Pujols has a "high grade" tear of the ulnar collateral ligament in his right elbow, as well as bone spurs, inflammation and arthritis in the joint -- all of which have likely developed as a reaction to the ligament tear. The ligament's condition has not appreciably worsened since it was first injured, in 2003, but the surrounding issues have become somewhat more pronounced over that time.
According to Paletta, Pujols was presented with three feasible courses of action over the winter. He could continue the path he had been on, which is treating the symptoms of his injuries while he continued to play. He could undergo arthroscopic surgery, which would address the bone spurs and the arthritis but not the ligament tear. Or he could have arthroscopy as well as Tommy John elbow-reconstruction surgery.
Pujols chose the non-surgical path, a decision that Paletta endorsed. The superstar may yet require reconstruction at some point, and according to Paletta, the intermediate option is likely no longer viable.
One concern with the arthroscopic surgery is that in many cases, bone spurs and the like actually help stabilize an injured ligament, and removing them can make the problem even worse. This situation occurred with Cardinals ace Chris Carpenter last summer.
"I think now our options are really likely down to two," Paletta said. "If his elbow condition can't be successfully managed and gives him significant problems again, then I think the horse is out of the barn and he should probably consider having the whole thing done."
Pujols visited with Dr. James Andrews over the winter to discuss his options. According to Paletta, Andrews concurred with the assessment that although three choices existed, only two were truly viable.
"In December, when he saw Andrews, a reconstruction was going to cost him all of 2008, essentially," Paletta said. "So again, go back to trying to manage the problem. Albert made a decision which I think personally was a wise decision."
The Tommy John procedure requires approximately a 12-month recuperation period for pitchers, but for offensive players, it's more like an eight-month process. That means that had Pujols opted for reconstructive surgery over the winter, he would have missed a large chunk of 2008.
Pujols has expressed optimism that he will be able to manage the condition this season. He first injured his elbow in 2003 and has been dealing with the symptoms for the past five seasons. He said in January that the discomfort was worse in 2007 than it had been in previous years. On the other hand, he also hopes that having a full winter off -- rather than playing deep into October -- provided him with needed rest.
If the pain is as great in 2008 as in '07, Pujols has said, he will shut it down rather than try to play through it again. A combination of severe discomfort and a flagging Cardinals season would likely add up to reconstructive surgery, with an aim toward being ready for the start of 2009.
"If he were to develop recurring elbow problems this year," Paletta said, "and they were to be unmanageable and he said 'I can't continue to play like this,' my recommendation would be to probably have the whole thing reconstructed. I believe, and I don't want to speak for Andrews, but based on the conversations Dr. Andrews and I have had, I believe that would be Andrews' recommendation as well."
In the meantime, however, the Cardinals will attempt to treat the injury's symptoms and keep Pujols playing frequently and effectively. That's everyone's preference, and Paletta did not rule out the possibility that Pujols might play his entire career without the operation.
"This is not a curable problem without a reconstruction," Paletta said. "What we hope is that it's a manageable problem. We've been managing this problem since 2003, when he first tore it. So we've been managing it fairly successfully for five seasons now. But there comes a time when it's not manageable anymore. And if it's not manageable anymore, the best answer for Albert probably, long-term, is to consider having the reconstruction done."
Matthew Leach is a reporter for MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.