Overuse of young pitchers fueling MLB's Tommy John surgery problem
The elbow of Jameson Taillon gave out last month at the age of 22 and after just 382 professional innings, all of them monitored with extreme caution by the team that handed him $6.5 million out of high school, the Pittsburgh Pirates. Taillon had been throwing more than 90 miles per hour since he was 16 and a sophomore in high school. He threw as hard as 99 mph as a senior.
The story of Taillon's elbow has become a common one. The epidemic of elbow and arm injuries to pitchers will get worse, and there is almost nothing major league teams can do about it. That's because much of the damage to pitchers is occurring before they sign professional contracts. The greatest threat facing pitching in the major leagues is the American system of treating teenage pitchers, with its emphasis on velocity, travel tournaments and showcases.
"Major League Baseball gets the blame for pitchers getting injured," said Glenn Fleisig, research director at the prestigious American Sports Medicine Institute in Birmingham, Ala. "But the fact is these pitchers definitely have some damage in their arm when they get them."
The qualifier of "American" is necessary, because the highly organized, highly competitive and highly profitable world of tournaments and showcases does not exist in Latin America. Consider, for instance, the high incidence of Tommy John surgeries already this season, in which the medical procedure to repair a blown out elbow ligament has become a major storyline of the baseball season. Matt Moore of the Rays is the 20th pitcher this year to undergo Tommy John surgery. But in a sport in which 24.2 percent of players on Opening Day rosters grew up in Latin America, only one of the 20 Tommy John patients came from there (Detroit reliever Bruce Rondon, of Venezuela).
"Latin American pitchers are allowed to grow into their velocity," said one international scouting director. "It's a common story to sign a guy throwing 84, 85 [mph] who eventually winds up throwing in the 90s. Michael Pineda is one. You're looking for someone with a good, athletic body who can throw the ball around the plate and has a feel for spinning the ball. The velocity comes in time, with training and better nutrition and physical growth. Here? The statistics don't lie. We need to look elsewhere around the world to learn a better way. It's time."
Beginning in July 2008, when he was 16 years old, Taillon threw at six events sponsored by Perfect Game, one of the country's top youth baseball services, in a 13-month period. Those events occurred in the summer, fall and winter. (In the spring, he was busy pitching for his high school team in The Woodlands, Texas.) His top velocities were meticulously recorded: 92, 93, 95, 96, 96 and 97. Every high school pitcher is known by the top velocity he "hits," even if he gets there once, as much as his very name.
As a high school senior, Taillon hit 99. In June of that year, 2010, the Pirates selected him with the second pick of the draft, in between Washington selecting Bryce Harper and Baltimore taking Manny Machado. He was labeled as another "can't miss" in the long line of Texas schoolboy power pitchers, including Josh Beckett and Roger Clemens.
Now he joins another long line: First-round high school pitchers who are blowing out their arms before they even accrue any major league mileage -- a line that hardly existed as recently as five years ago.
Go back to 2002, which featured a strong first-round high school draft class that included Zack Greinke, Cole Hamels and Matt Cain. None threw harder than 94 mph as seniors. All of them have thrown more than 1,500 innings in the big leagues.
Over the next five drafts (2003-08), teams selected 26 high school pitchers among the first 30 picks. Eighteen of those 26 high picks have posted a career WAR below 3.0, including six who never have played a day in the big leagues. Only eight of those 28 first-round high schoolers ever won as few as three games for the team that drafted them.
The hard-throwing high school phenom only has grown even riskier -- and that's because they are blowing out their elbows at a rate never before seen. Taillon, Cam Bedrosian (Angels, 2010), Dylan Bundy (Orioles, 2011), Taylor Guerrieri (Rays, 2011) and Lucas Giolito (Nationals, 2012) all were top-30 picks who already have undergone Tommy John surgery. All of them threw 95 mph or greater as underclassmen. Just look at how such early blowouts are increasing:
|Rate of Top-30 High School Draft Picks to Undergo Tommy John Surgery|
The disparity is even greater than it appears. Remember that the 2002-09 group has been pitching for much longer than the 2010-12 group -- a maximum of 375 player-years compared to a maximum of 74 player-years. When you consider length of time pitching, the first-round high school pitcher from 2010-12 is five times more likely to get Tommy John surgery than the top high school pitcher from the preceding eight years.
What's going on? Just in recent years, American teenage pitchers significantly have increased the intensity of two of the greatest risk factors for injury: Velocity and volume. And because of the growth in the travel/showcase model, the risks are only growing worse.
First, here is a basic understanding of how the arm works. It is "accepted wisdom" that pitchers break down because the act of throwing a baseball is "an unnatural motion." That is flat out bunk. The oldest skeleton ever found, the Nariokotome skeleton, which is about 1.5 million years old, showed the biomechanical adaptation for overhand throwing found in the modern Homo sapiens. Man has been throwing spears and rocks and such for eons.
What is "unnatural" is throwing 95 miles an hour under the stress of competition for as much as 10 months out of a year -- or more. And that's where pitching has become more dangerous, especially for teenagers. By throwing harder and more often under stress that requires maximum effort (tournaments and showcases), they are pushing their bodies closer to their physical limit more often with less rest. The intensity is an important distinction, because all throwing is not created equal.
"People like to say you have only so many bullets," Fleisig said. "That's not exactly true. One thousand pitches over a month is much different than 1,000 pitches over the course of two years."
Fleisig likes to use this analogy to capture how the tendons and ligaments of the arm and shoulder are stressed by pitching: Imagine those tendons and ligaments are a rubber band that can withstand 100 pounds of pressure before it breaks. If you apply 90 pounds of pressure nine or 10 times -- continually pushing the band to the brink of its limit -- small tears begin to form, and the band will break from the stress.
Now apply 50 pounds of pressure to the rubber band. If you do that 10 times -- 20 times, 50 times, whatever -- the band never breaks. That's because no tears form. It's the intensity of pitching that matters, not pitching itself. And the American amateur market keeps raising that intensity.
In the five years from 2008 to 2013, the average fastball velocity in the major leagues increased from 90.9 mph to 92 mph. Velocity is climbing on the amateur level as well, and for many of the same reasons: Year-round training, specialization, private coaching, both legal and illegal supplements and the ubiquity of radar guns, which have changed how baseball is played more than any piece of equipment since the aluminum bat -- if not all the way back to the fielder's glove. You can watch a travel game of 10-year-olds and find parents behind the backstop timing little Johnny's pitches with a pocket radar "gun" that looks like a smartphone. Even parents who know nothing about baseball can understand the most important measurable: If your kid can throw one pitch at 90 miles per hour, he is going to be courted by college coaches and professional scouts. An entire industry has sprouted on the promise of "increased velocity" -- primarily private coaches, training academies and enough gimmicks and gadgets to fill overnight airtime on a cable channel.
The problem is that the search for more velocity actually is working. The amateur market is flooded with kids throwing 90-plus. But teenage bodies often aren't ready to handle the strain of stressing the rubber band to its limit.
"Velocity is the word of the day," Fleisig said. "The pitcher in 2014, or say 2012, is different from the pitcher from just five years ago. Back then, with the increase in travel ball, you had to start worrying about pitching too much. Now you have to worry about pitching too much with more velocity. That's not a good combination."
Research by ASMI found that high school pitchers who threw harder than 85 mph are much more likely to have surgery before they turn 20 than those who threw less than 85 mph. The risks increase exponentially when the hard-throwing high school kid keeps pitching past the point of fatigue -- a familiar story when the coach is trying to win a travel tournament loaded with weekend games. The ASMI research showed that a high school pitcher who keeps pitching when fatigued is 36 times more likely to wind up needing surgery.
In one of the biggest studies of youth pitchers, a 10-year prospective study published in 2011, ASMI tracked 481 pitchers between the ages of nine and 14. Researchers found that pitchers who threw 100 innings or more in a calendar year were three and a half times more likely to be injured than those who pitched less. They recommended that no youth pitcher exceed 100 innings in a year and "no pitcher should continue to pitch when fatigued."
As Fleisig said, however, "year-round baseball," which began to become popular in the 1990s, has raised the volume of competitive pitching. The most talented pitchers -- that is, the ones who typically throw the hardest -- often pitch on multiple travel teams across multiple seasons, not including their school team.
Back in 1983, when the best athletes played multiple sports, a pro scout watched Tom Glavine pitch in the summer and asked the kid from Billerica, Mass., when he could watch him throw again. "Next year in the spring when the high school season starts," said Glavine, a standout hockey player who would put his baseball glove away for five months. Glavine never received a single pitching lesson until after he signed his first pro contract. He pitched for 25 years, including 22 in the big leagues, without hurting his arm. He will be inducted into the Hall of Fame this summer.
Today it is common for top pitchers to throw well more than 100 innings across 10 to 12 months. Worse, I have seen pitchers show up at college camps and showcases in the middle of winter -- trying to impress a college coach with velocity, of course -- without having pitched regularly or in competition for two months.
"And I see them at the other end, on Dr. [James] Andrews' operating table," Fleisig said. "They walk in on January 12 and say, 'I was at a showcase and hadn't thrown for two months and tried to throw as hard as I could."'
Tommy John was 32 years old and a veteran of more than 2,000 major league innings by the time he underwent what would become his eponymous surgery. It was an injury of long-term attrition. Increasingly, Tommy John surgery has become a young man's procedure. Of the 20 Tommy John patients this year, all of them are between 21 and 30 years old. (Nine of them were taken in the first five rounds of the draft.)
More telling still are the ages of Andrews' patients; they are getting younger and younger. In 1998, for instance, Andrews performed five Tommy John surgeries on youth and high school pitchers. They represented 12 percent of his total Tommy John surgeries for the year. Just five years later, Andrews performed 45 such surgeries on youth and high school pitchers, representing 26 percent of his total. By 2010, nearly one out of every three surgeries he performed involved a youth or high school pitcher.
The high-end high school pitcher always has been a risky bet. The 26 high school pitchers taken among the first 30 picks in the draft from 2004-08 had a failure rate of 69 percent, including about a one in four chance of never seeing the big leagues at all. And now the bet has grown even riskier as the threat of injury grows.
What seems to be a major league problem goes much deeper. By the time major league teams institute their pitch counts and innings limits and unleash a small army of coaches, trainers, therapists and medical professionals to try to keep pitchers healthy, it may already be too late. The American Way has them first, and when they are most vulnerable.
To be able to throw a baseball in the mid- to upper-90s at a young age is a blessing, which can translate into a college scholarship or, in Taillon's case, millions of dollars. But the blessing of velocity also can be a curse. The typical kid who throws very hard probably pitches on multiple travel teams, attends showcases across three seasons, sees a year-round coach, doesn't play other sports and keeps adding more velocity, even though his body may not bear well the wear and tear from its force.
The scout can look at the wonder of the prodigy -- a 17-year-old kid with top-end major league velocity -- and dream on it. He sees a first-round pick. A future ace. What he doesn't want to see is what people like Fleisig see. It is an image that is becoming more and more common: A rubber band about to break.