April 19, 2014 11:10:14 PM
At one time, the surgical procedure known as "Tommy John" surgery was a rarity.
First performed in 1974 by orthopedic surgeon Dr. Frank Jobe, then a Los Angeles Dodgers team physician, on Tommy John, the procedure grafts a tendon from someplace else in the body and uses it to replace the ulnar collateral ligament in the medial elbow. At the time of the surgery, Jobe said John's chances of a full recovery were 1 in 100.
These days, Tommy John surgery has transformed from a potential medical marvel into a common occurrence. The success of John, who won 124 games before the surgery and went on to win 164 after it before retiring in 1989 at 46, and many others who have had the surgery has created a growing demand for the surgery. In 2009, prospects of a complete recovery had risen to 85-92 percent, according to Eric Rosenhek, who wrote "The gory details of Tommy John surgery."
Once seen as something to avoid, pitchers are requesting the procedure after they experience pain in their shoulder or elbow. It sounds simple. A patient's arm is opened up around the elbow and holes are drilled in the ulna and humerus of the elbow to accommodate a new tendon. The tendon, normally from a human cadaver, replaces the damaged ligament. The misconception is that even though some pitchers return from the surgery throwing harder, others aren't able to come back after the surgery or the procedure makes them more susceptible to suffering the injury again.
"It's your fault in the media," a National League scout told The Dispatch this month. "The media reports all the success stories about how a guy in the big leagues is throwing harder than he ever has before after Tommy John. They ignore all the guys that can't stay off the training table after they get it done the first time."
The debate will continue in an attempt to find ways for pitchers from 12 years old to college age to avoid the surgery and to find a more efficient method of pitching that eliminates the injuries that lead to the surgery.
Overuse of young pitchers
Many believe overuse of pitchers is the leading cause of ligament damage that leads to Tommy John surgery. Dr. Jobe has said in multiple interviews that parents have asked him to give their child the surgery immediately after they felt any pain in their throwing arm. However, surgeons are hesitant to use the procedure and will do everything they can to follow a more conservative approach.
Dr. James Andrews, the orthopedic surgeon to many athletes and the man considered the go-to surgeon for the procedure, said April 12 in a interview with MLB Network Radio that kids competing all year in baseball is a leading cause to UCL injuries.
"We've researched it in our lab as well as our foundations in Birmingham and Pensacola, and the big risk factor is year-round baseball," Dr. Andrews said. "These kids are not just throwing year-round, they're competing year-round, and they don't have any time for recovery."
Andrews has found once a player becomes a teenager, he likely will finish his high school season and then begin play with a travel ball team, so his arm doesn't get a chance to recovery.
"Year-round baseball is the number one problem," Dr. Andrews said in terms of Tommy John risk factors. "Number two is playing in more than one league at the same time where rules don't count (presumably innings limits or pitch counts). In showcases for scouts, they try to overpitch and they get hurt."
Little League Baseball imposed strict per-game pitch limits five years ago, but Andrews told The New York Times he has performed about seven times the number of arm operations on young pitchers he did 15 years ago.
"It's a trend and an epidemic (because) I'm inundated from January, February, March, and into April with Tommy John injuries," Andrews said on MLB Network Radio. "We used to not see these injuries until they got into high level professional baseball, but the majority I'm seeing now is ninth, 10th, 11th grade in high school."
The idea of a pitcher being overused before he is 18 is a problem for professional scouts and college coaches. The Mississippi State baseball team already has had pitchers Paul Young, John Marc Shelly, and Will Cox undergo Tommy John surgery this season. Young won't throw a pitch in a game at Dudy Noble Field until at least 2015. The junior college transfer continually threw more than 100 pitches in starts while at Central Alabama Community College. He led CACC to the national championship in 2013 with a 2.44 ERA and 57 strikeouts in 55 1/3 innings. He ended his junior college career with a 140-pitch complete-game victory in the 2013 NJCAA National Championship game. The Cleveland Indians selected Young in the 21st round of the Major League Baseball First-Year Player draft. The 6-foot-3, 205-pound right-hander was expected to compete for a starting spot in the weekend rotation after he chose MSU over Florida, Florida State, Missouri, Ole Miss, and LSU.
In his first preseason outing this spring with MSU, Young experienced pain in his throwing arm and was referred to Dr. Andrews. Andrews performed Tommy John surgery on Young in early March. MSU restricts media access to athletes who are injured or recovering from injury, so Young was unavailable for comment. MSU shut down Young in the fall and prevented him from throwing and long tossing.
MSU coach John Cohen and the rest of the MSU coaching staff has declined to comment about players' injuries due to concerns about violating the HIPPA Privacy Rules.
Four years ago, Ben Bracewell pitched the final month of the season with a labrum injury of his pitching shoulder. The Dispatch was told at the end of 2010 season the injury involved the front part near the biceps tendon being damaged, but unlike most cases in this injury, the right shoulder remained strong. Bracewell was told by MSU team doctors and Andrews that limited pitching throughout May wasn't going to damage the injury any further or create a longer rehabilitation process after the surgery was performed.
Cohen suggested Bracewell's injury likely was due to a freak arm problem that they were aware of before he arrived at MSU. Former Briarwood Christian baseball coach Lee Hall strongly denied he overused Bracewell during his final year of high school.
"He never threw more than 90 innings for me in a 15-week season any of the four years he played for me at the varsity," Hall said. "When somebody gets to 90-100 pitches I get nervous. That's not abuse."
Since Bracewell has had labrum surgery and then Tommy John surgery two years later, Hall has stayed in close contact with the Bracewell family. He said he has full confidence in the throwing/conditioning program of MSU pitching coach Butch Thompson, who Hall calls a very good friend.
"I've got two sons, and the first coach I'd want them to play for is Butch Thompson," Hall said. "The arm is not made to throw overhand, and everything MSU is doing, I would trust 100 percent."
Baseball America national college baseball writer Aaron Fitt said a program that needs three of its pitchers to have Tommy John surgeries doesn't prove anything irresponsible is being done with the young arms.
"Pitchers have a likelihood of breaking down and getting hurt," Fitt said. "I tend to be in the camp that with some pitchers it's just part of the reality of throwing that hard for so long."
After having several pitchers go down with injuries in their first couple of years at MSU, Cohen and Thompson have become more conservative with how they use young arms in their program. The Bulldogs have shut down sophomore right-hander Preston Brown after he had shoulder pain three weeks ago in a bullpen session. Freshman Dakota Hudson was scratched less than an hour after his scheduled start Tuesday against Alcorn State after he reportedly had back and shoulder tightness.
ESPN baseball senior writer Keith Law, formerly a writer for Baseball Prospectus and an employee in the front office for the Toronto Blue Jays, has been critical of college coaches for abusing pitchers before they get a chance in professional baseball. Most recently, he was critical of North Carolina State's usage of Carlos Rodon, the projected No. 1 pick in the 2014 MLB draft.
In a start April 11 at Duke, Rodon returned to the mound for the eighth inning after having thrown 118 pitches.
"This was a clear example of a coaching staff putting their own interests over those of a pitcher, a perfect example of moral hazard at work in amateur baseball, one that calls for regulation by the NCAA," Law wrote in his blog for ESPN.com "The Wolfpack, despite having two of the best college players in the country this year, are 5-11 in the ACC (19-14 overall) and in danger of missing the NCAA tournament, a result that would be devastating given their talent level. The potential cost of missing the tournament is so high that the coaching staff has the incentive to try to win at all costs, including asking players to do things that may not be in their own best interests, such as throwing 134 pitches in one outing."
Law said later in the blog that only one MLB pitcher -- San Francisco Giants right-hander Tim Lincecum -- threw 134 pitches in an outing last season. Lincecum did that July 13 in a no-hitter.
In last year's NCAA Regionals, ESPN analyst Kyle Peterson, who was an All-American at Stanford and was selected in the first round by the Milwaukee Brewers, openly questioned the use of a North Carolina pitcher as a reliever during a nationally televised game against Florida Atlantic. Peterson, serving as a studio analyst that night, said the time had come to institute a pitch count in college baseball. North Carolina coach Mike Fox called left-handed pitcher Kent Emanuel out of the bullpen in a 13-inning victory against Florida Atlantic that sent his team to the Super Regional against South Carolina, and eventually to the College World Series in Omaha, Neb.
Emanuel threw 51 pitches in 1 2/3 innings. His velocity was down, according to Peterson and John Manuel of Baseball America, who was providing color commentary for ESPN's telecast of the game. Emanuel had thrown 124 pitches in 7 2/3 innings two days earlier in a start against Towson. After being selected days earlier by the Houston Astros in the third round, the club reached an agreement with Emanuel for $747,700, a source confirmed to MLB.com.
"My arm feels great," Emanuel said. "Believe it or not, I just got done getting an MRI, and the doctor said my shoulder and elbow look as good as any he's seen in this draft class. I'm good to go."
Emanuel threw nine innings in four games with the Astros rookie league team last year. This season, he has two starts with the team's Class A affiliate Quad Cities River Bandits in Iowa.
"To have pitch counts for college pitchers would be a terrible idea," Fox said. "I'm a little surprised it's even being discussed. I would not agree with that. I think pitch counts are overrated."
Radar gun = damage
Andrews said on MLB Network Radio his research shows a correlation with young pitchers trying to throw hard and UCL injuries.
"The radar gun is a problem because these kids are all trying to throw 90 mph," Andrews said. "The red line for the Tommy John ligament in high school is 80 to 85 miles per hour. The ones that throw beyond that are going beyond the development property of their normal ligament and they're getting hurt."
The reality of the situation, though, is 80-85 mph probably won't attract college coaches. With Tommy John surgery being so common, the risk of developing a UCL injury in the throwing elbow or a shoulder injury doesn't outweigh the reward of a professional contract or spot on a Division I college roster. At one point last year, MSU had 15 pitchers who could hit 90 mph or better on their fastball and had reached that point in high school. MSU's philosophy about stockpiling power arms is the norm in college baseball.
It used to be believed that the contortion of the mechanics of a curveball caused injury to a pitcher's arm, but scouts and college baseball analysts aren't positive there's a correlation to young pitchers throwing a breaking ball and getting injured.
A recent major study shows curveballs pose no greater risk than other pitches. In fact, many studies have shown that the greatest threat to young arms is throwing too many pitches.
"Science is banging heads with intuition and gut instinct," Glenn Fleisig, the research director of the American Sports Medicine Institute, told the New York Times in 2012. Fleisig has conducted studies on breaking balls and young arms since 1996.
"For years, we told people that curveballs were bad," Fleisig said. "Then we set out to prove it. We did not prove curveballs are safe, but we could not prove they were dangerous."
Andrews, who is the team surgeon for Auburn, Alabama, and several professional franchises, agrees with Fleisig's research in theory.
"What we found out in the lab is true," Andrews said. "For pitchers with proper mechanics, the force of throwing a curveball is no greater than for a fastball. But that's not what happens in reality on the baseball field. Many kids don't have proper mechanics or enough neuromuscular control, or they are fatigued when throwing curveballs. Things break down."
No solution but rest
Andrews admits there's no program, protocol, or plan to cut down on the number of UCL injuries. He said all the medical community can do is educate parents, coaches, and players in hopes of limiting the injuries.
"You can't prevent them," Andrews said on MLB Network Radio. "We can probably cut down the early injury rate, but kids are throwing so hard and are so competitive now. There's a dollar sign on top of them pushing themselves so hard."
Twenty pitchers scheduled to be on MLB rosters in 2014 already have had Tommy John surgery this spring. Studies and statistics have shown the first-round high school pitcher from 2010-12 is five times more likely to get Tommy John surgery than the top high school pitcher from the preceding eight years.
Fitt suggested trying to prevent pitchers from getting hurt would be "similar to trying stop football players from getting ACL injuries" because science has proven the overhand motion of a pitch being thrown isn't a natural movement.
"It's impossible," Andrews said. "We'd just like to control it better. If we could keep these kids clean through high school then we could see less injuries when they become mature college players and professional players. You have to prevent it at a young age."
The only solution appears to be rest. Most athletic research centers have proven playing multiple sports and not specializing in one keeps the body fit and allows for rest in specific areas and muscles. In one of the biggest studies of youth pitchers, the American Sports Medicine Institute in Birmingham, Ala., tracked 481 pitchers ages 9-14. The 10-year study published in 2011 found pitchers who threw 100 innings or more in a calendar year were three and a half times more likely to be injured than those who pitched less. The study recommended that no youth pitcher pitch more than100 innings in a year and "no pitcher should continue to pitch when fatigued." The research showed high school pitchers who keep pitching when fatigued are 36 times more likely to need surgery.
"In one of my patients I saw today, he has an ossification (bone tissue formation) in his ligament that probably occurred when he was 12 years old," Andrews said. "You can usually go back and see how a minor injury in youth baseball set them up for a major injury down the road."
This is why Thompson and the MSU coaches tend to respond cautiously when pitchers come to them saying they have a problem instead of following the old school mentality and telling them to pitch through soreness.
Brown hasn't thrown a baseball since injuring his shoulder. It is unclear when he will return to the mound. MSU will get an authorization from team physician Dr. Rusty Linton and a second opinion, most likely Andrews, before Brown resumes a throwing program this season.
Follow Matt Stevens on Twitter @matthewcstevens.