Baseball’s Elbow Problem Starts With Young Pitchers

Increasingly, baseball players of all ages are turning to "quick-fix" surgery to keep their pitching skills strong.

Part of the tradition of baseball has always been its love affair with statistics, especially the ones that seek to predict what will happen on the field—the chance of getting a hit, the odds of making an error. But there’s one record-setting statistic that baseball isn’t celebrating—the increasing occurrence of arm surgeries among its young pitchers. With already 46 “Tommy John” elbow surgeries in Major League Baseball at the midpoint of the season, this year is on pace to exceed the number of elbow surgeries in 2012, the year with the current record. But no statistic has been able to determine why pitchers are getting injured at higher and higher rates. Frustratingly, for the teams with these high-value young throwers, scrutinizing numbers like pitch counts and innings pitched in an attempt to predict or limit risk seemingly hasn’t stemmed the rising tide of hurt players.

In the baseball world, no injury has captured more attention than the “Tommy John” surgery. Named for Los Angeles Dodgers pitcher Tommy John, the first player who underwent successful surgery for repair of a torn ulnar collateral ligament (UCL), the surgery restores the stability of the elbow.

Originally performed by orthopedic surgeon Frank Jobe in 1974, the procedure involves removing a tendon from the thigh or forearm and grafting it into the elbow to reconstruct the damaged ligament. Tommy John’s name is now known more for his contribution to sports medicine than his long baseball career, even though he went on to win more than half of his 188 professional games following his comeback from what was previously a career-ending injury. Today, the surgery has become so successful it’s virtually become a rite of passage—one in seven Major League Baseball pitchers has had it.

However, these days elbow injuries and Tommy John surgeries are occurring at a record pace, and it’s not just grizzled veteran players with thousands of innings under their belts who are getting them—it’s young pitching phenoms like Matt Harvey (age 24) of the Mets and Jose Fernandez (age 21) of the Marlins. These highly-valued pitchers are getting injured even though they’re being held to strict pitching limitations designed to keep them healthy.

Part of this increase is due to players increasingly opting for the surgery (perceived as a “sure thing” cure) at the first sign of elbow problems, rather than the uncertainty of rest and rehabilitation. Well-established research points to an 80 percent rate of return to a prior level of professional performance after the surgery. “Players want the instant gratification of getting it fixed right away,” agrees Bobby Evans, assistant general manager of the San Francisco Giants.

But for all the high-profile pitchers that need the surgery, it’s the increase in young baseball players needing elbow reconstruction that has researchers concerned. This continued rise in arm injuries among baseball players has become so alarming that the American Sports Medicine Institute (ASMI), headed by the doctor who performs many of professional baseball’s surgeries, Dr. James Andrews, hurriedly issued a statement in May aimed at young players, their parents, and coaches. The position statement warned that the rises are indeed connected; after all, today’s pro pitcher in his twenties was an adolescent pitcher a dozen years ago. In many cases, the injury process leading to Tommy John surgery in today’s young pro pitchers actually began while they were adolescents, in some part explaining why limiting the innings and pitch count of young professional pitchers doesn’t always prevent injury.

Although youth baseball is as American as apple pie and July 4, in those innocent beginnings lies part of the reason for the rash of professional baseball injuries. For some, youth sports are no longer innocent and carefree. While previous generations of youth athletes played a sport for a three- to four-month season, single-sport year-round competition and training are becoming increasingly common for children and adolescents. The hope for many of these parents and children is that this will lead to college scholarships or spots on Olympic teams—despite the low odds that argue the contrary. Unfortunately, without an offseason or recovery period, year-round sports greatly increase the risk of burnout and overuse.

Experts blame this year-round format of competitive baseball, in which young players may play 70 to 80 games per year, for increasing the rate of injury. Research by Dr. Glenn Fleisig, also of ASMI, concluded that “adolescents who competitively pitch more than 85 pitches per game, more than eight months out of a year, or with arm fatigue are several times more likely to require elbow surgery.” Another study highlighted those players who pitched more than 100 innings in at least one calendar year as having about 3.5 times the chance of serious arm injury as those who pitched less.

Nino Giarratano, head baseball coach for the University of San Francisco has developed three of his pitchers into first round Major League Baseball draft picks. He agrees that much of the problem lies in the development of young athletes. “Youth coaches push their kids too hard without first making sure they are strong enough to handle the stress of throwing 100 pitches 10 to 15 times a season,” Giarratano says. When recruiting, he steers clear of overpitched high school throwers with obvious mechanical flaws, emphasizing, “It’s usually only a matter of time before a baseball player that throws at max effort with poor mechanics will break down.”

The ASMI position statement also places some of the blame on baseball’s fascination with high radar gun readings. "Do not always pitch with 100 percent effort," the paper advises. "The professional pitcher's objectives are to prevent baserunners and runs, not to light up the radar gun.” Unfortunately this may be a tough sell to kids, coaches, and parents, since kids who throw the hardest pitch tend to play the most, because they get hitters out. What’s more, pitchers who throw hard get rewarded with scholarships and professional contracts. The number of professional pitchers that consistently throw over 95 miles per hour has increased more than threefold in the past 10 years.

Throwing a baseball involves a complicated chain of events. Small inefficiencies in this precisely orchestrated process can cause problems, frequently at the weaker links of the shoulder and elbow. But don’t look to the big leagues for perfect technique—subtle violations of pitching mechanics can be seen in virtually every game of Major League Baseball. The reason, says MLB’s medical director Dr. Gary Green, is that “pitchers aren’t rewarded with outs by virtue of good mechanics, so they evolve their mechanics to be successful at getting hitters out.”

For Fleisig it’s a combination of factors. He emphasizes, “It’s not that improper pitching mechanics are any more pervasive today than in the past. In fact, I hope good biomechanics are more common than ever before. It’s more that long, long seasons are more pervasive and pitchers with high inning counts (especially those with improper mechanics) are at high risk for injury.”

But it’s difficult to alter this course of baseball’s evolution. Try telling a high school coach or his 18-year-old star pitcher that he needs to change his pitching mechanics, or that he shouldn’t try to throw so hard. That’s a tough sell, especially when Tommy John surgery is there as a proven fix for players who push too hard.

So it would seem that the surgery has become a victim of its own success, as athletes quickly opt for surgery before exploring potentially equally successful conservative measures. “Pitchers want to pitch as hard as they can, as long as they can,” Green says. “Then have surgery.”

A recently published survey conducted by New York Yankees team physician Dr. Christopher Ahmad found that a quarter of baseball coaches and players believed that the surgery would enhance pitching performance beyond pre-injury levels. Many of those surveyed—30 percent of coaches and parents and 50 percent of high school athletes—also believed that the surgery should be performed on those without injury to improve throwing performance or just to “get the surgery out of the way” because they assume it is inevitable.

So physicians and sports medicine researchers are tasked with battling the perception of youth or high school athletes whose vision of the surgery is dominated by the ESPN highlights of Tommy John success stories. Those experts fear that portrayal of the procedure might push athletes toward surgeries that they don’t need. Dr. Joshua Dines, an orthopedic surgeon who regularly performs Tommy John surgeries and has studied their effects in Major League Baseball, states, “There is a clear belief in the baseball community that Tommy John surgery will enhance performance.” Instead of rushing to surgery, Dines and others believe that young throwers should be educated on how to avoid arm problems, not just pitch through pain until surgery is the only option.

In reality, total recovery from a surgery of this magnitude is never guaranteed, and since the baseball career of most athletes does not extend beyond high school, 12 to 18 months of lost time on the field may mean the end of some players’ time as competitive pitchers, even if the surgery gives them back the ability to throw. Even in professional baseball, 50 percent of those returning from Tommy John procedures have arm problems requiring significant time on the disabled list in the years after surgery.

At this years’ Society for American Baseball Research conference, Stan Conte, medical director for the Los Angeles Dodgers, stated that soon-to-be-published research shows pitching velocity is reduced about three-quarters of a mile per hour on average in the year following Tommy John surgery.

By the time athletes reach college or professional baseball, most are aware of the risks and benefits of the surgery. Scott Feldman, now a starting pitcher for the Houston Astros, underwent Tommy John surgery while in the Texas Rangers minor league system, but only after other measures had failed. “My velocity dropped from the low 90’s to the 80’s because my elbow hurt with every throw,” Feldman says. After the surgery, Feldman was able to regain the velocity he lost when throwing through pain, but never realized any improvement in performance after the surgery.

“Everyone has a theory about why these injuries happen, and in a sense they’re all correct because there isn’t a single causative factor,” Green says. “At the end of the day, each person is different and no one yet knows why some pitch 20 seasons of injury-free professional baseball while others don’t make it through their first. Hopefully we better identify how these injuries occur so we can tell young throwers how to prolong their careers.”