MLB.com Columnist

Anthony Castrovince

Spreading knowledge can slow pace of elbow surgery

Spreading knowledge can slow pace of elbow surgery

The frustrating fact about the recent surge in Tommy John elbow ligament replacement surgeries is that, for many of today's professional pitchers, it's too late.

The damage has accrued over the course of years of max effort or overuse. The rubber band, as it were, is going to snap at some point.

But our best hope for curbing the need for this surgery -- a procedure that is actually more invasive and career-threatening than most people give it credit for -- is to get in the heads and hearts of amateur pitchers and their parents. Because only through an understanding of the proper protocol for pitching can we move the needle on injury prevention.

Thankfully, the foremost authority on repairing these injuries has plenty of thoughts about how to impede their proliferation. Dr. James Andrews signed off on those thoughts in a position paper released this week by his American Sports Medicine Institute, and they correspond directly with many of the thoughts I gathered while surveying some of today's more durable arms at the Major League level.

As is noted within the ASMI paper, which was drafted by the institute's research director, Dr. Glenn Fleisig, it is important to dispel certain myths about ligament injuries and the factors that lead to them.

A few of those myths:

1. Tommy John surgery and rehab are downright "routine."

Per baseballheatmaps.com, 716 professional players -- pitchers and position players -- have had Tommy John surgery, beginning with Tommy John himself in 1974. Stan Conte, vice president of medical services for the Dodgers, recently estimated that 25 percent of Major League pitchers have had it performed.

The sheer prevalence of the procedure seems to have created a false sense of security about its efficacy, especially as more and more pitchers come back from it earlier than the previously prescribed 12- to 18-month recovery window.

In reality, though, the successful return rate has been estimated by ASMI to be 83 percent, which means that one out of every six pitchers who has it performed does not return to the same level of performance. And the earlier a player has Tommy John performed, the higher his risk of needing a second surgery before the end of his career.

The ASMI paper points out that it is simply not true that a pitcher will throw better and harder after the surgery than he did before it.

"While there may be instances of pitchers throwing faster after returning from Tommy John surgery, this was due to the surgeon fixing the problem followed by the pitcher working intensely with the physical therapist, athletic trainer, strength coach, and pitching coach," it states. "However, performance usually decreases over time for MLB pitchers after Tommy John surgery (similar to the typical decrease over time for healthy MLB pitchers)."

2. Only those with high velocity are at risk for ligament tears.

It is true that those with high velocity -- especially at young ages -- are at an increased risk of injury. Dr. Andrews has estimated that high school pitchers throwing above 85 mph are going beyond the developmental properties of their ligament.

But the effort behind the pitch also matters. This is something Bronson Arroyo explained well in my aforementioned piece on durable arms.

"If I'm a max-effort guy," Arroyo said, "and I only throw 85 and I throw every pitch at 85, I'm still running at hot."

ASMI backs this up. The paper warns about the dangers of fatigue and the dangers of 100-percent effort.

"The best professional pitchers pitch with a range of ball velocity, good ball movement, good control, and consistent mechanics among their pitches," it states. "The professional pitcher's objectives are to prevent baserunners and runs, not to light up the radar gun."

3. The curveball is the biggest risk factor in young pitchers.

ASMI counters that overwork and pitching while fatigued are bigger risks. The paper warns against pitching year-round, because the ligament and body need time to recover and build strength, and it notes the importance of communication between the pitcher and the coaching and/or medical staff to ensure adequate rest, nutrition and hydration to repair the small tissue tears created by pitching.

This is one of the many dangers of youth players playing in multiple leagues. There is often a lack of communication between coaches, and it is, therefore, incumbent upon the pitcher and the parent to monitor workload.

In a perfect world, every pitcher, amateur or professional, would have a biomechanical analysis performed to determine whether they are applying too much torque or not showing enough shoulder mobility or hip stability. These analyses also serve as a baseline for comparison later in the pitcher's career. When I spoke with multiple experts for a story on science and strategy to save arms, the importance of individualization was stressed. Every body, every arm is different, and there is no cookie-cutter approach that works for one and all.

Still, amateur and professional pitchers alike ought to note the advice of the ASMI report, which goes on to debunk the theory that lowering the mound would prevent injuries and that Latin American pitchers are less-susceptible to arm injuries than U.S.-born pitchers. It will be interesting to see what, if any, impact this spate of surgeries and this increasing conversation has on usage patterns at the professional level.

In the end, there is no way to completely halt arm injuries, because the wear and tear of the motion and the action does take a toll. And many of today's Major League arms are likely already on the Tommy John track.

But we're getting better, more detailed information about the real risk factors that lead to Tommy John.

Here's hoping the next generation is listening.

Anthony Castrovince is a reporter for MLB.com. Read his columns and follow him on Twitter at @Castrovince. This story was not subject to the approval of Major League Baseball or its clubs.