Injured Arms–Risk vs Reward Part 1


With pitching in short supply and back of the rotation starters commanding large salaries, the question arises, “Are injured arms worth the risk?

Injured Arms: every pitcher gets them

Actually the questions is which injured arms are worth the risk because every pitcher’s arm is injured. Why?  Throwing a ball overhand is not a natural arm motion and forcing the arm to do things that aren’t natural is bound to cause injury. It’s no surprise that pitchers who throw the ball more than anyone except catchers, end up multifarious with elbow and shoulder injuries. Everyday players suffer them as well but the nature of a pitchers job insures they get the majority.  The great majority of professional pitchers recover and continue their career; teams look at medicals closely but the mere existence of a TJ surgery scar doesn’t scare them off. A rotator cuff repair or a second TJ surgery however should set off al kinds of alarms. Today I’m looking at TJ surgeries and tomorrow I’ll examine shoulders.

TJ By The Numbers

The question ever GM asks himself before signing a pitcher with TJ surgery in his medical records is ‘If I sign this guy what’s my risk?” The Braves recently offered Johnny Venters a new contract even though he won’t be fully recovered from his second TJ Surgery until midyear (if then) yet passed on Eric O’Flaherty who was only having his first TJ and  should be back sooner. Was that the logical thing to do?

During the discussion on the Venters signing the question of how many pitchers successfully return from a second TJ surgery arose.  I have that answer and a few more numbers to go with it thanks to the folks over at Beyond The Boxscore This is a complete history of TJ surgery for affiliated professional baseball players beginning with Tommy John as patient 1 and current through November 15th.

All Tommy John Surgeries 594  
Pitchers 519  
While Pitching in the Majors  242

No, these two lines don’t add up to the total because of the multiple surgeries

While Pitching in the Minors

290

Pitchers with two TJ Surgeries 35  
Pitchers with three TJ Surgeries 2         Jason Isringhausen Jose Rijo
Everyday Players    
Outfield 15  
SS 8  
Catchers 6  
1B 1  
2b 2  
3b 1  
UT 1  

Everyday players with 2 TJ surgeries

3

Josh Ford, Vance WilsonXavier Nady

For those who like pretty pictures here’s a graph of TJ surgery through the 2012 season. Players are linked to the team they were on when he had surgery.  That said the Braves are not on top of  the list because it’s alphabetical. These numbers are troubling, at least to me but this piece is about the risk after surgery

TJbyTeam

Success Rate

A successful TJ surgery returns a pitcher somewhere near his pre-surgical form.  According to a story from in the Ledger-Examiner  about 85% of pitchers achieve that. That number combined with close scrutiny of the rehab process by a players team means their risk is minimized so signing a first time TJ surgery is a pretty safe bet, but what about the second time?

As I noted above 37 pitchers visited their friendly orthopedic surgeon at least twice. Of those 29 had surgery before the 2012 season and could have returned to play this season. Removing the career minor league players leaves 25 potential returnees. I set a two complete season 30 game minimum as a qualifier as well. That created a list of 11 players, here’s that list.

Pitcher
Shawn Kelley
Chris Capuano
Jason Isringhausen
Al Reyes
Mike Lincoln
Scott Williamson
Hong-Chih Kuo
Doug Brocail
Jason Frasor
Lance Carter
Chad Fox

Adding in minor  leaguers  means a success rate of about  33% but there are some caveats to that number. The first is velocity. Of this list only Jason Frasor, Shawn Kelly and Hong-Chih Kuo regularly hit the low 90s after the second surgery. In fact one of the doctors involved said they were surprised to see anyone throw much over 80. He put the fact that some did down to an extremely tough rehab program.  The rest became soft tossers and most were relievers.

I included Isringhausen in the list but his two years came after his third surgery. After his second he appeared in 9 games before going under the knife again. He wasn’t as effective a reliever after his second surgery and was going to retire but they coaxed him back to throw 50 innings with a 4.14 ERA and a 1.380 WHIP for the Angels.

Second TJ surgeries are becoming more prevalent and that – doctors say – is because their patients are getting younger. Older patients look to the 12 to 18 month recommended time to rehab from number two and decide to retire while younger pitchers like Venters will go for it and as Frasor shows can be successful.  The second surgery return rate will go up as the pitchers getting them get younger but it is unlikely that it ever approaches much over 50%.

Ultimately the answer to whether a pitcher having a second or even a third TJ is worth the risk comes down to contract length. In today’s game there’s no such thing as a bad one year contract. The Braves had to either offer Venters a contract or let him slip into free agency. At $1.65Mthe Venters contract can be seen as a 50/50 proposition. If he recovers to be near the guy he was before it’s a shrewd move. If he throws one too many hard sliders and the UCL snaps again. . .well, it was only 1.6 million. A pitcher like Venters (and Alex Wood by the way) is particularly susceptible to that elbow coming apart again. His motion and the torque applied to his slider and even his sinker, strains that ligament more than a guy like Kris Medlen or David Hale.

That’s A Wrap

Medical science has extended the career of hundreds of athletes and improvements in techniques and procedures will continue to do things we can’t imagine. But the human  body is a complex contraption capable of some marvelous things on its own. The story of Jose Rijo is worth inserting here in a condensed version. Rijo had three TJ surgeries and two other arm surgeries during his career. After his third he came back and pitched a miracle year for the Astros and a less sterling one for the Dodgers. The thing is the last surgery was . . . well here’s how  John Erardi  of the Cincinnati Enquirer put it:

:. . . Dr. James Andrews winged it.

“He had to find a strand of ligament, a strand of tendon, anything he could find in there that would stay together and heal,” Reds medical director Tim Kremchek said. . .        “We’re not really sure how much of Jose’s ligament is there. But he has enough arthritis in his elbow, scar tissue, changes, bone spurs that have stabilized his elbow, plus his knowledge of pitching, to make him effective. . . Arthritis that forms in any joint will limit your motion and make it more stable. . .Jose had waited around long enough (that) his elbow was no longer unstable when he threw. His elbow is so stable you can’t budge it. It’s almost too stable. . . he was able to change his mechanics (to make allow him to pitch). . . . (his) body hadn’t pitched in six years, so his regular body is 30. But his elbow? His elbow is 86.”

That’s the story on elbow surgery, next up the shoulder.

 

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Tags: Atlanta Braves FanSided Tommy John Surgery

  • http://tomahawktake.com/ carpengui

    Major League Surgeries/Pitchers – Atlanta

    1992 Mike Bielecki*
    1996 Pedro Borbon
    1999 Kerry Ligtenberg
    2000 John Smoltz
    2005 Mike Hampton*
    2007 Mike Gonzalez*
    2007 Anthony Lerew
    2008 Peter Moylan**
    2008 Tim Hudson*
    2010 Kris Medlen
    2012 Arodys Vizcaino*
    2012 Brandon Beachy
    2013 Eric O’Flaherty, Jonny Venters

    >> 2011 Jason Hursh (had not yet been drafted by Atlanta)

    * – started with another organization (Vizcaino – 2 years w/Yankees; 3 w/Atlanta)
    ** – became a Brave (from Aussie baseball) in 2006.

    • Sealift67

      Borbon, O’Flaherty started with other organizations. Lightenberg I
      recall played independent ball. Medlen, Beachy, Venters, seem to be the
      primary Braves farm raised arms of note. Venters was possibly over-used.
      My question is whether there is a systemic issue and this is difficult
      to assess when you take into account mechanics and pitchers’ reluctance
      at times to acknowledge early symptoms.

      • fireboss

        The article says that the team the pitcher was a member of at the time is listed. The interesting thing to me is that the White Sox have the best numbers and pay the least attention to biomechanics and Don Cooper in particular has said he doesn’t mess with mechanics that work.

        Nolan Ryan pitched a good part of his career with a partically torn ligament so proper conditioning can extend a career without surgery. The problem is mechanics below the waist but habits are hard to break. If you read Smoltz’ book you find out how his physiology allowed him to pitch when he should have been done and shows just how much the individual and his desire or lack of it can affect the numbers. Fielder’s down year has everyone flitting about but he was going through a divorce and his kids are very important to him. With that settled Fielder will be better this year than last

  • Jeff Schafer

    Doesn’t surprise me that the Braves are on top of this list, seems like we lose a couple each year to this awful injury

    • http://tomahawktake.com/ carpengui

      FWIW – regarding Rich Dubee as new minor league pitching lead:

      With Philly (2004-2013):
      - major league TJ’s: 9 (3 in 2012)
      - minor league TJ’s: 8 (essentially 1 per year)

      With Miami (1994-2001):
      - major league TJ’s: 1 (but 4 occurred in 2002-2003; 2 in 2005)
      - minor league TJ’s: 1 (1 more in 2002; not counting those from 2004+)

      ————
      To add to the Braves’ history, here’s the minor league data

      1997-1999: 1 each year
      2000: 3 in this year alone
      2001, 2003, 2005, 2006: 1 each year
      2007: 2
      2010: 1
      2011: 2 (though this includes Jason Hursh while still at OKLA ST)

      So frankly, if there’s a trend here, I don’t know that we should expect any big rate reduction in the next few years… not convinced we have enough data to run with. But organizationally speaking, 2010-2013 had a pretty bad spate of these (7).

      • fireboss

        A lot of this has to do with how we grow pitchers before they get to the big leagues. They start way too young throwing breaking balls and damage the ligament before it’s fully developed and the growth plates in the arm along wit them; In Latin America it’s worse.

        One of the interesting things is that team with the least arm issues has a program overseen by a guy who pays no attention to biometrics; Don Cooper.

        Tom Hickey arrived in Tampa in 2006 and from 2007 forward the Rays have had 4 total and one of those was Isringhausen and another was a guy drafted out of high school who started playing rookie ball at 17. The database shows 5 but Hak-Ju Lee was actually a Cub when he had surgery. Tampa’s program is working and a lot of that is Hickey who’s a very underrated pitching coach IMO.

        • http://tomahawktake.com/ carpengui

          So you’re saying that we should go ahead and use Julio Teheran as the centerpiece in a trade package for David Price, right? (under the guise that he will inevitably have to go under the knife within the next couple of years)
          [semi-sarcasm; semi-serious]

          • fireboss

            I wouldn’t do that but I do worry about his arm. He’s been throwing hard for a long time and he uses a lot of arm and not as much leg as I’d like. But his motion is quiet and compact and that’s a plus.

            Alex Wood OTOH had his TJ 1in 2009/10 and is nearing his 5th post TJ year. UCL damage starts with what happens below the waist and Wood’s motion is one of oddest around though they have calmed his bounce back after releasing the ball.To quote a scout, his mechanics and arm action on the back side are all over the place. He’s a prime candidate for TJ # 2. I’d rather keep him and hope for the best however and we aren’t in on Price at all. Seattle might be the best bet for him

  • http://www.tomahawktake.com/ Chris Headrick

    I’ve posted on TJ issues a couple of times, and I always find that 5 year window theory I cited interesting, where players tend to start having troubles after the first TJ, on average about 5 years after the first. That’s not written in stone, but is an average. There are several approaching that 5 year window, and I wanna say Tim Hudson is one of them. There are not too many success stories for pitchers undergoing 2 TJ’s, and almost none after 3. Exceptions to the rule of course, but it is a risk, certainly, after 2.

    • fireboss

      There are none after three unless you consider Rijo’s arthritis repair success. The problem it seems is lack of something left to attach the new ligament too. Of the listed players only Capuano, Kuo and Frasor have sustained themselves as starters. The relievers were middle relief with Kelly the only hard thrower. If Venters comes back this year and I am not sure about that, he should be a trade candidate while his arm is still together.

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