explained Carroll. “Basically, the cells explode.” The cellular damage is thought to be caused by micro-tears in the connective tissue. A sports medicine expert I spoke with described it as the muscle “turning to mush” and becoming extremely weak.

Both tendonitis and tendonosis are generally caused by overuse. By the time you feel the soreness from tendonosis, the injury has been gradually building for many weeks.

Unfortunately, the same quality that makes tendons capable of enormous weight bearing – low blood flow – also makes them slow and difficult to repair. It often takes months, maybe half a year for an athlete to recover fully. Experts estimate tendons require over 100 days to make new collagen. Initial recovery is usually within 2-3 months and full recovery is within 3-6 months. Exactly what we’ve seen with Votto.

80 percent of patients fully recover. Getting Votto into that 80 percent — back to normal — brings us to PRP.

Platelet Rich Plasma Injections

In his second DL stint, Votto has received two platelet rich plasma (PRP) injections. PRP injections are a low risk procedure that has been shown to restore the healing process and provide significant improvement in both pain and performance. The goal of the procedure is to replace unhealthy tissue with healthy tissue.

A recent literature review by Drs. Ricardo Colberg and Kenneth Mautner concluded: “The overwhelming majority of studies in the literature report favorable outcomes after treatment of lower extremity tendinopathies with PRP injections, whereas only a few articles have reported adverse effects or no significant added benefit of the treatment.”

That’s the good news about PRP, the odds are high that it will work. The bad news is that PRP takes time to work. That’s why players in all sports are usually hesitant to have injections during the season. The Beacon Orthopedic website notes: “This can take weeks or months, but when successful, the effect is lasting. Most patients need 2-3 treatments spaced about 4 weeks apart. Most patients will not feel relief until a few weeks after the second treatment and that relief is gradual.”

Votto did not try PRP in his first trip to the DL. But after that didn’t work, he decided to undergo the procedure the second time around in hopes of permanent improvement. Votto’s last PRP treatment was July 21.

The Reds Have Been Clear from the Start

I’ve been plenty critical of the way the Reds have managed other injuries, especially Joey Votto’s meniscus tear in 2012. But this time, there hasn’t been anything mysterious or inappropriate about the way Votto has been treated, other than the inherent uncertainties in dealing with the healing of the human body.

As early as May 25, the Reds knew and said the healing process for Votto would take months. Bryan Price has indicated repeatedly that Votto may not be at 100 percent again this year. They clearly knew and indicated early on that Votto’s injury was on the severe end of the quad strain spectrum.

Every indication from the Reds front office, manager and training staff has been that this is a muscle/tendon injury, not structural damage to the knee. The treatment regimen – PRP – also definitively indicates it’s the tendon, not the knee.

Dr. Tim Kremchek, the Reds’ Medical Director and Chief Orthopaedic Surgeon, said on July 12 the plan was to get Votto back for the “stretch run” which John Fay interpreted to mean the last “four or five weeks” of the season (the first week of September).

Bryan Price said Tuesday (August 12) that it’s “reasonable” to think that Votto would return to baseball activity in the “next week-and-a-half to two weeks.” That’s late August.

It’s reasonable to be skeptical of the estimates. But you can’t say the Reds haven’t provided information or a timeline, all along the way. And so far, it has proven reasonably accurate.

Adding Insult to Injury

It’s plain to see for anyone of good will, that plenty of information is readily available discussing quad strains, tendon injuries and PFP treatments in general, and concerning Joey Votto’s injury in particular. The beat reporters covering the Reds, John Fay, C. Trent Rosecrans and Mark Sheldon, have kept their readers informed on the topic. John Fay, in particular, has written several articles that have brought important knowledge and understanding to the topic.

But that hasn’t stopped others in the media and broadcast booths from using the legitimate and expected uncertainty about Votto’s recovery to darkly insinuate that either something mysterious is going on or that Votto isn’t eager to return.

Paul Daugherty recently (again) questioned Votto’s commitment to returning. He wrote on Wednesday: “And while Phillips is busting it to get back in time for what the naïve believe will be a September run, we are told that there is no timetable for Votto to return to what Bryan Price calls ‘baseball-related activities.’ The only thing that’s clear about Votto’s strained distal quadriceps is that Votto will return when Votto believes Votto is ready, and not an inning before.”

Comparing Phillips and Votto’s recovery is lazy and unfair. Phillips had a clear cut injury that was fixed with surgery and has a well-established recovery regimen and timetable. Votto’s injury, by it’s nature, is immersed in uncertainty and risk of backsliding. Also, is it really that surprising, given their respective personalities, that Brandon Phillips has been highly public in his rehabilitation efforts and that Joey Votto has been private?

No serious commentator could question Joey Votto’s desire to play baseball. He’s often spoken of the immense importance of playing every day. And Votto has backed up those words with deeds. He played 161 games in 2011 and all 162 games in 2013. This season, Votto played on his weak knee until the team made him stop. When he returned from the DL the first time Votto tried to compete on one leg. A source who is around the team regularly said: “You can’t question Votto’s desire to be the best player he can.”

Of course not. He’s the last person who should suffer the insult of character assassination.

But as my high school debate coach used to advise, consider the source.

When you realize that it’s exactly – and I mean precisely – the same people who criticized Joey Votto’s approach to hitting who are also questioning his injury recovery process, well that’s really all you need to know.

The Long Term

Many Reds fans are rightly concerned that this episode, combined with Joey Votto’s previous meniscus injury, means that the Reds first baseman will fight knee issues the rest of his career.

That’s possible. But certainly not inevitable. People do return to complete health from tendonosis. PFP treatment has increased the odds.

I asked Jordana Bieze Foster, the editor of Lower Extremity Review and a medical journalist specializing in sports medicine, if a player with tendonosis who received PRP and returned to healthy was at a greater risk of recurrence of tendonosis.

Her reply: “I don’t think anyone knows. There aren’t many long-term PRP studies. But increased risk seems unlikely.”

Going Forward

Let’s not pretend that Votto’s recovery time-table was devised independent of the Reds remaining schedule. In May, you give a short rest period a shot, cross your fingers and hope against odds that’s enough because the alternative is daunting. When that doesn’t work, you regroup. You take out the calendar, find September 1 and count backward. That accommodates two PRP treatments and a stretch run. If it all works.

We’ll know soon. If and when Votto returns to baseball practice in late August, his knee will either feel healthy or it won’t. It might and it might not. There’s no way to know that now and no reason to speculate.

At that point, the Reds will face a tough decision, either to bring Votto back or let him continue to rest and rehab the quad strain, maybe take another PRP treatment or two.

The pros and cons are obvious. Returning too early carries risk. We’ve already watched Votto try to come back too soon earlier this year. How did that work out? And there’s a chance of reinjury if the tendon isn’t ready.

On the other hand, the entire point of PRP and taking two months off was to change the approach. The sports medicine expert I spoke with this week said that while there is always a risk of relapse, the chance that Votto’s condition would revert all the way back to zero was remote. Remember the literature review of studies indicates that PRP works.

It would make the Reds decision easy if the team were either clearly out of the race (Votto sits) or clearly in it (Votto returns). Pulling Votto back would raise the white flag in front of his teammates and fans who are expected to continue to fill Great American Ball Park and watch on FSO.

But the Reds position won’t be clear-cut. Absent a sudden collapse or unlikely winning streak, the Reds will bang along around .500, a handful of games from the second Wild Card spot. Don’t be surprised to see Joey Votto back under that circumstance.