While the Orioles had hoped that third baseman Manny Machado could avoid offseason surgery on his left knee, it became obvious to the club since the season ended that a non-surgical recovery could result in a greater chance of Machado injuring the knee again.
That resulted in the decision, announced Thursday night by the team, for Machado to undergo reconstructive surgery to repair a torn medial patellofemoral ligament in his left knee on Monday.
The estimated recovery time for the surgery is four to six months. Machado said in a statement released by the team Thursday night that he hopes to be ready for the beginning of spring training, which is four months away.
"I think he will be fine," Orioles manager Buck Showalter said Friday. "It was probably something that was going to have to be done at some point, and the more you talk to the experts who have done these surgeries, there's a high percentage that he's going to [injure] it again sometime next year. … When you take in all the information, it's really a no brainer."
When the season ended, the Orioles were optimistic they could pursue a recovery plan that would avoid surgery – and renowned orthopedist Dr. James Andrews agreed with that prognosis – but they always planned to re-evaluate Machado four weeks after the initial prognosis.
Time, however, became a factor, and if Machado was to have any chance of being ready for spring training, a decision to have surgery had to be made quickly.
The medial patellofemoral ligament is a small ligament that connects the kneecap to the femur. It helps keep the kneecap centered. If the ligament is not in tact or is torn, the kneecap can become dislocated.
When the Orioles first diagnosed the injury, executive vice president Dan Duquette said it wasn't necessarily a new injury. Machado suffered a kneecap injury two years ago in the minor leagues while playing at Low-A Delmarva.
Dr. Daryl Osbahr, an orthopedic surgeon and the director of sports medicine research at MedStar Union Memorial Hospital, said that sometimes surgery is needed to prevent further injuries to the kneecap.
"With non-operative management, we hope that we can get that ligament to tighten up again and heal in a good position," said Osbahr, who has not examined Machado. "When it doesn't heal in a good position or heals in an elongated position, then the athlete can be susceptible to another dislocation."
Osbahr said that Machado's rehabilitation will be just as important as the surgery, which will be performed by Dodgers orthopedist Dr. Neal ElAttrache on Monday in Los Angeles.
"The most important thing is protecting the kneecap in the early post-operative period to make sure you're not providing excessive force to it and then over time, allowing the strength to build up to support the kneecap in staying in the same position," Osbahr said. "The important part is making sure he's corrected any deficiencies or any weaknesses that are around the kneecap to support it to enable a player to play at the same level. It's all about keeping the kneecap stable.
"The surgery is universally very successful in returning players back to play, including baseball players. Once the injury had been fixed and the rehabilitation is successful, we typically hope the athlete can get back to 100 percent of the prior level. When people do have kneecap dislocations, sometimes they happen because a person is prone to them and sometimes they happen because of an excessive force or just being in the wrong place at the wrong time."
Showalter said he expects Machado to be ready for spring training. But unlike last season, when Machado played often during the Grapefruit League schedule, going on the road regularly in preparation for his first full big league season, Showalter said he doesn't have to rush Machado into games.
"He's going to make this club," Showalter said. "In some ways, I think it's good for him to take a little time to get off his feet. … I look for him to be playing in games in March. Who knows? That's just from everything I've taken in."
Osbahr said that would be good for Machado, because he should gain strength in the knee as spring training progresses.
"Some knees rehabilitate faster and some knees rehabilitate slower," Osbahr said. "The important part is not pushing it too quickly. If the knee allows a player to get back in four months, you can let him get back. But that player might see continued benefits for an extended amount of time. They might feel 100 percent, but with every day and week they get out there, they might continue to see benefits and be more and more game ready. That's the great part of spring training. It gives an extra month of time to rehabilitate to make sure that an athlete is game ready."
Machado played in every game since his call up from the minors in August 2012 until he was injured Sept. 23, when his left leg came down awkwardly on first base during a game at Tampa Bay.
Showalter made it clear Friday that the injury won't change how often Machado plays in the regular season. The Orioles had five starters who played at least 156 games this past season: Adam Jones (160), Nick Markakis (160), Chris Davis (160), J.J. Hardy (159) and Machado (156).
"It won't change anything," Showalter said.