Last Friday, one of Major League Baseball’s most talented and marketable young stars was lost for the season when the Marlins’ Jose Fernandez went under the knife to repair a torn ulnar collateral ligament (UCL); aka Tommy John surgery.
Fernandez just might be the best young pitcher in baseball (Clayton Kershaw fans would probably disagree) and already possesses one of the most devastating breaking balls in the game, a knee-buckling curveball that ranks right up there with Kershaw’s hook and Yu Darvish’s slider.
The news is a major blow to baseball, as Fernandez has injected excitement into a lifeless Marlins organization. Miami is currently last in the National League in attendance, as they have been eight of the last nine seasons. The 2014 attendance figures are up over last year, currently hovering above 21 thousand per game; however, those numbers have been closer to 29 thousand in Fernandez’s five home starts. And now he is done for the rest of the 2014 season and possibly longer.
Fernandez’s Tommy John surgery follows in the footsteps of other young, hard-throwing phenoms like Stephen Strasburg and Matt Harvey. According to raw data from Jeff Zimmerman (and baseballheatmaps.com), it makes Fernandez the 33rd pro pitcher to endure such fate this year. Martin Perez of the Texas Rangers, who leads the majors in complete games and shutouts, became the 34th pitcher on Monday.
If that seems like a lot of names hitting the DL before Memorial Day, it’s because it is. The issue is growing and the trends over the last two decades have become a major concern for all involved with the game.
“It’s not an epidemic – yet, but I think I see the storm clouds gathering,” says Stan Conte, the Dodgers’ vice president of medical services.
All of which begs the question – just what the hell is happening out there?
Evolution of the Issue
Every generation, every decade, every year, athletes across sports are becoming bigger, faster and stronger. Physiological developments that push the limits of the human body bear natural consequences side effects: notably, players are breaking down more often. And as they do, modern sports medicine innovates new and better ways to put Humpty Dumpty back together again.
Perhaps no sports-related procedure has been more successful at saving and prolonging careers than UCL reconstruction surgery, and there is no better place to start tracing the surgery’s evolution than the procedure’s namesake, Tommy John.
In the midst of an excellent 1974 season for the Los Angeles Dodgers, Tommy John tore the ulnar collateral ligament in his left (pitching) elbow. A torn elbow ligament, the most common cause of what was simply referred to as “dead arm” injury during most of the 20th century, had been a harbinger of doom for most baseball careers, much in the same way a torn ACL signaled the end of football careers (Boobie Miles Gale Sayers, anyone?).
The revolutionary operation, pioneered by Dodgers team doctor Frank Jobe, involved grafting a tendon from the forearm into the elbow to act as a ligament, similar to other ligament reconstructions (such as ACL). At the time, Jobe estimated the chance of John regaining his form was 1 in 100.
Tommy John was a veteran of 124 wins and more than 2,000 major league innings when he underwent history’s first UCL reconstruction surgery; his injury was one of long-term erosion. After John returned to baseball in 1976, he went on to pitch 14 more seasons and win 164 games before retiring in 1989 at age the 46 (his 288 career wins rank 7th amongst left-handers in baseball history).
Despite the resounding success of the surgery, dead arm remained an infrequent injury issue for pitchers, with an isolated case or two per year over the next two decades. But beginning in the late ‘90s, “Tommy John” turned into a staple of the game.
Bearing the familiar triangular scar is now commonplace. Per baseballheatmaps.com, an average of 15.8 MLB pitchers per year had Tommy John surgery from 2000 to 2011. That number spiked to 36 in 2012 and could set a new high this season. And according to research presented by Conte at the 2014 ASMI Injuries in Baseball Course, 25% of Major League Baseball pitchers have now undergone Tommy John. Twenty-five percent.
So what exactly is happening and why is the problem getting worse? “Bad mechanics” used to be an industry buzzword but the consensus seems to fall on a couple of key factors that are influencing pitchers long before they ever throw a professional inning: velocity and volume at the amateur baseball level.
Force = Mass x Velocity x Innings Pitched
With great power comes great responsibility. While that was self-evident to Peter Parker, it remains a lot less clear to the prep coaches around the country that boast power arms on their roster; consider the cases of young flame-throwers like Jarrod Parker or Jameson Taillon.
Parker, who was a Top-10 pick out of high school in the 2007 Draft thanks to a mid-90s fastball and two above-average breaking balls, underwent Tommy John surgery this March…for the second time. His first came back in 2009 at the age of 20, after just 215 minor league innings.
Taillon, the number two overall pick in 2010 who has been hurling 90-plus mph heaters since he was 16, had his elbow ligaments give way earlier this year at the age of 22, after just 382 professional innings.
Both pitchers had pitched under close monitoring and with extreme caution by organizations (Diamondbacks and Pirates, respectively) that handed them millions of dollars right out of high school. Yet their arms still gave out. The story of their elbows have become commonplace, and one of the lynchpins between their storylines is that they’ve thrown hard since they were young.
Fastball velocity is on the rise all across baseball. At the major league level, average fastball velocity increased more than a full mph from 2008 to 2013 (90.9 mph to 92 mph). Many of the same advancements in year-round and specialized training have filtered down to boost velocity at the prep level as well.
After all, making a radar gun read 90 mph is like running a 4.4 forty-yard dash or checking in at 7-feet tall; it means college coaches and professional scouts will soon come calling. And that provides parents an irresistible temptation to specialize players early and accelerate the developmental process.
The problem is you can’t rush Mother Nature. Teenagers, unless exceptionally blessed genetically, don’t have bodies developed enough to handle the strain of max-effort fastballs that light up radar guns. On a recent MLB Network Roundtable focused on pitching injuries, Dr. David Altchek, Medical Director for the New York Mets, noted that the UCL in teenagers is a developmental ligament that is only designed to withstand the stress of a fastball around 80 mph. Simply put, youth players don’t possess the functional strength or ligament progression to support the arm speed needed to generate high velocity.
While the premise is intuitive, we are now seeing data to back it up. Research from the American Sports Medicine Institute (ASMI), founded by the famed Dr. James Andrews, has shown that high school pitchers who threw harder than 85 mph were much more likely to go under the knife before they turned 20 than those who didn’t.
High-velocity arm speed generates strain that weakens the ligaments and tendons, but ultimately a frayed ulnar collateral is the result of long-term (ab)use.
In a 10-year study published by ASMI in 2011, researchers tracked 481 pitchers between the ages of 9 and 14 and found that those who threw 100 innings or more in a calendar year were three and a half times more likely to be injured than their amateur counterparts. Those risks increase exponentially when you have hard-throwing high school kids pitching past the point of fatigue – data showed a high school pitcher who keeps pitching when fatigued was 36 times more likely to wind up needing surgery.
What Do We Do Now
The good news for baseball players, parents and fans is that the solution to fix dead arm already works great. New research on pitchers from 1986 to 2012 showed more than 97% of MLB pitchers undergoing Tommy John returned to pitch at the minor league level at the very least, with 83% returning to the major league level, and players’ careers continuing an average of 3.9 years following surgery.
The better news is that the blueprint for healthier young pitchers is already clear. Cut down on the total innings, stop playing in so many high-stress environments (i.e. showcase tournaments) where players are trying to light up radar guns every pitch, and take longer breaks from the game, instead of year-round travel ball that only stops for Christmas/New Year.
But the success of fixing the problem seems to be impeding the larger issue of preventing the problem in the first place. And given the success rates of corrective surgery mentioned above, it is tough to construct a scenario in which the risks of burning out young arms outweigh the rewards of college scholarships and professional signing bonuses. There is one thing that can (hopefully) be held up as a sign of caution to parents and coaches alike.
As Conte points out, the shoulder is not designed to “throw repeatedly for two hours as hard as you can. It’s just like the tires on your car. Tires are designed to run for 40,000 miles — unless you drag-race. They’re not designed for that. So they wear out a lot sooner.”
If you know you can get your tires changed with 97% certainty and that you’ll be able to drive again, you might continue to drag-race without caution. But what happens when you need the wheels changed a second time?
From 1996 to 2011 (16 years), the total number of repeat Tommy John procedures in major league baseball was 18. In the three years since, there have been 14 “revision” surgeries, including six in 2014. And the success rates of those revision procedures have been estimated below fifty percent, and as low as twenty.
The infamous Dr. Andrews, who has performed more Tommy John surgeries than just about anybody in the country, stated at the roundtable discussion that procedures he performs on youth and high school pitchers now account for more than those of college or pro players. By comparison, he performed just five Tommy John surgeries on youth pitchers in 1998.
That is a whole lot of young pitchers starting the clock on their second surgery before ever throwing a college or professional inning, and a whole lot of young men that will see their stars burn bright too quickly and their promising careers cut short by completely preventable damage during their developmental years.
I grew up watching the Atlanta Braves and the Big Three, Greg Maddux, Tom Glavine and John Smoltz. Almost 13,000 major league innings between the trio and just one major surgery, Smoltz’s Tommy John at the age of 33. They were something you could count on and look forward to every year. Now two-fifths of the Braves’ planned Opening Day rotation (Kris Medlen and Brandon Beachy) have undergone Tommy John number two and may never see the big leagues again.
That is bad for the game and even worse for the players involved. How long will it be until we start seeing the replacement ligament treads wear out on some of baseball’s biggest names, and will we finally start taking better care to preserve the next Strasburg or Harvey or Fernandez when it does?
Only time will tell, but stormy weather is definitely heading our way.