A Tommy John Surgery Theory

jose fernandez

Neil Weinberg is the Founder of New English D and the Associate Managing Editor at Beyond The Box Score. You can follow and interact with him on Twitter @NeilWeinberg44

I’m not a doctor and I haven’t spent years studying the fragility of the human elbow when it is asked to fire baseballs at 95 mph. This isn’t an idea grounded in any new research, but it’s an idea I’ve been thinking about over the last week as UCL tears claimed more big name victims. Everyone has an idea about what’s behind the rise in UCL injuries, but no one seems to have the right or complete answer to the problem because they keep happening to our favorite hurlers. As teams and the league move forward and try to determine a set of best practices for keeping pitchers healthy, I’d like to offer a theory about what’s behind the rise in Tommy John Surgeries over the last few years.

In the last calendar year alone, Jon Roegele has confirmed 64 such surgeries for pitchers and players such as Jonny Venters, Joel Hanrahan, Dylan Bundy, Matt Harvey, Kris Medlen, Luke Hochevar, Brandon Beachy, Jarrod Parker, Patrick Corbin, Jameson Taillon,Matt Moore, Ivan Nova, Jose Fernandez, and soon, Martin Perez. That’s just a sample of the players who went under the knife for the same surgery this year. It’s starting to feel like a crisis. Maybe it’s a blip. A cluser. A random flux. But as the best medical minds in the field start to show signs of concern, it’s worth rethinking the problem.

It’s entirely possible that high workloads in youth baseball, higher velocity, more sliders, and more intense workout regiments are behind the rise in UCL injuries. I don’t have evidence to dispute that per se, but it also appears as if all of the things we’re doing to keep pitchers healthy doesn’t seem to be working. Maybe these pitchers are doomed by the time they enter professional baseball and the problem needs to be attacked sooner, but it’s also possible that we’ve misunderstood the rise in injuries.

Again, I’d like to stress that this is an idea we should investigate and not one which I can support at this point in time. I threw it out on Twitter a few days ago and it got some positive feedback, so I thought it was worth articulating.

What if we aren’t actually observing an increase in UCL tears? I know that doesn’t make sense given everything I just told you, but hear me out. What if everything we’re doing to protect young pitchers is actually working exactly like it’s supposed to. Let’s use Matt Harvey as an example. Pretend Harvey was born 20 years earlier and was entering the majors in 1992 instead of 2012.

Harvey wouldn’t have been exposed to youth pitch counts. He wouldn’t have spent nearly as much time playing competitive baseball as a kid. He wouldn’t have spend as much time in the weight room. Imagine that, instead of having all of this training and all of this access to surgical procedures as a kid, Harvey was basically just a kid who played for a few months every year.

In this world, Harvey probably wouldn’t have Tommy John Surgery in 1994 as a member of the Mets. But I wonder if that’s because he never would have made it to the major leagues in the first place? Maybe his UCL was always going to blow out and in the 2010s, he was protected enough that he was able to keep it intact until he made it to the big leagues. In the 1990s, that ligament would have blown out when he was 16 and he would have lost zip on his fastball and never made it to the show.

Maybe we aren’t observing a spike in tears, maybe we’re observing an increase in the number of pitchers who blow out their elbow later in life. Instead of those with “fragile” UCLs going down in high school, they’re going down when they’re 24 or 25.

Let’s say you have 100 14 year old kids. Let’s say of those 100 talented pitchers, 20 of them have the stuff to make it to the MLB level in some capacity. In 1990, I would argue that of those 20, only 9 or 10 of them would make it to the show because the other 10 or 11 would hurt their arms during their high school or college careers such that MLB teams wouldn’t have interest. The problem is that we don’t have data on UCL injuries going back far enough. We have data on the UCLs that got repaired, but not the ones that weren’t.

In 2010, perhaps our training techniques are allowing all 20 of those pitchers to reach the majors, but our training techniques couldn’t protect them forever. We delayed the surgery, but we couldn’t avoid it. The elbow was always going to crumble, but we’ve done enough to make sure a chunk of amateur pitchers survived into their pro careers.

Maybe guys simply pitched through the injury two and three decades ago. If that’s the case, we aren’t seeing a spike in injuries, we’re just seeing a spike in this particular response to the injury. This is a data problem. We simply don’t know if this theory has legs because we don’t know how many pitchers ruined their UCL without having TJS in the 1980s. And we can’t really know.

I’m fully aware that I’ve presented a theory that can’t really be tested. In a technical sense, we’d want to expose one group of pitchers to the modern practice of protecting them and one to the older model and track them throughout life. But the primary problem is that such a strategy is horribly unethical. Maybe MLB could fund an opt-in MRI tracking study, but beyond that, you can’t play God with the futures of minors.

I know that James Andrews and his colleagues are reporting lots of damage to the UCLs of young pitchers, but we simply don’t know what they would have seen if they were studying them twenty and thirty years ago. The rise of the surgery might be because there are more UCL tears or because the surgery is better and more available, so people with hurting elbows go in for an exam.

As I said earlier, this theory might not hold. But right now, it seems like we’re doing a terrible job protecting pitchers so it’s worth exploring. Instead of assuming we’ve failed, what if we’re actually succeeding in a really impressive way? Maybe instead of looking at Jose Fernandez‘s injury as a failure, maybe he’s having the surgery specifically because we were able to protect him long enough to develop into an MLB caliber starter. It’s worth considering. Maybe instead of a crisis, this is actually a success story about the pitchers we never would have had a chance to see rather than the pitchers who we’re losing for a year.

  • tomf41

    Really interesting perspective, Neil. I’m gonna have to ponder your thoughts.

  • Will Carroll

    Nice theory, Neil, but the problem is that youth, high school and college players are seeing an even bigger rise in UCL tears. If Harvey were in HS now, he’d have Tommy John and be back pitching in a year. Jeff Hoffman was a top-10 draft candidate, tore his UCL, and now will likely be drafted in the comp picks — still first round, because the operation is so successful and predictable.

    Also, we do know what pitchers had 20 years ago. 1994 isn’t that long ago and Dr. Andrews and others were seeing youth patienst as well as major leaguers. The UCL sprain is easily diagnosed, even then, and we didn’t see this number of injuries.

    I like the thought process, but I don’t think some of the underlying assumptions are as unknown as you think.

    • http://www.newenglishd.com Neil Weinberg

      1) The 20 year timeframe was a little casually selected. Maybe 30 years would have been better.
      2) Are we sure that prep pitchers are getting hurt more, or just that they’re going in for the exam and surgery more? Are their records of untreated UCL injuries going back very far? If the surgery wasn’t as successful it seems like more guys might have concealed an injury.

      But again, just a theory. Perfectly open to being wrong.

      • The Captain’s Blog

        Your second point is the key…we may think pitchers are getting hurt more now on the HS level because 20 years ago, the injury wouldn’t have been treated (or the pre-onset symptoms like lost velocity might have scuttled the prospect status without an actual tear).
        In a sense, you’re saying we’ve replaced natural selection with being overprotective. It’s a very interesting thought…and one at least as plausible as many of the other theories being advanced.

        • dontstopbelieving

          That’s been my theory too (also, of course, without evidence). There could have been tons of pitchers – amateur and even pro – who suffered velocity losses and the result was a gradual decrease in performance (heck, Fernandez and Harvey were still throwing in the 90’s presumably after they tore their UCL’s) that ultimately “weeded them out” of baseball but without the publicity that each TJ surgery gets now. Now, given that TJ surgery is commonplace and is not perceived to be career-ending, a pitcher at any level will be much more willing to have the surgery rather than trying to rest and hope his velocity comes back.

      • Will Carroll

        1) I think we’d have to go further back to check the historical theory. Keith Olbermann has a similar take on that and I think it should be investigated. There was an uptick about 15 years ago and I can’t tell you why.

        2) Yeah this is an easy diagnosis. MRIs give a good view, but it’s not hard to diagnose it even manually. Search “milking maneuver elbow” and you’ll see what I mean. Obviously, pre Tommy John, this was a career ender for most.

        Even if wrong, you bring up interesting points. The more smart discussion and ideas we get out there, the better.

  • sunshipballoons

    Maybe comparing players who came up in the US, where we do treat arms more carefully, with those who came up elsewhere (Cuba? Venezuela?) we could create some sort of statistical study. This seems like good fodder for 538.

  • C.J.Wainscott

    I agree with TomF, this is a very thoughtful way of spinning what ultimately amounts to a statistics puzzle.

    Now, if Peter’s hypothesis were correct, the counter-question would be this: How do we explain the variance in pitchers with longevity then vs. now? Aren’t the same # of pitchers in the game now as there would have been in 1990? So even if younger people stay healthy just long enough to have a blowout in their young major league career, that doesn’t quite explain the generational difference in the quality of the guys that do make it to the bigs. If there were fewer pitching injuries in 1991, and if we suppose that the pitching quality/benchmarks are the same both then & now, and there are also roughly the same # of pitchers in both eras, then we’d all have to scratch our heads and wonder why the past generation that did make it up to the bigs possessed such endurance/longevity.

    • SteveFromNorfolk

      We have added 4 MLB teams and their associated farm systems since 1990 – Colorado, Arizona, Tampa Bay, and Miami. That’s around 300 more pro pitching spots available.

  • pft2

    If the theory is true then there should be a reduction in TJ Surgeries in the minor leagues the past few years. Maybe someone has the data to research this

    Its a plausible theory, but I wonder if HGH testing might not be even more of a factor. HGH can help in the recovery process between starts to repair microtears that develop after each start, and perhaps retard the progression to a full blown UCL tear. No evidence for that beyond correlation.

    Pitchers are taller, stronger and throw harder in art due to optimum pitching usage, so one would expect an increase, but the increase should be more gradual than it seems to be with what seems to be an explosion of such injuries the past 2 years