Injured Arms–Risk vs Reward Part 1

Ulnar Collateral Ligament ( Tommy John) Surgery is so common most people think it’s routine but it’s far from that Please Credit Graphic Created by USA Today Sports

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.

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

While Pitching in the Minors

290

15

8

6

1

2

1

1

Everyday players with 2 TJ surgeries

3

Josh Ford, Vance Wilson,  Xavier 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

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.

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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