Phillies pitcher Roy Halladay (right) leaves the game during the first inning against the Miami Marlins at Marlins Park. Doc had to have shoulder surgery and now the question is, should the Braves try to sign him? Mandatory Credit: Steve Mitchell-USA TODAY Sports

Injured Shoulder - Worth the Risk?


Last week I looked at the success rate for Tommy John surgery and how impacted a GM’s decision about signing pitchers. To recap, after one surgery the odds of success are good, after two not good at all particularly if it’s an older pitcher, so no more than a one year contract please.  Today it’s the turn of the shoulder and particularly rotator cuff injury and repair.

They shoot horses don’t they?

How bad is the hint of a  shoulder injury to a pitcher?  Bad enough that they’ll hide it until they can;t stand the pain. Why?   In May of 2004  Will Carroll wrote a piece for slate called Labrum, It Nearly Killed Him where he laid it on the line.

“. . .if pitchers with torn labrums were horses, they’d be destroyed. Of the 36 major-league hurlers diagnosed with labrum tears in the last five years, only midlevel reliever Rocky Biddle has returned to his previous level. . .when your favorite pitcher comes down with labrum trouble: He has a 3 percent chance of becoming Rocky Biddle. . .”

By 2010 it had improved but not a lot. ESPN’s Jerry Crasnik wrote a piece on shoulder surgery where he opined that while pitchers consider TJ surgery at least a chance at extending their careers, “. . .shoulder problems are often viewed as a death sentence.”  He went on the quote Rangers team orthopedic surgeon Dr. Keith Meister who explained why.

“The stresses and loads that the shoulder sees are far more complex than what the elbow sees. . .movement(s) are more complex, so the problem becomes much more complex.

Unlike the UCL which is really two bits of ligament, the rotator cuff is actually a group of four muscles surrounding the shoulder blade (scapula) and connect it to the upper arm. When you move your shoulder the subscapular bursa rubs on the bone and starts to fray; not just pitching. any movement. If it wears when the average guy lifts his beer now imagine the stress on it when  a pitcher throws a 90+ mph fastball.  Dr. Meister called the rotator cuff the tire tread if the shoulder and added, “… when you wear the tire tread out, more often than not the shoulder goes.”

To carry that analogy a bit farther, when I bought my new tires they were rated at 60,000 miles but of course that depends on what kind of miles they are. It’s really impossible to know how many miles a pitcher’s arm is good for. Between 1996 and 2008 John Smoltz threw 48,809 regular season pitches and at least 3000 in the post season. When he finally went under the knife Dr. Andrews told him it looked like a firecracker had gone off inside. To get Smoltz shoulder back together took nine separate reattachments of the muscle. That my friends is a blowout at 90mph.   If you’ve read his book Starting and Closing, you find the Smoltz had an advantage most pitchers don’t have, a really out of the ordinary body that allowed him to pitch longer than others might have done.

A SLAP in the career

Every movement of the muscle frays the cuff like the those little balls of fabric on your shirt collar that tell you it’s time to buy a new shirt. You can cut them off – I’ve actually shaved a collar or two in my time – but the shirt is still worn out. Those little bits of cuff eventually wear off and start floating around inside the shoulder joint. the muscle gets inflamed and the doctor says you have bursitis. As more pieces of muscle break off and float around it makes bursitis worse and the shoulder has to be cleaned out.  The clean out – known as a debridement – is more or less what I did to that shirt collar. they insert three scopes, shave off the bits of muscles sticking up and ready to come off they suck them and all the bits that were causing the inflammation out. Those debridements account for the majority of shoulder surgeries you see where the pitcher comes back close to his best relatively quickly.  The arm gets normal movement back pretty quickly – 3 months or less – and a well planned conditioning that lasts from six months to a year does the rest. Sometimes though, it doesn’t work that way.

The worst of today’s shoulder injuries are call SLAP (Superior Labrum Anterior to Posterior) tears. Doctors are never absolutely sure what they will see or had bad the tear is until they slide the scope inside, particularly with professional athletes who play in pain most of the time.  When a man like that says it hurts so badly they can’t play, they are usually sent for an MRI; a contrast MRI is the most definitive but even that isn’t perfect. It’s not until they get that camera inside that they know the extent of the injury they have to fix. I can tell your from speak from recent experience a torn rotator cuff is painful; the picture below was my shoulder in January before they sewed it back together; a 94% tear.

Rotator tear before

94% tear of the right rotator cuff Graphic Credit Fred Owens

 

The doctor and the physical therapists told me that no matter how good the therapy was, it would be a year before the shoulder was anything resembling normal.  Jason Schmidt told Crasnick that he thinks two years is a better target for some pitchers.  Schmidt signed huge contract with the Dodgers then six games and 25 innings later he was done for good – though he didn’t know it at the time. His arm hurt as usual but one day his velocity dropped to between 82-85 and when he managed to raise it a bit he couldn’t locate his pitch. When they looked inside the doctors were amazed he could get the ball to the plate at all. He had a torn labrum, frayed biceps tendon and an inflamed bursa. Two surgeries later Schmidt tried to come back but couldn’t. He was 35.  He told Crasnik.

“After you get your shoulder fixed, you try to throw from your normal arm angle and feel a little pinch . . .you drop down a little bit and don’t have that pinch, but you can’t locate. .  since you’ve dropped down, you start putting pressure somewhere else and . . . you feel soreness in another spot in your shoulder. It’s a never-ending battle.”

In his book Smoltz explained it like this.

The best way I can think to describe this is to have you imagine what it would feel like if someone suddenly disengaged the power steering in your car while you were driving. You would still be to steer your car and get to where you needed to go, but it would be a lot more work than you were used to. That’s how pitching after shoulder surgery felt to me.

Ted Lilly gave up last week. Between 2005 and the end of this season Lilly was on the DL because of his left shoulder 11 times with two surgeries; a debridement and a labrum repair.  He also had surgery on his neck but when he announced his retirement today he said his neck is good but the pain in his shoulder is always there.

 “It’s principally the pain in my back and shoulder. I’m having problems there. I feel like I can’t return to being the pitcher I was a few years ago.”.

That’s what happens to shoulders. They wear out and as of today can’t really be fixed.

Numbers

The Rangers did extensive research on elbow and shoulder injuries between 1995 1nd 2003. They found that less than 50% came back to near their previous levels following shoulder surgery. In 2012 Jay Jaffe over at Baseball Prospectus put together a list of pitchers who had shoulder surgery and how well they did afterwards, his list is here.  He found 67 pitchers who had some type of shoulder surgery. I updated the stats in his story to post 2013 numbers so they won’t match those he quoted exactly.

  • 18 never got back to the major leagues
  • 20 pitched less than 100 major league innings
  • 13 are still active 11 MLB 2 minors

Here’s are the pitchers with some major league time from his list. I do not show those who had surgery within the last two years.

Pitcher Surgery Age WAR Active
Jose Valverde 2004 26 7.6 Out Of Baseball
Steve Karsay 2004 33 -0.4 Out Of Baseball
Travis Blackley 2005 22 0.9 Active
John Van Benschoten 2005 24 -2.9 Out Of Baseball
Bryan Bullington 2005 25 -0.1 Out Of Baseball
Jon Rauch 2005 26 5.5 Out Of Baseball
Grant Balfour 2005 27 9.0 Active
Kerry Wood 2005 28 3.4 Retired
Wade Miller 2005 29 -0.2 Out Of Baseball
Casey Fossum 2006 28 1.6 Out Of Baseball
Mark Mulder 2006 29 -0.9 Out Of Baseball
Brian Lawrence 2006 29 -0.4 Out Of Baseball
Pedro Martinez 2006 34 3.2 Retired
Ricardo Rincon 2006 36 0 Out Of Baseball
Anibal Sanchez 2007 23 7.3 Active
Freddy Garcia 2007 30 2.7 Active
Kris Benson 2007 32 -0.6 Out Of Baseball
Jason Schmidt 2007 34 -0.2 Retired
Troy Patton 2008 22 3.3 Active
Chad Cordero 2008 26 -0.2 Out Of Baseball
Dustin McGowan 2008 26 0.2 Active
Casey Janssen 2008 26 5.6 Active
Kelvim Escobar 2008 32 0.1 Out Of Baseball
John Smoltz 2008 41 0.3 Retired
Jose Ascaino 2009 24 -0.1 Out Of Baseball
Boof Bonser 2009 27 0.1 Minors
Jeff Francis 2009 28 1.5 Active
Erik Bedard 2009 30 1.7 Active
Joaquin Benoit 2009 31 7.2 Active
Ted Lilly 2009 33 5.6 Retired
Mike Hampton 2009 37 0.1 Retired
Clayton Richard 2011 28 -0.9 Active
Brandon Lyon 2011 31 0.7 Out Of Baseball

 

That’s A Wrap

The pitchers who are still active or who came back and had some success had their surgeries before the age of 30. While there are a couple fo exceptions like Anibal Sanchez, most of the success of those came back was in relief. Starters who remained starters with success like Garcia and Lilly because soft tossers. Before anyone throws things at me I am aware the Chris Carpenter (2002 age 27), Gil Meche (2001 age 22), Al Leiter (1989 age 23),Trevor Hoffman (2002 age 35), Curt Schilling (1995 age 29) and Jason Isringhausen (2002 age 30) all had success after shoulder surgery.  I narrowed it down to the last 10 years but all of these guys fall into the those aforementioned groups.  Bottom line,  if you’re over 30 with a lot of miles on your arm your chances of returning to form are slim to none. . .and slim left town.  At least for now. Former Brave pitching prospect Tommy Hanson lost velocity and was unable to locate his pitches and eventually an MRI disclosed a partial tear of his rotator cuff.  He decided not to have surgery and is a non-tender candidate today.   Jair Jurrjens‘ inexplicably lost velocity and had trouble locating. In February 2010 he complained of shoulder tightness and even though the MRI was clean I suspect a look inside would find at least the need for at least debridement and at worst SLAP damage. Since 2011 he’s thrown 55 major league innings and put up a 6.63 ERA, 1.796 WHIP. Everyone focused on his more obvious knee injuries but those are the classic signs of a damaged shoulder.  Like I said, MRIs can’t see everything.  That brings me to the question of Roy Halladay.

Some have suggested that signing  Doc is a good idea; the healthy Doc from a few years ago obviously was.  However, he’s going to be pitching at 37 years old and prior to his surgery he’d thrown 40465 pitches in regular and post season play. That he came back really quickly told me two things; 1) it wasn’t a severe surgery  2) he worked hard everyday to get back that quickly.  I don’t believe Halladay will be the pre-surgery guy and even if he is successful by adapting his pitching style to the worn shoulder, how long will it hold up? Older players who have one surgery are very prone to have a two.  Halladay’s work ethic is beyond question, he’s without a doubt working daily and he is determined to pitch again. Originally I was against it but, if he would accept a low base salary with incentives based innings pitched – which he might just do – I’d sign him for a year maybe with an option for more. After all, there’s no such thing as a bad one year contract. . . or so I’m told.

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  • http://tomahawktake.com/ carpengui

    First off: great job. I mean, like *really* great job. Second reaction: This article scares the heck outta me. Third thought: J.R. Graham. All indications I’m hearing suggest that he’s okay to resume pitching now, though I also am curious about the nature of his particular shoulder ailment (and we’re a bit short on details).

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

      I agree, great article. Don’t know why it scares you. These things have always been present, even if we didn’t know about it. This knowledge the club docs have though, and they act accordingly. Well, sometimes :)

      • http://tomahawktake.com/ carpengui

        Simply this: it’s apparently worse than I knew.

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

          Ode’ to Atlanta.

    • fireboss

      The numbers are sort of hidden for several reasons. First pitchers don’t go to the doc until forced to do so because they know that if the answer is surgery it’s not simple, Smoltz’s book if full of him saying how he adapted instead of went to the doc. Moylan became a side arm thrower because of an arm injury.

      Secondly the process is generally a gradual one and so it’s caught in the expected aging decline area instead of wtf happened to him thing we had with Hanson and Jurrjens. I said and wrote that both were shoulder issues because of the indicators but everyone said I was crazy. They Hanson said he had a tear but was strengthening it instead of surgery. The problem he and a guy like Alex Wood have is their delivery is so violent to the shoulder in particular that it is sort of bound to happen. For Wood the elbow takes the beating first but the shoulder will eventually follow. One reason I think relief is his future; less innings less pitches = longer tire wear.
      Finally it’s the I just can’t do it so I quit thing. MRIs don;t show all injury and a doc is reluctant to go in without proof. I suspect countless minor league pitchers just quit because their arm hurts all the time. Oddly some tears aren’t always painful enough to treat. Unlike McCann who was in real pain you could see and should have been operated on in August 2012 some guys just lose it with no more than normal – for a pitcher – pain.
      Graham is interesting. His strain was early in the year yet they kept him out all season indicating that perhaps there was some inflammation and they wanted it to go away on its own. They get away with that because it’s the minors and because people say “he’s young, he’ll get over it.” This spring will be an interesting time for Graham.
      There is a potential treatment called bicep tendon relocation that’s used a lot for Joe Q Public but has never been tried on a major league pitcher who tried to come back . Schilling had it done in June of 2008 and says he could have pitched but then what else would he say? Docs are split on it but one day someone will volunteer to have the bicep tendon cut and relocated to the humerus by attaching it with a screw -ewww- because it’s his last chance. If it works they’ll name it after him if not we’ll just hear surgery was unable to fix his shoulder.

      • http://tomahawktake.com/ carpengui

        Let’s hope Graham was held back in the name of being Overly Cautious.

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