Harvey's choice of rehab over Tommy John surgery a reasonable one
On Monday, Mets ace Matt Harvey paid a visit to Dr. James Andrews in Pensacola, Fla., for a second opinion regarding his partially torn ulnar collateral ligament. While neither the team nor the pitcher have revealed the diagnosis at this writing, CBS Sports' Jon Heyman has reported that rather than undergo Tommy John surgery immediately, Harvey will attempt to rehabilitate the injury and begin a throwing program in one or two months and then reevaluate his situation to see if surgery is necessary. The Mets are expected to make an announcement later on Tuesday.
Delaying surgery is a reasonable decision. Since the Mets revealed Harvey's injury back on Aug. 26, the sports talk radio world has been filled with armchair orthopedic surgeons clamoring for the 24-year-old righty to undergo surgery ASAP. The reality is that even with the high success rate of Tommy John surgery (estimates of 85 to 90 percent are common), the general medical protocol is to avoid surgery if possible, first by waiting a few weeks for inflammation to subside so as to get a better view of the injury through an MRI, and second by attempting to rehabilitate either until the patient regains functionality or concludes that he can't do so without surgery. Little is lost, because by strengthening the area surrounding the injury, the patient is in better shape to proceed with rehab following the operation.
If he does have to undergo surgery, Harvey won't pitch for the Mets in 2014, a year in which the team wasn't expected to be competitive anyway. The normal recovery time of 11-12 months means that at best, Harvey might have been able to begin a rehab assignment in August and rejoin the Mets in September, a timeline similar to that of Stephen Strasburg in 2010-2011. The Nationals' ace went on the disabled list on Aug. 22, 2010, underwent surgery on Sept. 8, began his rehab assignment on Aug. 7, 2011 and returned to the majors on Sept. 6 of that year, making five starts totaling 24 innings.
What's not apparent is the severity of Harvey's injury relative to that of Strasburg, who was said to have "a significant tear." In an article from Monday's New York Times, Tim Rohan reported that Strasburg's teammate Jordan Zimmermann had an 80 percent tear, making surgery a foregone conclusion. Current Mets pitcher and journeyman reliever David Aardsma had a 50 percent tear, which the late Dr. Lewis Yocum "said it was too close for him to call," regarding surgery. Via former SI.com contributor and current Bleacher Report writer Will Carroll, most surgeons will advise surgery if the tear is 25 to 33 percent. As Andrews protege Dr. Craig Levitz explained for Rohan's piece, Andrews' task was to determine the severity of Harvey's tear:
A healthy U.C.L. is taut, Levitz said, and a partly torn U.C.L. is loose, which makes it unstable. If Harvey’s U.C.L. is unstable, when Andrews pushes on his forearm and biceps, there will be a space between the bones. This is where Andrews’s expertise comes in. He has seen so many of these injuries, Levitz said, that Andrews can diagnose, to the millimeter, how unstable the ligament is.
“He can tell if it’s three millimeter, two millimeters, one,” Levitz said.
That test should influence Andrews’s diagnosis. If the ligament is unstable, the discussion will be over, Levitz said. Harvey would be wasting his time rehabilitating it. But if it is stable, Levitz added, “I think you’d be foolish not to rehab it.”
If Harvey is going the rehab route, the presumption is that Andrews — considered by many to be the foremost sports medicine expert in the country — believes that the ligament is stable enough to proceed. According to Carroll, the list of pitchers who have avoided surgery after a low-grade UCL sprain (a sprain is a tear of a ligament) includes Scott Atchison, Zack Greinke, Takashi Saito, Ervin Santana and Adam Wainwright as well as several minor leaguers. Wainwright, who suffered a sprain as a minor leaguer in 2004, didn't undergo surgery until the spring of 2011, by which point he'd already completed five major league seasons and change, including three seasons of at least 200 innings. He'd also made it to his first big payday, having signed a four-year, $15 million deal in 2008 that provided a reasonable financial cushion if his recovery went awry. Harvey is making just under $500,000 this year and won't be eligible for arbitration until after the 2015 season.
One other high-profile pitcher who has avoided Tommy John surgery thus far is Roy Halladay, who was shut down in late September 2006 due to elbow pain and told that surgery was "almost certain." Upon further examination once the swelling subsided, doctors found no serious tear, so Halladay rehabilitated via strengthening exercises over the winter and adjusted his throwing regimen. From the New York Times' Jorge Arangure Jr.:
During spring training in 2007, Halladay did not throw his curveball or his cutter until his fourth start. He also reduced his bullpen throwing sessions and stopped throwing curveballs during side sessions.
From 2007-2011, Halladay averaged 32 starts, 239 innings and eight complete games a year. He also won a Cy Young award, placed second twice and in the top five two other times, and pitched a no-hitter and a perfect game. While he missed time in each of the past two years due to shoulder woes that required surgery earlier this year, his elbow hasn't troubled him further. Halladay spoke to Harvey shortly after his diagnosis in late August, offering encouragement as well as details from his own experience.