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Weighing the effects of Tommy John surgery on fantasy pitchers

One of the biggest disappointments of the fantasy year has been the mediocre pitching of Minnesota's Francisco Liriano. In 2006, he was the heir apparent to Johan Santana and in contention for both the AL Cy Young and Rookie of the Year awards. But elbow pain landed him on the DL and later that year he had Tommy John surgery. He returned in '08 and went 6-4, but his strikeouts were down while his WHIP and ERA were up. This season, he's been even worse with a 5-12 record and an ERA of 5.80. Could his '09 numbers have anything to do with trying to come back from the surgery too quickly?

Every year pitchers go under the knife to have their Ulnar Collateral Ligament (UCL) replaced, which starts the clock on the rehab process to regain velocity and form. The original rehab time to return to pre-surgery pitching efficiency after this procedure is 18 months. But in recent years a team's desire to get its multi-million dollar investment back on the mound combined with the athlete's natural need to compete have driven the rehab time down to 12 months. This shortened rehab schedule has produced mixed results.

This article will look at the results of certain pitchers who have come back from the surgery. Based on what is discussed below, here's the protocol you should follow when evaluating any pitcher that has the procedure done:

1. Start watching for updates about their rehab efforts about 11 months from the date of their surgery.

2. Barring a setback, expect the pitcher to return at the one-year anniversary. But also expect the pitcher to be less effective then his pre-surgery numbers indicate.

3. While not foolproof, have more faith in the return to form of starters that are allowed to work out of the bullpen that first season back.

4. While the pitcher will be healthier than at the time of the injury, do not expect him to exceed the talent he showed before the injury.

5. Again, not foolproof, but in a best case scenario, beware a fall off after six or seven seasons of post TJS play.

UCL surgery involves replacement of a damaged elbow ligament using one from another part of the body -- typically the hand, wrist, forearm or hamstring -- which is then wrapped in a figure-eight pattern through holes drilled in the arm's humerus and ulna bones. The procedure is more commonly known as Tommy John surgery after the Dodgers' starter who received the procedure in 1974 and came back to have a prolific career into the '89 season.

Prior to John's successful comeback, a torn UCL meant a pitcher's career path was headed towards coaching or broadcasting. However, after returning during the '76 season, John was able to add 2544.2 IP to the 2165.2 he had already thrown, and logged more than half of his 288 career wins after his surgery. Even by today's standards pitching an additional 14 post-surgery seasons was a remarkable feat, and John's results are the medical equivalent of Cy Young's 511 career wins: It's foolish to even discuss whether someone will come close to matching it.

Dr. Frank Jobe, the surgeon who performed John's surgery, was a former Dodgers team physician and argues that Sandy Koufax could have extended his career with it (he claims Koufax's career-ending arthritis was caused by a stretched UCL). Regardless, the surgery has become routine -- taking about one hour to complete -- and is available to pitchers at any level that tear their UCLs. Dr. James Andrews, among the handful of top TJS surgeons in the country, claims the surgery sees a success rate of 85%, up from 60% about 15 years ago.

Pitchers have reported a post-surgery increase in velocity. Former closer Billy Koch claimed to have hit 108 mph on a radar gun after rehabbing. Others, like Kerry Wood, agree that they too have seen higher velocity numbers thanks to the surgery. However, this is likely a case of pro hoc, ergo propter hoc ("after this, because of this"), the argument that blames rain on a just-washed car. The surgery and the higher velocity are related, but not directly. And not all pitchers experience this increase.

Doctors postulate there are other reasons a pitcher might see increased velocity post-surgery. The pitcher likely pitched with a torn UCL prior to the surgery, so he had not been pitching at peak performance. Replacing the UCL allowed the pitcher to get back to where he would have been before the ligament damage, but not necessarily to a point of improvement. Also, the rehab process works to build up the shoulder and elbow, which means the pitcher is probably in the best shape of his life, concentrating on health, nutrition and fitness for a full year. And sometimes, the pitcher matures physically during the resting period. Any one of these reasons -- or any combination -- could lead to increased velocity.

Koch (yes, him again) once said, "[My arm] felt so good when I came back, I said I recommended it to everybody ... regardless what your ligament looks like." Sure he was being facetious, but since we're talking about potential multi-million dollar careers, many didn't take his comments that way. There has been talk of prophylactic TJS on healthy ligaments, but that would run south of anybody's interpretation of the Hippocratic Oath.

What is more disturbing is the increase in surgeries among younger pitchers. Dr. James Andrews estimates that 20% of his TJS patients are major leaguers, another 20-25% are minor leaguers, and the remaining 55-60% are college or high school athletes. The late Nick Adenhart had the procedure done when he was 18 and former MLB pitcher Dewon Brazelton got it when he was 15. Doctors have quoted lower success rates in high school pitchers mainly because the commitment to rehab is likely harder for the youngster who may decide the work is not worth it, as opposed to the major leaguer who knows the seven or eight-figure cost of not returning to form.

The initial rehabilitation time between Tommy John's UCL surgery and his return to the majors was 18 months, or basically the end of the '74 season to the beginning of the '76 season (technically, from 9/25/74 to 4/16/76). In his first season back John -- a sinker curveball pitcher -- made 31 starts (207.0 IP) with a 3.09 ERA and pitched six complete games. While his 10-10 record was mediocre by his standards, his underlying statistics were not far off his pre-surgery numbers and he was voted the NL's Comeback Player of the Year.

Since John's UCL surgery, post-TJS rehabilitation has become better defined. The arm is initially immobilized for a week then put in an adjustable brace. The patient is engaged in range-of-motion exercises working up toward swinging a golf club by the 12th week. By the 16th week the pitcher starts throwing on flat ground and then throws from a mound at six months. By the end of 12 months the pitcher has thrown breaking balls and can pitch batting practice. It is at this point the pitcher may return to competitive pitching. However, that's just from a muscular and joint point of view. The pitcher still has to mentally trust the arm (something some say Liriano is yet to do) and get back his mechanics, and it often takes another season before he can be considered back to full effectiveness.

Differences in physiology, surgery effectiveness, and environment can affect the length of the rehab. Also, the pitcher has to make sure to work on his shoulder while rehabbing his elbow, or risk a DL stint with shoulder problems because they allowed the muscles to weaken during times of limited arm movement.

With the established time to return to effectiveness being 18 months but the time that a pitcher can return to competition being 12 months, the more patient teams have used the compromise of having the starting pitcher return by way of the bullpen. The plusses are obvious as the pitcher, who may not still be back to physical and mental game shape by the end of the 12 months, need not be stretched back to pitch 100 pitches in an outing. Also, giving him one-inning outings allows him to get the feel of his pitches back with less damage to the team, and the manager can be more selective on when the pitcher enters a game.

Perhaps an argument in favor of going to the bullpen is the high-profile closers and relievers that have been able to perform well at the major-league level post-TJS. Danys Baez, Rod Beck, Manny Delcarmen, Octavio Dotel, Frank Francisco, Eric Gagne, Tom Gordon, Hong-Chih Kuo (twice), Jose Mesa, Rafael Soriano and Bob Wickman were all able to pitch competitively after receiving TJS. And just to set the record straight, Mariano Rivera did have TJS, but once the doctors opened up his elbow they found the UCL was fine and only needed to be moved. Therefore, technically Rivera had the surgery, but did not have the procedure done to his arm.

Perhaps the highest-profile example of going the post-rehab bullpen route is future Hall of Famer John Smoltz, who had surgery just prior to the 2000 season. When he returned in mid-May of '01, he started five games before determining he wasn't cutting it as a starter. The Braves needed a closer and Smoltz needed less innings, so he eased into that role and recorded 10 saves that year with a total of 59.0 IP (25 as a starter, 34 as a reliever). The next three years he amassed 144 saves, including an NL record 55 in '02, before returning to the rotation in '05. He then had three straight 200-IP seasons as a starter. Despite his injury-filled and disappointing '08 and '09 seasons, pitching for seven full seasons at an All Star level following the surgery make Smoltz a success story.

The blueprints for Smoltz's move to the bullpen in '01 may have been drawn by the Cardinals in the previous season. Starter Matt Morris had TJS at the beginning of the 1999 season and returned at the end of May in 2000. The Cards sent him to the pen for the season where he pitched 53 innings. The next season they put him back in the rotation, and he made over 30 starts in five of his next six seasons, including two All Star appearances (he likely should have been an All Star in '05 as well). His eight seasons of post-surgery competitive baseball along with Smoltz's seven seasons are strong arguments for the Morris-Smoltz Bullpen Model for recovering TJS patients.

Let's look at some current starting pitchers and see what their post-surgery careers have been like. For each I'll note the player's current team, the date of their surgery, and their age at the time of the surgery. And keep in mind for each Chris Carpenter and A.J. Burnett there's a Jesse Foppert and a Runelvys Hernandez who has not been able to mount a successful comeback.

Rick Ankiel (STL, 7/16/03, 23): What path might Ankiel's career have taken if he had retired Andres Galarraga (the fifth batter of that fateful playoff game against the Braves in '00) for the third out of the inning rather than facing nine batters? After a demotion all the way down to Single A, he sat out the '02 season with an elbow sprain and underwent TJS in '03 after 10 starts. He came back in September of '04 and thrived as a reliever (23 K in 23.2 IP in the minors, 9 K in 10 IP in the majors). However, Ankiel later admitted to taking Human Growth Hormone (HGH) during his rehab under doctor's orders. HGH was not banned at the time, and the claim is that the drug spurred the growth of collagen, aiding recovery. Because Ankiel subsequently switched to the outfield, it's difficult to conclusively say he was completely recovered by September of '04, but perhaps a combination of HGH and the Morris-Smoltz Bullpen Model led to his return.

Brandon Backe (HOU, 9/7/06, 28): Backe started as a reliever for the Rays and Astros before Houston turned him into a starter. A decent innings eater for the Astros, he saved his best performances for the '04 and '05 playoffs (2.95 ERA in 7 games). His '06 season was spent mostly on the DL and in September he had TJS. Backe aggressively tried to shorten his rehab time, and when he returned almost exactly one year to the date of his surgery, it looked like he had bucked the trend going 3-1 with a 3.77 ERA. However, his '08 results were awful as he went 9-14 and saw his ERA balloon to 6.05. Backe was released this year and had now been diagnosed with a torn rotator cuff. At 31, there's a still a chance he can contribute in the majors, but remember that TJS doesn't improve talent.

Erik Bedard (SEA, 9/11/02, 23): Bedard was hailed as the next Johan Santana as he rose through the Orioles organization, but he underwent TJS after only 0.2 innings in the majors. He did not return until the start of the '04 season, where he pitched adequately, but inefficiently (almost 20 pitches per inning). In '06 he started to pitch more efficiently and won 15 games for a team that would only win 70. In '07 he was in contention for the AL Cy Young until he was shut down for the last month with a strained oblique. In '08 he only made 15 starts because of what was later found to be a cyst on his labrum in his throwing shoulder. In '09 he again only made 15 starts, this time because of a torn labrum and inflamed bursa in the same shoulder. While recovery from TJS can be difficult, returning from a torn labrum is arguably harder. There is a chance the elbow, back and shoulder injuries are related (some claim that they can all stem from not enough power in the legs), but Bedard's best days may be behind him.

A.J. Burnett (FLA, 4/29/03, 26): The hard-throwing Burnett appears to be a success story for TJS, but it depends on how you define "success." Yes, he's still starting six years later and has been within his career range for strikeouts. And his '08 and '09 win totals are good. However, after experiencing the best control of his career the year after surgery at age 27 (1.17 WHIP, 2.85 BB/9), he is yet to re-approach those numbers and has seen his WHIP and BB/9 creep up. He had bouts with elbow pain in '05 and '06 and a strained shoulder in '07, but has been relatively healthy the past two seasons (not including losing a fingernail to his car door), but with his propensity for injury, as he approaches the 6-7 year mark after surgery, keep an eye out for anyway downward trend in his health.

Paul Byrd (BOS, 7/01/03, 32): After getting TJS in the middle of the '03 season, Byrd returned less than a year later for the Braves, starting 19 games and going 8-7. Byrd hasn't been able to match his best pre-surgery seasons, but has found MLB employment as a starter ever since. This season he said he wanted to sit out the first half and spend time with his family and then sign with a contender, a la Roger Clemens. He recently signed a minor league contract with the Red Sox, but his career is likely done.

Chris Carpenter (STL, 7/24/07, 32): Carpenter was a highly-regarded young pitcher for the Blue Jays but had shoulder surgery in '02. After signing with St. Louis he excelled for three years, including winning the NL CY Young in '05. In '07, he made only one start before eventually getting TJS. Carpenter made three starts in '08, going 0-1, but was then sidelined with a sore shoulder. In retrospect, the injury likely saved the Cardinals from themselves as they were desperate to get him back on the mound. By the time he returned for this season, he was rested and ready and has only been sidelined in '09 by a torn oblique suffered while batting. His elbow appears healthy and he's making a serious run at the NL Cy Young. Carpenter may be a good data point for the argument that if you give a pitcher his full 18 months, he'll reward you with pitching up to his potential.

Ryan Dempster (CHC, 8/04/03, 26): Dempster was cut loose by Cincinnati after his TJS and was picked up by Chicago, who got him back on the mound three days shy of his surgery's one-year anniversary. The Cubs followed the Morris-Smoltz Bullpen Model and kept Dempster in the bullpen in '04 (23 appearances). In '05 they tried putting him back in the rotation but after going 1-3 in seven starts, Dempster took over as closer from LaTroy Hawkins, who had 4 blown saves to go with 4 recorded saves 34 games into the season. Dempster thrived and kept the job for three years. In '08 he returned to the rotation and won a career-best 17 games while surpassing 200 IP for the first time since 2002. This year he is still a starter but did miss a month to a broken toe. While his '09 hasn't been as good as '08 (that's why they call them "career years"), he is still a viable starter six years after his surgery, another positive data point for the Morris-Smoltz Bullpen Model. Conversely, that may mean he has one or two more good seasons left in him.

Adam Eaton (COL, 8/21/01, 23): Eaton was in his second year with the Padres when he was shut down for TJS in August '01 (the same season he stabbed himself with a paring knife while opening a DVD). He returned just a couple of weeks past the one-year mark and made six starts. In '03 he saw his numbers improve while his '04 and '05 campaigns were the best of his career. However, '05 also saw a DL stint for finger problems, and once he left Petco Park in the offseason, his career took a tumble with ERA's north of 5.00 and WHIPs above 1.55. Eaton just got called up by the Rockies, but likely won't contribute much. The verdict on Eaton is he did recover from TJS, but likely has played out the string on his talent.

Mike Hampton (HOU, 9/25/05, 33): When a Hampton DL stint is announced, it's met with a yawn. It's hard to remember that Hampton was a workhorse for the Astros and Mets, and didn't run into trouble until he logged two seasons at pre-humidor Coors Field. Hampton spent most of '05 on the DL with a strained forearm and then a herniated disk. He finished off the year with TJS and planned to return for '07, but strained an oblique during batting practice (hitting, not pitching) and was shut down again after surgery to repair a torn flexor tendon in his elbow. He then pulled a hamstring in the Mexican League (I'm not making this up) and at the start of '08 hit the DL once again for a strained pectoral muscle, suffering a minor setback when he tweaked his groin. Finally on 7/26/08, Hampton made his first start since TJS, and got hit very hard (6 ER, 4.0 IP). He made 13 starts that year and amassed a 3-4 record, which did not reflect his underlying stats, which were close to his pre-Coors days. This season he has made 21 starts -- his highest since '04 -- but his 5.30 ERA and 1.554 WHIP indicate that four years after TJS, he may not be a viable MLB option much longer, especially as he is now back on the DL with a shoulder strain.

Eric Milton (LAD, 6/15/07, 31): Milton was an All Star for the Twins and pitched well for the Phillies, but then saw his career derail when he signed with the Reds. While pitching miserably for them, Milton then went under the knife in June of '07. He did not become a viable MLB pitcher again until May of '09, and had a gap of almost three years between MLB wins (8/8/06 to 5/27/09). In the meantime Milton also had knee and back problems, and is currently on the DL following back surgery. Milton may still have something to contribute as evidenced by this two wins and 20 K against 6 BB in 23.2 this season, but he just turned 34. The smart move might be to send Milton to the bullpen.

Brian Tallet (TOR, 8/26/03, 25): Tallet was essentially in his rookie season with Cleveland when he got his surgery and did not return to the majors until two years later. It wasn't until '06 when he became a dependable MLB pitcher -- out of the bullpen -- and sported a 2.88 ERA for Toronto last season. With the Blue Jays' epidemic of starting pitching injuries this season, he was thrust into the role of starter. His effectiveness has varied and he currently has a 5-7 record and a 4.99 ERA. The Blue Jays have sent him back to the bullpen where he can thrive as a specialist.

Randy Wolf (LAD, 7/1/05, 28): Wolf had his best season in '03 when he went 16-10, but has worked his way back from TJS to become a dependable starter. He returned a little over a year after surgery to go 4-0 in 12 starts, but the win total was deceptive as his ERA and WHIP ballooned to career highs. This year he is 7-6 (mostly the victim of hard luck) with ratios better than that '03 season. With three strong years post-surgery, the lefty likely has just as many good seasons left in his soon-to-be 33-year-old arm.

Kerry Wood (CLE, 4/8/99, 21): Wood is the poster boy for over-use at an early age having come up through the Texas high school system and then making his first start for the Cubs in 1998 at age 20. He was the NL Rookie of the Year, but when he returned in '99 his elbow gave out in spring training and had TJS. He returned a little over a year later in May of 2000 but wasn't the same fire-balling strikeout machine he was in 1998. The next year, he got back on track and in 2002 and '03, threw over 200 innings in each season for the first time (in '03, his season and playoff innings totaled a whopping 238.2). In order to protect his elbow, he abandoned his knee-buckling curve for a slurve. But after that heavy '03 season, he seemed snake-bit with injuries including triceps problems, knee surgery, a hot tub injury, hip problems and shoulder issues, which eventually led him to the bullpen. Wood is currently trying to hang on as Cleveland's closer, but he has already blown 25% of his save opportunities this season. The strikeout rate will likely never return, and he's not dependable for saves, which means Wood may only be able to contribute as a middle reliever.

Below are some notables that have had TJS within the past year and the date of their surgery. Note that most surgeries are done during spring training or the baseball season as that is when pitchers are working the hardest and most likely to have or notice an injury. That means the pitcher will likely return the next season and be more effective two seasons later.

The next pitcher to return will be Tim Hudson. The Braves will likely throw him into the rotation mix, so don't expect great results from him this year. If you're a Hudson or a Braves fan, drop John Schuerholz and Frank Wren a line and suggest they keep Hudson in the bullpen the rest of this year.

Tim Hudson (ATL) 8/8/08Shaun Marcum (TOR) 9/30/08Billy Wagner (NYM) 9/12/08Pat Neshek (MIN) 11/18/08Ryan Feierabend (SEA) 3/4/09Mark Worrell (SD) 3/25/09Jesse Litsch (TOR) 4/17/09David Riske (MIL) 4/20/09Joey Devine (OAK) 4/21/09Shawn Hill (SD) 4/22/09Scott Proctor (FLA) 5/12/09Taylor Buchholz (COL) 6/17/09Josh Outman (OAK) 6/23/09Tyler Yates (PIT) 7/15/09Edison Volquez (CIN) 8/3/09Jordan Zimmerman (WAS) Scheduled for 8/19/09

Thank you for reading through a much longer column than usual. Thanks to USA Today for its background articles on the history and procedure of Tommy John surgery and post-surgery rehabilitation. All quoted statements in my column, including statistics from Dr. James Andrews, come from those articles. See you next week.

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