The act of throwing a baseball 90 mph, 100 times a game, every fifth day, 34 times a season plus spring training, destroys the body. It frays ligaments and tears muscles and sometimes breaks bones.
One of the ligaments it frays with startling regularity, the ulnar collateral ligament, lives on the inside of the elbow. Sometimes it unravels slowly, like a rope. Sometimes it snaps like a rubber band. Every time, it inhibits the pitcher's ability to throw hard, or throw strikes, or even throw at all.
Charlie Morton is throwing now, though only from 75 feet, off of flat ground. Five months ago, the Pirates right-hander, 29, had surgery to repair his UCL, a procedure that has not changed much in its 38-year existence. The ligament replacement procedure, known to the world as Tommy John surgery, sports a remarkable success rate. Improved techniques have helped more pitchers return to play, but the player's rehabilitation, which takes around a year, is more important to a successful return.
The surgery has become commonplace, both because of its effectiveness and because pitchers keep damaging their elbows through poor mechanics and overuse. Doctors and coaches understand how the injury occurs. The best option, of course, is applying that information and preventing the injury from occurring in the first place.
"Pitching coaching and pitching information is, I think, 10 years behind the rest of it," said Pirates special assistant to the general manager Jim Benedict, a former pitcher who has worked with Morton during his rehabilitation. "I think it's such a valued position as far as finances, and I think we're behind."
Charlie Morton has thrown 7,918 pitches in his major league career. Add his warm-up pitches, bullpen sessions, spring training, high school ball and anything he threw off a mound since Little League and his total pitch count becomes incalculable. He has no idea which one directed the first salvo at his UCL.
Morton said his elbow hurt on and off for a few years prior to the 2012 season, but he experienced none of the symptoms of UCL damage: no swelling, no drop in velocity or loss of command. At the end of May, the pain became bad enough that Morton needed a diagnosis.
"That whole time for a month, I needed surgery," Morton said. "I just didn't know it."
Morton, who spent the first two weeks of the season on the disabled list after offseason surgery to repair a torn labrum in his left hip, made nine starts in 2012. He pitched at least six innings in four of his final five starts, but allowed four runs in four innings against the Cincinnati Reds in his last start, May 29.
"I pitched terrible, but that's legitimately all I had," Morton said. "Four-seam, changeup. Curveball that hurt and a sinker that hurt. Am I really doing anything for anybody?"
Tests confirmed that Morton had a full thickness tear of his UCL.
Before Tommy John was a surgery, it was a name, as in Los Angeles Dodgers left-hander Tommy John. John hurt his elbow in 1974, and when rest and rehab failed he needed another option.
Dr. Frank Jobe, the co-founder of the Kerlan-Jobe Orthopedic Clinic that handled medical treatment for the Dodgers, had an idea. He would, in essence, replace the shredded ligament with a tendon from another part of the body and tie the bones in the arm back together.
Feel that bump on the inside of the elbow? That's the epicenter of this business. The ulnar collateral ligament connects the humerus, the bone in the upper arm, to the ulna, one of the two bones in the forearm. The anterior band of the UCL stretches from the humerus to the ulna and resists forces that try to pull the elbow apart -- such as those generated by hurling a baseball.
"It's one of the primary stabilizers of the elbow, and as such it plays a key role in allowing these guys to throw as hard as they can and as consistently as they can," said Dr. Lewis Yocum, an orthopedic surgeon at the Kerlan-Jobe Orthopedic Clinic in Los Angeles and the team physician for the Los Angeles Angels.
Jobe took a tendon from John's right wrist, drilled holes in the humerus and ulna and looped the tendon through the holes in a figure-eight pattern. Thirty-eight years later, Dr. James Andrews, a leading orthopedic surgeon, performed basically the same surgery on Morton.
Morton pulled up his jeans to reveal the scar on his left knee where Andrews removed the gracilis tendon from his upper leg, which he would use for the procedure. Morton's wife, Cindy, got a better view from an observation room.
"She's watching Dr. Andrews, Dr. Andrews cuts the tendon out and holds it up and he's testing it, playing with it like a piece of spaghetti," Morton said.
John missed all of the '75 season, but pitched another 14 years after that. He retired at 46 after 26 major league seasons with 288 wins. Thousands of pitchers have had the procedure and many have returned to successful careers in the majors, including Pirates starter A.J. Burnett, John Smoltz, Chris Carpenter, Stephen Strasburg and Brian Wilson. According to USA Today, about one in every nine pitchers who appeared in the majors in 2002-03 had the surgery, and a 2010 study in The American Journal of Sports Medicine found that 83 percent of pitchers who had the surgery returned to their previous level of competition.
"There have been some modifications, but they're not major modifications," said Dr. Christopher Ahmad, the team physician for the New York Yankees and an associate professor of clinical orthopedic surgery at Columbia University. "There's really a lot of credit given to Dr. Jobe for developing a surgery that has not changed that much over 40 years."
The surgery, though brilliant and revolutionary, does not guarantee a return to the field. It provides a blank slate on which patients can reconstruct their mechanics and eliminate weaknesses or bad habits through vigorous rehabilitation.
The rehab process takes about a year, and that's not an arbitrary timetable. That's how long it takes for the tendon to "ligamentize," or convert from a tendon to a ligament, like the tissue it replaced.
"That new tendon that gets put in, it undergoes biologic changes," Ahmad said. "It gets blood supply, vessels actually grow in and around it. It incorporates into the bone."
As the players begin to throw, Ahmad said, the ligament responds to incremental increases in stress and adapts to them. From there, the onus lies on the pitcher to strengthen his entire body and eliminate weaknesses in what Ahmad called the "kinetic chain," the rest of the body's movements during the delivery.
"If you go to enough games and watch enough pitchers, you'll look out at the pitcher and say, that guy's either hurt, or he was, and he wasn't rehabbed properly," Benedict said. "In rehab, it's a great opportunity to get you back to discipline, to get you back to a good routine where you don't take anything for granted."
It's a lonely process, working out for almost a year without seeing the mound in a competitive setting, but Morton had support. He moved to Bradenton, Fla., to be close to the Pirates' spring training facility and worked out with injured Pirates prospects Ryan Beckman and Josh Bell. Beckman had Tommy John two days before Morton.
Morton started throwing four months after the surgery. He said he feels strong enough that he has to promise Pirates rehab coordinator Jeremiah Randall that he's not trying to throw hard, really. He just is.
"I had literally been thinking about throwing, going through it in my mind," Morton said. "I was dreaming about throwing. I picked up the ball and it wasn't foreign."
Experts have isolated some of the causes of UCL damage, but preventing it remains a tricky business.
Fatigue and injury, the experts said, contribute to elbow stress. Tired legs can cause a pitcher to 'fly open,' or rotate his torso too far ahead of his arm, and increase the load on the UCL. Improper technique when throwing a breaking ball can affect the elbow. Overcompensating for another injury may increase the stress on the ligament.
Overuse -- throwing too many pitches or pitching too often -- causes the ligament to fray, especially in young pitchers.
"That's why people get gun-shy looking at the Florida and California kids in the draft, because they're all playing on two or three different teams and playing year-round," Yocum said.
Benedict said Morton thought the damage started in 2007 or '08. Before Morton lowered his arm slot after the 2010 season, his head moved outside and he raised his arm high overhead during his delivery.
"It possibly could have come from throwing his breaking ball a lot and kicking his head out to do it that caused it," Benedict said.
Benedict has shown Morton the old delivery on film.
"My front side's flying open, my arm's dragging through, obviously it's putting a lot of stress on there," Morton said. "I used to throw a lot of curveballs."
As for the hip injury, which Morton pitched through in 2011, Benedict said, "I think there probably was some favoring but it's not something we talk about."
Benedict stressed the importance of individual assessment in injury prevention and cautioned against rushing the player through the minors.
"It's the ability to evaluate the person that you're looking at, that you're going to work with, not lump them all into one pile," he said.
Yocum and Ahmad pointed to total body strength and a commitment to mechanics, proper breaking pitch instruction and a respect for the rest the arm needs. The sad truth of the matter is that no proven Tommy John prevention strategies exist.
"The game loves black and white, and it's gray," Benedict said. "Everybody loves black and white, right or wrong, and it's none of those things."
Morton hopes to throw bullpen sessions by January. The Pirates must tender Morton, an arbitration-eligible player who made $2,445,000 in 2012, a contract by Friday or he becomes a free agent. Morton said he was open to returning to the Pirates if they non-tendered him.
"I want to be a Pirate," he said. "We love it here."
In the meantime, he will return to Bradenton. Commit to his mechanics. Lift weights three days a week. All in the hopes that sometime next June, he can return to a major league mound and reap the benefits of the hamstring tendon holding the bones in his arm together, the procedure that gave him and so many others a second chance. He will do this because as effective as the surgery is, it doesn't guarantee a return.
"We're not as good as the original architect," Yocum said. "We've been very blessed and fortunate that we can do what we can do, but it's hard to duplicate the original equipment."pirates
Bill Brink: firstname.lastname@example.org and on Twitter @BrinkPG. First Published November 26, 2012 5:00 AM