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Under The Knife: Pressure can make or break the pitcher

The All-Star break makes for a nice, if artificial, halfway point. It's where we can look back, but more important, look ahead. I try to use this break -- the one point of the season where there's usually not new injuries -- to bring out some stuff that's a bit different. Monday, you saw the ranking of the Top Doctors in Baseball. Today, I'm proud to bring you some research from Dan Wade that I think will help us understand the forces that create injury and help you avoid having those kinds of pitchers on your fantasy team. Dan's work is the first I've seen that relies on advanced measures, but is easily understandable and observable by everyone from scouts to those of us watching at home. I hope you're as impressed by Dan's work as I am:

Since 2007, major league baseball teams have lost almost $3 billion in injury cost to players on the disabled list. A huge portion of that cost comes from players who get hurt early in the year and miss entire seasons at a time. When a pitcher tears his UCL and undergoes Tommy John surgery, it typically takes nearly 200 in-season days for him to return to the active lineup; most seasons last about 180 days. While shoulder injuries are now far more costly in terms of both time lost and money wasted paying a player who physically cannot contribute to the team, elbow injuries aren't going away. The best teams in baseball typically lose 400 days or less to players on the DL over the course of a season, which simply won't happen for a team where one player accounts for nearly half that total.

Losing any player for a full season and beyond is never a good thing, but when the pitcher who goes down is slated to anchor a staff -- Adam Wainwright, Stephen Strasburg, Scott Baker and Daniel Hudson all fit that description -- teams can lose far more than their shot at recognition. While there are certain red flags for elbow issues, finding a set that applies to both starters and relievers is more than trivially difficult. Pitch counts aren't particularly useful for starters, but for relievers they don't begin to yield usable information; consecutive days of use might be a better measure for relievers, but it doesn't even begin to make sense for starters. One thing that both starters and relievers have to deal with, however, is pressure.

That actual game pressure is something that's virtually impossible to simulate in a lab setting, which is why this game data may deviate from the data presented by some of the leading biomechanics experts. Time and again the research has shown that offspeed pitches don't tax a pitcher's arm any more than a normal four-seam fastball does, provided, of course, that the mechanics don't change between the two. However, add in mental fatigue from bad weather conditions, an umpire with a particularly tight strike zone, an opposing hitter who has been hitting everything that night, or a pressure-filled game situation in late September and even a pitcher with typically clean mechanics can slip into poor form to get a few extra ticks on his fastball or a sharper break on a pitch. It would be great to simulate these stressors in a lab, but there's just no way to make a set-up man feel overworked and underpaid relative to his teammates if he doesn't already feel that way normally, which is why the concept of a proxy variable comes into play.

Assigning a number to the amount of pressure a pitcher feels or internalizes borders on impossible, but there is an objective measure for the extent to which a game is on the line known as leverage index or LI. The stat, invented by Tom Tango nearly a decade ago, is useful for looking at which plays and players determined the outcome of a game. For the purposes of this article, it's primary use will be to determine when the most pressure is on a pitcher. While the correlation between the pressure a player feels and the actual pressure of the game situation might not be exactly 100 percent, it's as good a proxy variable as exists until players agree to submit to functional MRIs between innings (which will definitely happen six months after the robot umpires are first installed.) Using leverage index, it is possible to observe whether a pitcher is changing his approach -- if not his mechanics -- when the pressure is on.

Fangraphs breaks down each game, play-by-play, and sorts them by leverage, making it possible to cross check those exceptionally intense moments with MLB's Gameday PITCHF/x system to determine which pitchers are throwing an abnormal amount of secondary pitches. An LI of 1.00 is average, anything below that is considered low leverage, while high leverage begins at about 1.50; according to Fangraphs' glossary, just 10 percent of all game situations have an LI over 2.00. When Heath Bell came into Sunday's game against the Cardinals, the LI was a moderate 1.76, then fell to 1.13 after he struck out Carlos Beltran to open the frame. By the time the game reached its walk-off climax, the LI had soared to 10.78.

Those moments -- those top 10 percent -- are the ones that will show what changes a pitcher might make when the pressure is really on. One thing that was important to consider when picking a sample of players to study was each player having a variety of high leverage situations to look at, lest a particular day skew the results because a particular pitch was working better at that moment than another. Having a broad variety of high-leverage appearances to look at helped ensure that a one-day quirk wasn't going to produce a false positive.

The results are nothing short of astounding. There isn't anything complicated or hard-to-explain about it. A sharp pair of eyes in the dugout and the standard pitcher charts could replicate this work easily on a team-by-team basis, but this gives you access to the same information. Of the 16 pitchers sampled, just under half increased their usage of a single secondary pitch -- usually a slider, changeup, curveball, or two-seam fastball -- by 10 percentage points or more over their average usage. For reference, a control group saw an average increase of just a hair over one percentage point, so the double-digit increases really are a substantial deviation from the norm.

Another five pitchers increased their usage, but in a less dramatic way. For pitchers like Brian Wilson, who already throw their secondary pitch upwards of 40 percent of the time, a four or five point increase in secondary usage is more than a trivial increase. All told, the Tommy John patients studied who showed an increase in their secondary usage were: Baker, Carlos Carrasco, Rubby De La Rosa, Sergio Escalona, Cory Luebke, Ryan Madson, George Sherrill, Joakim Soria, Arodys Vizcaino, Wilson, and Blake Wood.

Like every single baseball truism or cliché, there are some examples who don't quite fit the pattern. John Lackey did the exact opposite of the players listed above, throwing his offspeed pitches less and using his four-seam fastball a lot more, though the fact that he was pitching through an already torn UCL may have something to do with his pitch selection. Jose Ceda threw fewer sliders and Danny Duffy kept his pitch selection remarkably consistent irrespective of leverage. Brett Anderson and Mike Pelfrey went to their primary pitches more frequently in high leverage situations, but because both tended toward offspeed pitches in all situations, neither threw more fastballs. Anderson increased his slider usage by five percentage points, but his slider was already his primary pitch; Pelfrey increased his sinker usage by a remarkable 29 points, but again, it was already his primary pitch.

Hard and fast rules are nearly impossible to come by when it comes to sports medicine, and having specific numbers to support those rules are even harder to find. Everybody is different, every training staff has different strengths and weaknesses, and there can even be an element of luck when it comes to injuries and recovery time, but that's why red flags that can largely be applied to pitchers in general have the potential to be so valuable. This isn't a theoretical construct. Eleven teams are missing key players and a keen eye may have noticed the trouble signs before the tendon tore. With any luck, teams will start keying into details like this and there will be more intervention-based DL stints and fewer players who end up on a super surgeon's table, looking at 180 days away from their team.

The takeaway from this isn't that every pitcher who throws a lot of sliders when the game is on the line is absolutely going to blow out his elbow, but it certainly should give a team pause when they notice a pitcher -- whether they're starting or relieving -- trying too hard to make a slider bite, a two-seamer cut, or a changeup drop too frequently when the pressure is high. Some pitchers may get away with it, but it's becoming increasingly clear that they're the exception to the rule.

Dillon Gee had a clot busted, but there's more going on inside his shoulder. The symptoms sounds similar to thoracic outlet syndrome, so his season is still in jeopardy. He'll have surgery Friday and a best case scenario is a late September return, though long term he'll be fine ... The Mets will have Johan Santana, who will make his start as scheduled on Sunday. He sprained his ankle in his last start, but showed no issues with it in a side session on Thursday ... Roy Halladay threw three innings in Clearwater (A) with no issues. Despite the stamina question, it looks like he'll come off the DL to take a start next week... CC Sabathia had no issues with his groin strain in a side session. He'll come off the DL next Tuesday ... Lots has been made of Carl Crawford saying he'd need Tommy John surgery. This is a lot like how Albert Pujols was back in the mid-'00s and he still hasn't had Tommy John. Like everyone, Crawford is one throw away. The more interesting question is whether he could DH next season and beyond ... ELLSBURY ...Dustin Pedroia is hitting again, taking batting practice without any sort of protective device. We'll see if the short rest really helped his thumb heal up ... Neftali Feliz will work two innings for Round Rock (AAA) this weekend. Alexi Ogando will go one. Look for their usage to give clues about their roles in Texas once they're healthy ... Lance Berkman won't need a rehab assignment - or at least the Cards won't ask him to go on one. He'll be back early next week ... Kyle McLellan was working his way back from an elbow injury, only to tear his labrum. He'll need surgery and is done for the season ... Ben Sheets will get his first start for the Braves on Sunday. I'm curious to see if his arm can hold together for more than a few starts. Even so, he was effective for a few starts a couple years ago and that would be a plus for the Braves ... Joba Chamberlain is starting his rehab assignment. His first outing was Tuesday and he showed a 97 mph heater. His elbow and ankle both seemed to be no problem. He'll need to be back in the Bronx by mid-August now, barring a setback ... Matt Capps will be activated and goes right back to his closer role for the Twins ... Emilio Bonifacio didn't hit well during his rehab assignment, but the thumb held up. The Marlins will have him workout Friday and will decide the next step then. It's likely to be activation ... Brian Roberts is going to decide on hip surgery by this weekend. The labral tear could cost him the rest of the season ... Scott Kazmir is making a comeback with a team called the Sugar Land Skeeters. Seriously ... Yes, it's theoretically possible that Mariano Rivera could return this season. It's also theoretically possible that Heidi Klum is going to show up at my door wearing nothing but a trench coat. Rivera's is just a little bit more likely, but it's a lot more likely that he's healthy for next season ... Drew Storen blew threw his rehab and minor league hitters. He'll be back for the Nats this weekend. With Stephen Strasburg's shutdown the talk of the break, would the Nats consider shifting Strasburg to the pen rather than just making him a cheerleader? ... Nick Markakis is expected to be activated. He hasn't hit well during the rehab and it feels like he's been a bit rushed through this hamate injury ... Ted Lilly is still a couple weeks away from a rehab assignment. His health or lack thereof will be part of the equation on how hard Ned Colletti pushes to acquire a starter ... Lorenzo Cain will come off the 60-day DL and take over the CF job in Kansas City, while Royals fans wait for Wil Myers. Cain could be a speed boost for someone desperate for steals, though the hip could hold his numbers and opportunities down early ... Jesus Montero has been cleared to play after his concussion ... We talked about Billy Hamilton on this week's Inside Fantasy. He was just promoted to Pensacola (AA), so we'll see if more advanced catchers can stop him ... Odd note in this report on the Marlins failure to sign their first round pick. Bloodwork? I've never heard of a team requiring that.

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