Take-home points from Dr. James Andrews and ASMI's Tommy John surgery paper
It's no secret that Tommy John surgeries are up around professional baseball, and most notably in the major leagues. Every time a pitcher leaves the mound with an arm injury, the baseball world cringes, bracing for the telltale MRI that will add another name — from the famous (Jose Fernandez) to the obscure (Jose Cisneros) — to the rolls of those out for the remainder of the season and suddenly facing a career crossroads as their ulnar collateral ligaments are reconstructed. On Wednesday, the American Sports Medicine Institute released a position paper outlining the leading causes of the injuries, dispelling some common myths about the surgery and offering recommendations for keeping both youth and professional pitchers healthy.
Co-founded by Dr. James Andrews, the sports world's top orthopedic surgeon, and featuring the research of Dr. Glenn Fleisig, the ASMI is the leading authority on pitcher biomechanics and injuries, and they're a go-to source for insight into a problem that they've termed "an epidemic." What follows are the top five take-home points from the paper, which itself is only around a thousand words, not including research citations.
But first, some numbers. Via the disabled list data at Baseball Heat Maps, 42 Tommy John surgeries have been performed this year, 39 of them on pitchers, 20 of whom were major leaguers. With three days to go in May, that's already the second-highest season total on record. The high of 35 came in 2012; by this date, 16 pitchers had gone under the knife, so it's fair to say that the current pace threatens that all-time high, particularly given that June is the most common month for the surgery. On Wednesday, Angels reliever Sean Burnett hit the disabled list with what was believed to be a torn UCL, and on Thursday, the bad news broke about Dodgers reliever Chris Withrow; cue "Another One Bites the Dust." Updating the chart I published in connection to Matt Moore's surgery back in April gives a general sense of the trend at the major league level – it's up sharply over the last three years:
Onto the five points…
1. Rest is vital for arms and bodies
Particularly for adolescents, the amount of competitive pitching and pitching when fatigued strongly elevates the risk of elbow injuries. Year-round pitching without "annual periodization" — a time to rest — is a major problem, because the UCL and the rest of the body needs time to recover, to heal the small tears in tissue that are caused by pitching. For youths, the ASMI cautions that pitching for multiple teams (which may not coordinate with each other as to the volume of pitching) is a risk factor; a separate 2013 paper breaks down by age group the organization's recommendations for the number of pitches in a week, season or year, and the amount of rest necessary between various pitch counts. For professionals, the organization cautions against pitching in winter league baseball.
2. Maximum effort and high velocity increase the risk
The ASMI suggests that youth pitchers do less maximum-effort pitching and more throwing, including playing other positions (though playing catcher increases the risk). Professional pitchers shouldn't always pitch at 100 percent effort but rather focus on consistent mechanics, good control and a range of velocities while reminding, "The professional pitcher’s objectives are to prevent baserunners and runs, not to light up the radar gun." The higher the velocity with which a pitcher throws, the more important it is to follow other guidelines regarding proper mechanics and rest.
3. The curveball itself isn't a danger, but poor mechanics are.
The ASMI's biomechanical and epidemiologic research shows that there's not a strong connection between elbow injuries themselves and the curveball, but rather between injuries and improper mechanics. The paper emphasizes the importance of the kinetic chain, using the whole body in a coordinated sequence, and recommends that professional pitchers undergo biomechanical analysis to gather baseline data for future re-evaluation as performance changes.
4. Latin American pitchers are at risk at the same levels as U.S.-born pitchers
Out front, the paper links the rise of professional Tommy John surgeries to a spike in adolescent TJs at the turn of the century, noting that the torn UCLs of pro pitchers in their 20s look to have worn out over time. For all of the fingers quite reasonably pointed at U.S. youth baseball — including traveling teams as well as Little League and high school — American pitchers haven't monopolized the operating tables. Without specifically identifying the as-yet-unpublished demographic survey conducted by Dodgers head athletic trainer Stan Conte — which he discussed with Fox Sports' Ken Rosenthal last week — the paper cites his numbers showing that 16 percent of Latin American pitchers in professional baseball have a history of Tommy John surgery, the same percentage as for U.S.-born pitchers.
5. Lowering the mound isn't a panacea. Communication and education are key parts of a holistic approach
In the wake of Fernandez's surgery, SI's Tom Verducci suggested that MLB should lower the mound, with youth organizations following suit, because it would reduce the forces on a pitcher's arm and restore higher levels of offense to the game. He cited a statement by Mets team physician Dr. David Altcheck and major league pitcher-turned-biomechanics expert Tom House about the increased slope of the mound leading to increased forces on arms. In a follow-up column, Verducci noted that those assertions had been refuted by Fleisig, but that House stood by his statement. The ASMI is sticking by its position as well; the paper says that "Elbow torques during full-effort pitching on a mound and full-effort throwing on flat ground are about the same."
To combat all of the increased risks, the ASMI stresses open communication between a pitcher and his coaching and medical staff. The paper emphasizes the importance of planning and monitoring while stressing the need for pitchers to report soreness, stiffness and pain so as to avert more severe injuries, and for trainers, coaches, medical staff and front office to take a holistic approach and share knowledge with the organization. Proper exercise, nutrition and hydration are vital, as is rest. The recommendations of the ASMI won't reduce the number of elbow injuries overnight, and all of the points within their paper bear expansion as to the proper ways to implement their ideas. Still, this is a step in the right direction, one that offers hope of combatting the problem at the grass-roots level so that young pitchers don't put as much wear and tear on their arms, whether or not they reach the professional ranks. That, in combination with biomechanical analysis and better communication within professional organizations, appears to be the best shot major league teams have at ultimately reducing the number of arm injuries, not just UCL tears. Even with relatively high success rates for returning from Tommy John surgery, the sport is losing too many good arms.