BRADENTON, Fla. -- Francisco Liriano was in pain. For two seasons after Tommy John ligament replacement surgery ended his promising second season in the majors - the one in which he finished third in AL rookie of the year voting in 2006 - Liriano had continued discomfort in that left elbow.
In 2009, after posting a 5.80 ERA to go with a 5-13 record and 4.3 walks per nine innings, he tried something different.
"I just went home and started doing pushups," Liriano said, "and got better."
The cause and prevention of elbow ligament damage is a fickle concept, one with many theories and few absolutes, and this spring has called further attention to the issue. For a week or so, it seemed, every day sent a new pitcher to the surgical procedure that will keep him off a mound for the next year.
The Atlanta Braves were hit hard, losing starters Kris Medlen and Brandon Beachy to Tommy John surgery. Oakland A's pitcher Jarrod Parker needs it, as do the Kansas City Royals' Luke Hochevar and the Detroit Tigers' Bruce Rondon. Arizona Diamondbacks starter Patrick Corbin might need the procedure as well.
Medlen, Beachy and Parker will have the surgery for the second time. The rate of return for first-timers is fairly high, due to the perfected techniques used in surgery and refinements made on the rest of the pitcher's body and mechanics as he recovers. The recovery rate drops the second time around, which is what makes preventing another injury so important.
"The majority of the exercises I was doing while rehabbing were shoulder exercises," said Charlie Morton, who had Tommy John surgery in June 2012 and returned a year later. "You're working on internal rotation, a lot of internal rotation, stretching, try to keep your range of motion."
The procedure, named after the first pitcher to undergo it in 1974, replaces the damaged ulnar collateral ligament in the elbow with a tendon from another part of the body, usually the wrist or hamstring. Pitching puts enough stress on the elbow as it is, but muscular weaknesses or injuries in other parts of the body can cause pitchers to overcompensate and increase the stress. Poor mechanics, especially when the arm lags behind the body during delivery, can also add stress to the ligament.
The rehabilitation process simultaneously allows the tendon to secure itself to the bone -- it's replacing a ligament, so it undergoes biological changes as well -- and lets the pitcher strengthen his legs, core and shoulders so he doesn't blow out his elbow again. That's why pitchers come back throwing harder. The surgery doesn't make them "stronger," though having connective tissue that's in one piece helps; they become stronger during rehab.
Sometimes, as Beachy, Parker and Medlen found out, that's not enough.
Several pitchers have pitched in the majors after multiple Tommy John surgeries, including Jason Frasor, Doug Brocail, Chris Capuano and Brian Wilson. Kyle Drabek, Daniel Hudson and Cory Luebke are in various stages of rehab from their second procedure.
Jose Rijo, the 1990 World Series MVP, reportedly had Tommy John three times. Any more than three or four and the doctors start running out of expendable tendons in the rest of the body.
As Morton put it, there is no one thing that causes, or prevents, elbow damage.
"I know people that are really strong and have strong shoulders that have had elbow problems," he said. "And I know people that I wouldn't classify as overly strong-shouldered that have never had elbow problems."
A pitcher's delivery is similar to an engine. Several things have to happen, in order, for it to work properly, and if something happens too early or too late, it puts undue stress on the rest of the operation.
"Everything stacks on top of each other and can throw your body off kilter," said Mark Melancon, who had Tommy John surgery while in the New York Yankees organization. "Making sure your posterior chain is intact and working correctly with your other body parts. A lot of that stuff can result in an arm injury, in my opinion."
The Yankees staff that worked with Melancon thought his injury could have resulted from the hyperextension of his elbow when he threw his curveball. Now he keeps the elbow slightly bent as he follows through across his body.
Morton said he noticed discomfort prior to his surgery because his timing was off. His forearm lagged behind the rest of his body. Now, he knows he's thrown a good fastball when it feels like his hand is in front of his body.
"When you throw a good pitch, when you throw a good pitch that feels good, it's like hitting a pure golf shot or hitting a baseball on the sweet spot when you make a good swing," he said.
Liriano said he didn't hear much talk about timing in Minnesota after his surgery. The addition of pushups, while seemingly a simple solution, makes sense: The exercise strengthens the entire upper body and could make up for any instabilities or compensations.
Possibly because of the myriad causes of elbow ligament damage, from overuse to improper mechanics to compensating for an injury to bad luck, there is no surefire way to prevent it. Washington Nationals starter Stephen Strasburg's surgery displayed the futility of innings counts. Baltimore Orioles prospect Dylan Bundy, as fit a minor leaguer as you'll find, also needed a ligament replacement.
"When I talked to my grandfather about baseball, when he started playing, it wasn't, 'Oh, I started playing, and my parents came to watch me, and they were making sure I didn't throw too much,'" Morton said. "It was, 'We went out in the backyard and we threw, we played. Every single day, that's what we did. As hard as I could. This is all we did.'
"That's the one thing that makes me want to stay involved with baseball after I'm done, just to help people from that aspect. Just to help."
Pitchers who have been lost for the season since spring training began because of elbow problems requiring Tommy John surgery:
Bill Brink: firstname.lastname@example.org and on Twitter @BrinkPG.