Fighting back vs. Tommy John surgery



If Stephen Strasburg served as a warning shot and Matt Harvey a wake-up call, consider Jose Fernandez a body blow to the game of baseball.

Fernandez is the Miami Marlins' 21-year-old ace. The hard-throwing right-hander's journey to the major leagues included stints in a Cuban prison and a boat trip to Mexico. He debuted at age 20 in 2013 without ever pitching above high-Class A ball and won the National League rookie of the year award.

Now he is out for the season, banished to surgery and rehabilitation by the same elbow injury that sidelined Strasburg and Harvey in the past and so many more pitchers this year. Fernandez's case is one in an increasing series of ligament replacement procedures - known as Tommy John surgeries - that are affecting more major leaguers now, and more younger pitchers, than ever before.

"Now it's almost part of your development to go through it," said Pirates special assistant to the general manager Jim Benedict, a pitching savant who works with the organization's arms. "That's been a little bit disturbing that it's an accepted practice."

As though identifying amateur talent wasn't hard enough, teams preparing for the first-year player draft, which begins Thursday, face the additional challenge of trying to determine which young pitchers are less likely than others to get hurt. The reality is, injuries to the pitching elbow often begin years before they need surgery. Pitching year-round in adolescence and specializing in baseball rather than playing other sports, coupled with the fact pitchers throw harder now than ever, have contributed to elbow injuries that might not reveal themselves fully until years later.

"Unfortunately there really is no answer right now," Pirates head athletic trainer Todd Tomczyk said. "Our concern is that this trend is going to get worse, and from my lens, it starts way before we even get them at the major league level."

The procedure

This year, according to data compiled by Baseball Heat Maps, 20 pitchers who were either in the majors, had guaranteed roster spots or strong chances of making the team out of spring training have had the procedure. Two more, according to reports, might need it in the coming weeks. That's more than the 19 in all of 2013 and more than halfway to the record of 36 in 2012. The patient roster includes notable starters such as Fernandez, Arizona's Patrick Corbin, Tampa Bay's Matt Moore, the New York Yankees' Ivan Nova, the Texas Rangers' Martin Perez and the Oakland Athletics' Jarrod Parker.

The victims are getting younger. Right-hander Jameson Taillon, the Pirates' top pitching prospect, needed the surgery this spring at 22. Strasburg needed it at 22 in 2010, Harvey at 24 last year. Moore and Corbin are 24 and Perez is 23. Parker had the surgery for a second time at 25.

The ulnar collateral ligament, or UCL, connects the bones in the upper arm and forearm at the elbow and acts as a stabilizer on an overhead throw. Due to various factors - overuse, poor mechanics, compensating for another injury, simple wear and tear - the UCL can fray, tear or snap. Tommy John surgery, named for the Los Angeles Dodgers left-hander who first had it in 1974, replaces the damaged UCL with a tendon from another part of the body. Recovery takes roughly a year.

The elbow has six growth plates, Tomczyk said, that do not fully mature until the age of 15 or 16. When young pitchers throw too many pitches, or throw too often and do not allow their developing bodies appropriate rest, they increase the risk of injury. A 10-year study from the American Sports Medicine Institute that surveyed pitchers ages 9 to 14 found that pitchers who logged more than 100 innings per year were 31?2 times more likely to have elbow or shoulder surgery, or stop playing because of injury.

"If that's not proof, I don't know what is," said Dr. Glenn Fleisig, the ASMI research director, who worked on the study.

Fleisig worked on another study, published in the American Journal of Sports Medicine in 2006, concerning pitchers ages 14 to 20. The study found a correlation between more games and innings pitched, pitches thrown and months pitched per year and higher risk for elbow and shoulder surgery. Specifically, averaging more than 80 pitches per game and pitching more than eight months per year increased the chances for injury by four and five times respectively.

A decade ago, USA Baseball adopted guidelines to safeguard youth pitchers. Little League Baseball replaced innings limits with pitch counts, which are considered a better indicator of stress on the pitcher, in 2007.

"All these guidelines have been very well published, very well studied," Tomczyk said. "However, they're not being followed."

Overuse and velocity

A 100-inning season for a youth pitcher is possible due to the proliferation of the single-sport athlete, the pitcher who does nothing but pitch for the majority of the year. A study published in "Athletic Training & Sports Health Care" in 2012 found that a quarter of Little League pitchers also pitched for travel teams. A pitcher can adhere to the pitch limits of his Little League or high school team, then go pitch for his travel team or take private lessons and render those limits ineffective.

"I think specialization of sport is the worst thing that's happening to young athletes," Pirates general manager Neal Huntington said. "We're asking too much of them."

All this data, all these studies, and yet: In mid-May, according to several reports, Dylan Fosnacht, a high school pitcher in Washington state, threw 194 pitches over 14 innings in one game. The absurdity of the outing drew the attention of Rays ace David Price, who tweeted to Fosnacht: "haha you're a beast @DFosnacht5 ...but let's be a little smarter brotha!! Love the competitiveness though!! #urcoachshouldbefired."

Fernandez, Strasburg and Harvey are key cases not only because of their youth and prominence, but because of their velocity. The trio led qualified pitchers in average fastball velocity in 2013. A study published in the American Journal of Sports Medicine in 2010 found a correlation between pitchers achieving high velocity and those who had elbow injuries. The three pitchers studied who threw hardest all needed Tommy John surgery.

According to Fangraphs.com, which uses PITCHf/x data gathered at ballparks, the average fastball velocity in 2013 was 92 mph. That is more than a mile per hour faster than 2008 and the average has increased each year.

"Never in the past were there so many pitchers in Major League Baseball and minor league baseball throwing a 95 mph and faster fastball, which our data show, the faster you throw, the more stress there is on the elbow as a generality," Fleisig said.

The draft

Already this spring, two top draft prospects, UNLV's Erick Fedde and East Carolina's Jeff Hoffman, needed Tommy John surgery.

Huntington declined to discuss in detail the Pirates' methods for predicting who will stay healthy, but noted that the organization doesn't possess a magic formula and that, "It's more an art than a science."

"We don't think that we've got this thing figured out," he said. "We're still having some Tommy Johns. We think we have them at a much lower rate than most in the industry do, but that doesn't necessarily mean what we're doing is right."

Huntington did say the organization likes athletes who play multiple sports, due to the added rest for the arm and the intangible, team-related benefits. Benedict said the team looks for pitchers who are athletic, flexible and don't use maximum effort to pitch.

The Houston Astros, who pick first overall Thursday, have $7,922,100 to spend on a signing bonus for that selection, according to Baseball America. The final selection in the first round can still sign for more than $1 million. Pitchers represent six of the top 10 largest current contracts in baseball, by average annual value, and 10 pitchers have contracts worth a total of $100 million or more. There is money to be made on the mound, and that financial incentive will drive families to spring for private lessons or travel teams in the well-meant but misguided hope of giving a young pitcher the best chance to succeed.

The lure of those multimillion-dollar contracts becomes

"a cookie out there that's hard to pass up," Tomczyk said.

Prevention

This past week, ASMI released a position statement that sought to correct misconceptions about elbow injuries and make recommendations for reducing risk. Among them: Don't always pitch at maximum effort, reconsider participation in winter ball so as to allow the elbow to rest and report pain or stiffness to the training staff.

Fleisig recommends having a biomechanical evaluation. On Friday, an ESPN report detailed a phone application, created by ASMI founder and noted orthopedic surgeon Dr. James Andrews, called Throw Like a Pro. The app, reportedly due out in a few weeks, will provide exercises and warm-up routines, as well as track pitch counts and the corresponding days of rest required.

"From the prevention side, limiting the amount of full-effort pitching is the No. 1 factor," Fleisig said. "?...?It really falls on the parents to step up and become more educated, and many are nowadays."

MLB's medical advisory board is looking into the issue, Tomczyk said, "leaving no stone unturned." MLB and ASMI participated in a study during spring training, Fleisig said, examining the biomechanics of pitchers with and without a history of Tommy John surgery.

But the shift, studies show and experts say, must start before those pitchers reach pro ball, and the road ahead is long. Benedict recalled the brief period in which his son wanted to pitch in Little League and his disbelief with the pitch counts.

"I said, 'My kid's not pitching,'?" he said. "One of the coaches came up to me and said, 'Why don't you like your kid?' I go, 'Are you kidding me? I'm protecting him from you.'

"I'm going, OK, this is where it starts. Thank God my kid said, 'Dad, I don't want to play baseball. I like basketball.' I said, 'Great. Let's go play some hoops.'?"

Bill Brink: bbrink@post-gazette.com and Twitter @BrinkPG. 


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