The next step for Carlos Beltran may be much more significant than running on a baseball field, which he plans to finally do Monday in Port St. Lucie, Fla. As long as Beltran continues to show only marginal improvement after the January operation on his right knee, the odds of his needing microfracture surgery steadily increase.
Given Beltran's medical history and numerous procedures on that knee, he's becoming a more likely candidate for the surgery, which involves poking holes in the bone so the resulting blood flow and clotting creates a substitute for the missing cartilage.
"For a high-performance athlete, there aren't many other choices," said Dr. Ronald Grelsamer, a knee surgeon and chief of patellofemoral reconstruction at Mount Sinai Hospital in Manhattan. "If you have an area of raw bone, there aren't that many options."
It is those areas that are causing the bone bruises that sidelined Beltran for six weeks last season and also sabotaged his rehabilitation efforts during the winter before he opted for surgery, which initially created friction with the Mets' front office. The team described the operation as an arthroscopic procedure to "clean out the arthritic area" of his right knee. That wording indicates a chronic issue that is not going away anytime soon. "Very often, these bruises are nothing more than arthritis," Grelsamer said.
Another important distinction to make, Grelsamer says, is that the size of the bruises - or their existence alone - does not necessarily mean Beltran is unable to play with them. When Beltran visited Colorado last month for a post-op checkup at the Steadman-Hawkins Clinic, where his latest surgery was performed, he was told that one bruise had improved but another remained the same.
Still, Beltran returned to moderate baseball activity this week - taking batting practice, playing catch - but limited himself to jogging in the hydrotherapy pool before those workouts.
"The first thing to make clear is that a bruise does not imply trauma," Grelsamer said. "Number two, the image that you see does not correlate well with how a patient feels in general. So although it's nice to follow an MRI, it doesn't tell you how a person is feeling, and therefore is not in and of itself going to determine what a person can or cannot do.
"At the end of the day, most health professionals are going to go by what the patient is telling them. So if Beltran says, 'I feel pretty good,' then chances are the doctors looking after him are going to say, 'If you can swing a bat and you can run, then by all means, do it.' The fact that the MRI is imperfect suggests that he may one day have a relapse. But who knows when that will come. A relapse could be in 10 years."
In the last week of March, Beltran said he hoped to run again by the first week of April but refused to make any predictions about when he would rejoin the lineup. He whiffed on that running timetable by more than a month, and no one in the front office has dared to even guess a potential return date for the centerfielder - or even the next milepost in his rehab process.
Beltran told the Daily News earlier this week that it was too painful to run for even a minute on a treadmill during his visit to the Colorado clinic. Coming more than three months after the Jan. 13 surgery, that was an ominous sign. "If they've tried treatment X, and at the end of that treatment, the patient says, 'It hurts after a minute of running on the treadmill,' then there's still a problem," Grelsamer said. "Then you have to go to the next step up the ladder."
Figuring that out is the problem. Beltran was equipped with a knee brace in Colorado to help in the rehabilitation and is likely to need it upon his return to the field. He also received an injection of Synvisc - a temporary lubricant for the knee joint that Grelsamer compared to using eye drops for dry eyes.
"These are often conditions that are managed," he said. "They're not cured, they're managed."