"The fans need to understand that there's a real risk in pushing this," said Dr. James Andrews. "[Strasburg] is exactly right with what he's doing."
Andrews, who runs a sports medicine and orthopedic center in Birmingham, Alabama, has performed thousands of Tommy John surgeries in his career, many on major league pitchers. A sports doctor for nearly four decades, Andrews has treated a long list of sports luminaries that includes Michael Jordan, Jack Nicklaus, Roger Clemens, and Charles Barkley, and he serves as teamdoctor for the NFL's Washington Redskins and multiple college football teams.Though he could not discuss the specifics of Strasburg's case because he is not Strasburg's doctor, Andrews emphasized that the second year of a pitcher's recovery from Tommy John surgery - the first year the pitcher returns to game action - is the most important period for the long-term health of the elbow.
"The re-injury rate is highest in the second year," Andrews said. "So standard procedure is to watch the fatigue factor the first year back [pitching]."
The Tommy John procedure is designed to reconstruct the all-important ulnar collateral ligament in the elbow that connects bones in the upper and lower arm. Pieces of a tendon are taken from elsewhere in the body and inserted into holes drilled in the ulna and humerus bones, in effect re-creating the damaged ligament.
But the tissue of the inserted tendon is extremely weak for the first 12 to 24 months as it regenerates and gets a new blood supply, Andrews said. As a result, a pitcher's first year back can put an extreme strain on the tendon, putting it at risk for another tear.
Despite all the recent advances in sports medicine, there is no quantifiable innings benchmark for a pitcher in his first year back from Tommy John, Andrews said. But if a pitcher does re-injure the reconstructed ligament, the statistics are grim. Andrews' Tommy John patients have an 85 to 90 percent recovery rate from the surgery, but for those unlucky few that have to redo the procedure, the success rate drops to 25 to 35 percent.
"A redo is a career-threatening operation," Andrews said. "You're dealing with the existing scar issue, and you have to re-drill holes into already weakened bones. The scar tissue bleeds more, so the infection rate is higher. You don't wish that on anybody."
Baseball history is littered with pitchers who flamed out at a young age because they either were overworked in their early 20s or rushed back from a career-threatening injury too early. For every unbreakable workhorse like C.C. Sabathia or Greg Maddux, there's a Steve Avery or Mark Prior, pitchers who had several great years to start their careers before permanently breaking down in their late 20s.
Some sports pundits have proposed middle grounds for Strasburg: shut him down now until the playoffs start, or only start him every other turn in the rotation. But Andrews said that a stilted throwing schedule would likely increase the chance of re-injuring the elbow.
"If you shut someone down for a month and crank them back up to a high level, a playoff level, there's some worry there might be a higher rate for re-injury," he said. "You don't just all of the sudden go to a playoff level after you've been shut down for a period of time. There's rust there."
Strasburg has the makings of an all-time great pitcher, Nolan Ryan with a breaking ball and better command. More to the point, he's a human being, not a cog in a championship-winning baseball machine. Strasburg's absence could very well prevent Washington from finally bringing a World Series title back to the nation's capital. But an organization cannot in good conscience start a player when its own doctors - bound by the Hippocratic oath to "never do harm to anyone" - recommend that the player be sat to preserve his long-term health.
"You can't just think about the team for that one year," said Andrews, who consults for several major league clubs. "If you make that judgment as a medical doctor, it's often the wrong decision. We love to wear those World Series rings around, too, but you have to do what's best for the player."
Losing Strasburg for this postseason will be a bitter pill for long-suffering Washington fans to swallow. But when they are presented with the medical details, most fans will accept the ultimate truth: A World Series title that comes at the willful expense of a player's health is a title not worth having.
Even armed with the medical details, many Nationals fans remain unconvinced that shutting Strasburg down is the right thing to do. A common refrain among posters on the Nats fan forum is, as commenter PowerBoater69 puts it, "doctors always err on the side of caution, they don't know crap." But the overall sentiment, even among the most loyal Washington fans, seems to favor long-term success and the health of the team's most valuable asset over a short-sighted push for a championship that could conceivably end Strasburg's career.
"I have suffered longer than most with bad baseball in Washington, and I still say the team should do as they plan, and as they have been advised by doctors," a poster named Welch wrote on the Nationals fan forum. "Shut him down."