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Joey Votto Quad Strain Will Challenge Reds, Raises Questions About His Health

The news came from Ken Rosenthal of Fox Sports. Joey Votto, the Cincinnati Reds star first baseman, stayed in Cincinnati for an MRI and a consultation with team physician Dr. Tim Kremchek rather than joining the team at the start of a six-game road trip.

The finding was that Votto has a strain in his distal quad, the part of the thigh muscles nearest to the knee. The injury is to Votto‘s left leg, the same one he had two surgeries on in 2012. The team will take the next few days to see how he responds to treatment and rest before making a decision about the disabled list.

The diagnosis of the Grade I strain is a positive given earlier indications of a knee problem, but it’s not good either. There is very clearly an issue with his movement pattern, and the injury will affect the stable base that Votto needs in order to hit well in his manner. It could be a discrete injury, but there has to be concern that the previous knee problems have caused changes that led to a cascade injury. 

In 2012, Votto had a simple meniscus tear. He had a meniscectomy and, during rehab, took things a bit too fast, leading to a need to go back in and repair the knee a second time. Votto struggled when he returned because he had a hard time finding a stable base for his swing. The extreme loss of power is certainly a worry in the short term with this latest injury.

The Reds medical staff will use all of their available modalities to help Votto, but most of this is going to be about his healing response. Votto has a tendency to be very reticent about injuries, trying to play through them until his performance has suffered, then trying to get back too quickly. If Votto shows some healing over the weekend, the Reds may try to let him come back with some restrictions. If they decide that he’d be better served by more time, they won’t hesitate to push him to the DL

With Votto‘s giant contract hanging over his head and potentially becoming a major issue for the Reds if his production drops, this latest knee problem is a major concern. At worst, Votto is beginning to have degenerative changes in his knee, which would likely reduce his availability and production. Votto had a major drop-off in power once he returned from surgery in 2012, and that could become permanent.

Votto has had a disappointing season, as pointed out by Cincinnati radio host Lance McAllister. Some of that may be due to the knee, especially if he has been trying to play through this. However, there’s been no real sign that Votto is having problems. He’s not a speed guy and has a lumbering gait when healthy, so this may have been impossible to see. 

The Reds are already without Jay Bruce, who recently had knee surgery to correct a similar problem. The fact that the team has two such similar injuries in a short period of time could be coincidence, but there’s also the possibility that there’s an issue with the movement patterns they are using. That’s unlikely given the stability in support and medical staff, but it’s something I’m sure the team is checking.

While Votto is out, the team will give Neftali Soto a look, with Brayan Pena being another possibility. Neither is a fantasy option, and both are a major downgrade at the position for the Reds.

Votto shouldn’t be out much longer than the 15-day minimum in the worst-case scenario, so the Reds will simply have to try to get offense elsewhere in the short term. Bryan Price, the new manager of the Reds, will have to show how adaptable he is offensively while missing his two biggest bats.

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Marlins Send Jose Fernandez to DL, Diagnosed with Sprained Elbow

The Miami Marlins got quite the shock on Monday. Jose Fernandez was sent to Los Angeles for an MRI to check his elbow. According to Ken Rosenthal of MLB Network, the diagnosis was a sprained elbow. That diagnosis specifically points to UCL involvement. The UCL is the ligament replaced in Tommy John surgery.

Naturally, the Marlins are very concerned. After his MRI, Fernandez was sent back to Miami to consult with team physicians. The team is worried, as indicated here:

The trip to Los Angeles is guided by the Marlins being on the West Coast. It is commonly believed but unconfirmed that Fernandez was sent to the world-famous Kerlan-Jobe Clinic. While he could have had the MRI anywhere, Los Angeles Dodgers team physician Neal ElAttrache is one of the most respected surgeons in the game and could give a consult. Baseball teams do not travel with their own doctors and often use those of other teams in similar circumstances.

Fernandez, who finished third in last year’s Cy Young voting, has only pitched 220 innings in the major leagues and had only 26 starts in the minor leagues, as he dominated at every level he stopped at. While Fernandez was born in Cuba, he lived in South Florida and went to a U.S. high school, where he was scouted closely throughout much of his career.

Like most pitchers, there are no good stats on how much he was used in high school or for travel teams, but he was someone who showed up at many of the showcase events with his plus velocity. There is no evidence that Fernandez was overused at any level. Fernandez has even been praised for his pitch efficiency.

Fernandez has plus velocity, though he is certainly not solely reliant on it, as Troy Tulowitzki recently found out. His mix of pitches is almost identical to last year. His velocity had been consistent, but in the fifth inning of his last game, it appeared to have taken a major drop down. This could be where the injury happened.

Fernandez has none of the red flags we normally look for. He has no high-innings totals and was all but shut down at the end of his rookie season by the Marlins. He has no games with excessive pitch counts. Few point to any mechanical issues, though Chris O’Leary suggests that Fernandez has changed his mechanics. 

If Fernandez is found to have a sprained UCL, it will be further proof that all the standard things that teams currently do to protect pitchers aren’t working. Fernandez isn’t yet locked into the path that too many pitchers are headed, losing a year of his young career to surgery and rehab, but we have to wonder what more has to happen before baseball changes its approach.

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Hyun-Jin Ryu Just Latest Dodger Pitcher to Head to DL with Arm Problem

Just as Clayton Kershaw is coming off the disabled list, Hyun-Jin Ryu is heading onto the disabled list with a shoulder injury. The Los Angeles Dodgers swap their No. 3 pitcher for their No. 1, but their depth has already been tested by injuries, making any further time lost a tough proposition.

Ryu is headed to the DL with what the Dodgers are calling shoulder inflammation. They have been non-specific about the severity and location, but given that the Dodgers medical staff has not asked for an MRI, they must feel that they have a good handle on it. Team sources tell me that Ryu‘s shoulder is more tender than painful and that the push to the DL was precautionary.

Ryu has no significant history of shoulder problems, going 192 innings in his first MLB campaign. Ryu showed good stamina throughout the season, though the Dodgers were very cautious with his innings, especially early in the season. 

The Dodgers cleared Ryu to start a throwing program after some progress with the inflammation, and he should have a couple throwing sessions before getting up on a mound. If all goes well, he could come off the DL sometime late next week.

The Dodgers have a current rotation of Kershaw, Zack Greinke, Dan Haren and Josh Beckett, with Paul Maholm holding the five slot. With Chad Billingsley finishing up his Tommy John rehab and Zach Lee at Triple-A Albuquerque, the Dodgers have some flexibility even with Ryu out. Beckett, Haren and Maholm are essentially pitching for their slot each time out until Ryu and Billingsley are back.

Billingsley did have a mild setback, getting some tendinitis during his rehab. That pushes his return back until mid-June at the current pace, but he is expected to slot right into the rotation when he gets back.

Ryu remains a solid middle-rotation option in fantasy and should be able to put up solid numbers. Missing a couple starts will hold his innings down around the same mark he hit last season, which is a positive. Another big positive is that Ryu hasn’t shown any loss of velocity despite the shoulder issue. Fantasy players should get him back in their rotation once he returns.

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Michael Bourn Hamstring Injury Could Mean Big Trouble for Indians

Michael Bourn could be headed back to the disabled list after starting the season there. His repaired left hamstring is acting up again, a big problem so closely after surgery. The Cleveland Indians speedster is being evaluated by their medical staff, according to MLB‘s Jordan Bastian, and no decision has been made on a return.

Bourn‘s 2013 season ended with him headed for surgery after a severe Grade III strain was not going to heal on its own. Stitching muscle back together is very difficult. A surgeon once told me that it was like trying to cut your steak and then stitch it back together. (He told me this at a steakhouse. Yeah.) 

While Bourn was able to return without significant issue, the fact that he is having trouble is problematic. It’s not known where the new injury is. It could be at the repaired area, nearby or further up or down the muscle. Any is problematic as it further weakens the muscle that Bourn needs to play his kind of game.

Hamstring injuries do have a tendency to be recurrent. Because the muscle repairs itself with scar, it is never as strong. This exacerbates the normal strength deficit the hamstring has to the quad, it’s antagonist. Any imbalance leads to further movement disruption and usually only gets worse from there.

Terry Francona had a very interesting quote in the article above about the situation. “We just want to make him understand that he’s got to be honest, and then we’ll sit down with him and make decisions. That’s kind of how we always do things.” 

Francona‘s quote is intriguing in that he felt the need to articulate it. Lonnie Soloff and his medical staff are among the most respected in the game and have been there for years. Having to say that Bourn should be honest has to be a reflection that they’ve had issues with him somewhere along the line. 

The Indians should make a decision shortly on Bourn, retaining the retro move back to the weekend. They called up Nyjer Morgan, who had filled in for Bourn at the start of the season. Morgan is a streaky player, so he’s not a bad desperation play in fantasy.

Bourn‘s long-term value is tied up in his speed. With only two steals in five attempts and reduced range in the outfield, Bourn hasn’t demonstrated that at all. Further hamstring issues call into question whether it’s coming back at all. 

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Cut Forces Matt Cain to DL, but Don’t Expect Much Time Off from Giants

Missing any time is frustrating to Matt Cain, but the San Francisco Giants are making good use of a little understood MLB rule in order to minimize that lost time. Cain’s finger laceration will only cost the minimum time due to the Giants’ use of the “retroactive” provision of the disabled list rules.

Henry Schulman of the San Francisco Chronicle had the scoop that Cain cut himself when trying to cut sandwiches into “fancy little triangles.” He dropped the knife and (get this) tried to catch it. That didn’t work out well, leaving him with a nasty cut on his index finger.

The cut didn’t require stitches, but sources tell me that the Giants medical staff did use several techniques, including adhesives and protective coverings to help the cut heal quickly and properly. Things were looking good up to Monday, when, in the pregame warm-up, Cain felt like the cut was going to “pop open.”

The Giants decided to skip him and did so in part because they understood the retroactive provision. Essentially, the rule allows a team to backdate a DL stint to the day after the player’s last appearance. Cain was able to be backdated to April 25th, which makes his effective DL stint only a few days.

Cain is scheduled to pitch this weekend in Los Angeles and will be eligible to come off the DL on Friday. If the finger has healed up, he’ll come off the DL and make the start. The Giants will “shadow” him, meaning they’ll have a long man ready in the pen in case the finger becomes a problem. This does limit the pen slightly for a few days, but is the smart move.

Yusmeiro Petit took both starts in Cain’s absence and is likely to be the shadow. Petit‘s place as the de facto swingman is another smart usage of roster spots and skills by the Giants. The Giants also recalled Jake Dunning when placing Cain on the DL, giving them another arm that could be used as a long relief arm or as an emergency starter.

In the long term, the fancy little triangles won’t cost Matt Cain much time, and it shouldn’t cause any issues once the laceration is healed enough to pitch. On and off the field, the Giants have worked to minimize an injury, showing others just how this should work.  

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Pitch Counts Are Good for Kids, Bad for Major Leaguers

Pitch counts are now an acknowledged part of baseball. For all the sabermetric advances in the game, the one that’s made the most inroads into the consciousness of baseball fans and the actions of baseball teams is the simple pitch count.

The problem is, it’s not helping.

Baseball has stuck to something simple, sticking to clickers over research. While the Moneyball revolution has taken over front offices, the old-school mentality is still allowed to manage and mismanage health with a minimum of information. Often pitching coaches have nothing more to go on than a number on a clicker and a cliched response to “how do you feel?” 

Injuries continue to trend up. While it’s well known that Tommy John surgeries are up over the first few weeks of the season, already over the total of all of 2013, it’s not just elbow reconstruction. Injuries have cost MLB a billion dollars over the last five years, and worse, that total has held over any rolling five-year period, according to data in my proprietary injury database and confirmed with MLB and independent data.

Pitch counts and systems of counting were first popularized by Craig Wright in his seminal work The Diamond Appraised. Wright, along with Dr. Tom House, theorized that high usage would be problematic for both performance and injuries. While House was famous at the time for his work with Nolan Ryan, he’s long been an advocate of pitch efficiency and agreed with Wright. However, there wasn’t much change at the major league level.

In 1999, Dr. Rany Jazayerli of Baseball Prospectus (and now Grantlandintroduced a better measure, called Pitcher Abuse Points (PAP). That system was improved upon by Jazayerli and Keith Woolner, now a top executive with the Cleveland Indians. Both systems measured the exponential increase in damage of pitchers above 100. 

It’s key that the 100-pitch mark, first stated as a rule of thumb by baseball legend Paul Richards, held up to Jazayerli and Woolner‘s research. However, there’s actually nothing special about the number itself. Moreover, it’s clear that the response to hitting that mark is individualized. While their research showed that there is increasing risk, there was no clear correlation to injury. 

Over the last 15 years since Jazayerli‘s research was published, pitch counts have become orthodoxy. As a pitcher approaches 100 pitches, managers get the bullpen going whether or not a pitcher appears tired. It’s key to PAP that the research was focused on short-term results after high pitch count games rather than longer-term injuries, though it goes without saying that the two should go hand in hand. 

It could be argued that other factors reduced pitch counts from their historic levels to their modern equivalent, such as the La Russa model of bullpen management, increased power around the game that necessitated increased effort/velocity on every pitch, the Jobe “Thrower’s Ten” exercises that reduced shoulder injuries among other factors. That said, the widespread reduction of pitch counts coincident to the Jazayerli/Woolner research seems causative.

Conversely, modern managers have resisted using a “quick hook” when pitchers are in trouble early as well, so as not to extend the bullpen. Starters have become simply another role, just as the closer, the setup man and the LOOGY (lefty one out guy) have become defined, even rigid, bullpen roles. The starter is now designed to go six or seven innings, more or less 100 pitches, every start regardless of any other circumstance.

Jazayerli acknowledges that in today’s game, as a result of his research and baseball’s response to it, high pitch counts matter less, simply because they so seldom happen. “[T]he difference between 100 and 120 pitches is so much less meaningful than the difference between 120 and 140 pitches. It’s not that pitch counts don’t matter – it’s that pitch counts at the level they are in 2014 hardly matter anymore,” Jazayerli told me by email.

Remember that this is all focused on major league pitch counts. Pitchers at this level are the elite of the elite and have already not only survived the long path to the big leagues, they have largely remained injury free. What is reasonable to expect from physically mature pitchers making millions of dollars is nothing like what we should expect from high school athletes or younger. However, over and over, we’re reminded that this is exactly what we’re doing. 

I could link to story after story about pitchers at the high school or college levels that are going 150 or more pitches. I could link to story after story about youth pitchers that play for two or three travel teams and pitch several games a week, often at high pitch counts.

This is in spite of Little League taking a proactive stand on pitch counts. Little League commissioned Dr. James Andrews and Dr. Glenn Fleisig of the American Sports Medicine Institute to research the effect of pitch counts on youth pitchers. Their research, done over a period of years, led to Little League adopting strict pitch count rules in 2007. In a one-year followup, Dr. Fleisig said they did see a reduction in injuries, though he has not done a longer-term study on the effects. 

Unfortunately, these regulations have had an unintended consequence. At the same time that Little League was taking a stand, there was a rise in travel teams and showcase events. In both of these, there is a lack of regulation and a surplus of radar guns. The combination is often cited as a major cause in the rise of pitching injuries.

In the absence of an athletic trainer or other trained medical professional, pitch count is a reasonable tool to be used. When I wrote Saving The Pitcher in 2004, we tested the ability of several groups—scouts, ATs and moms—to detect fatigue. All of them tended to be close and matched well with pitch count. The pitch count had to be individualized, but in the absence of better measures, pitch count regulation or monitoring is likely the best available option.  

“Pitch counts are an artificial control,” said Dr. Glenn Fleisig. “We know that overuse is accumulated and that pitching when fatigued is damaging, so this works for a broad population. It’s not individualized. Some pitchers could go 100 pitches and some could go 50, but we set the limits to do the most good possible. It’s up to the coaches and athletes at some point.”

However, the best available option for youth players with no professional supervision should be far from the best available option for million-dollar arms. Sadly, that’s not the case even in 2014. 

Indeed, the problem is that at the major league level, we learn nothing from the pitch count. If it was merely a linear fatigue problem, relievers would never get injured. What we have is a multivariate issue that goes well beyond what a simple counting stat could ever hope to accurately measure. So why are we stuck on something so simple and ineffective?

Alan Jaeger, one of the top pitching instructors in the country who has worked with many pro pitchers, thinks that the culture itself is the problem. “There is no question in my mind from 24 years of both training arms, and having a pulse on how arms are trained in the amateur community (more throwing/conditioning), compared to the professional community (less throwing/conditioning) that the most fundamental reason why we have so many arm problems is conservatism and restriction at the professional level.”

Jaeger thinks that what we’re seeing is a symptom, not the cause. “The pitch count is simply a by-product of this mentality. So until we deal with the foundation of why arms are breaking down, I feel strongly that we aren’t going to unearth the real answers by ascertaining the role of pitch counts.”

What baseball needs is an accessible direct measure of fatigue. While pitch count is a reasonable proxy, it only works in the aggregate. Greg Maddux may be effective for 85 pitches, but for those, he’s a Hall of Famer. Livan Hernandez could go 150, but no one’s expecting him to head for Cooperstown. Both can be useful, even leading a staff, but neither pitch count on its own tells us much about the pitcher.

Instead, we need a measure of both fatigue and recovery. Baseball in 2014 has no direct measure and few teams are even seeking out this kind of measure. While recovery is understood as a key point, even in a five-man rotation, few teams are doing anything to measure this. We have a descended wisdom only a few decades long, and in those decades, we’ve seen injuries increase.

We do have to consider that at some level, pitch counts do work. They may not reduce overall injuries, but for a certain important subset they work. Jazayerli points out, “I also did a simple study when I wrote about Stephen Strasburg for Grantland back in 2012, looking at the attrition rate of 22-year-old starting pitchers in the majors five years later. Prior to about 1998, roughly 50% of them were still starting regularly five years later; since 1998, that rate has jumped to two-thirds. Maybe it’s a coincidence; maybe it’s not.”

At the same time, we’re seeing a major increase in severe injuries to youth pitchers. Many of the Tommy John surgeries that the top orthopedists do will be on high school pitchers or younger. With the increase in revisions (second or third Tommy John surgeries), the decrease in the incidental age is going to increase the number of revisions we see if the pitcher continues to overuse or overstress his arm.

SI’s Joe Sheehan also believes that we are seeing some effects. “I think we’ve reduced injuries or ineffectiveness due specifically to short-term overuse. Pitchers definitely used to get broken by their managers, and that just doesn’t happen any longer.” Given the lack of 120-plus pitch starts, this is reasonable, which means we’re likely seeing more high-effort trauma. 

The next step is a more direct measure of fatigue. “There’s no such thing as a fatigue-o-meter,” said Fleisig with a laugh, “but if there was one, every team better have one.” There are possibilities on the horizon for such a device. Right now, there are available proxies like heart rate variability and direct measures like the use of portable ultrasounds that could check the integrity of muscles and ligaments very quickly. While it’s unlikely a team would do this between innings, doing it between starts would be a very low-cost solution.

There is also the new baseball tracking system that is expected to come into play this year. While the system is still being developed, it is often referred to as “OMGFX” given all of its information. One possibility is that it will be able to give us in-game, real-time measures of fatigue and pitching mechanics. If so, baseball will have a powerful tool, though one that would be impossible to get out to even minor league stadiums. 

What this comes down to is a failure of imagination and execution. Pitching coaches are working from what they did “back in the day” and seldom the best research. They’re certainly not conducting any research or being given the proper support from their organization. This is a system failure, but one that could be easily corrected given the will of the organization, some of which have made strides.

Angel Borrelli, a top kinesiologist who works with and analyzes MLB pitchers, says it best. “Nothing could be more impersonal than dealing with pitch counts (a number) when not firstly dealing with the pitcher (a human and not a machine).” The system is failing pitchers by not treating them as individuals, and that would be easy to change.

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How Lingering Neck Injury Could Impact Yu Darvish Early in 2014

Yu Darvish has been great since joining the Texas Rangers, but a neck injury has forced the team to bench its ace, according to Darvish has a sore neck and is heading back to Dallas for more tests. It is very likely he will start the season on the disabled list.

More worrisome for Rangers fans is that Darvish hasn’t been able to shake what was initially described as simple neck stiffness. Darvish continues to describe the pain as minor and that it initiated when he “slept on it wrong.” 

Now, he’s headed to see Dr. Drew Dossett in Dallas. Dossett is one of the world’s top spinal surgeons, but don’t read too much into it. Dossett is a team physician for the Rangers as well as the Cowboys. Some might remember Dossett as the doctor who made the final call on Tony Romo’s late-season surgery.

There are many possibilities for this condition, with the most likely being some small herniation of a cervical disc. If so, the nerve would be irritated, causing the pain. The disc could be inflamed for many reasons. Trying to calm that aggravation can be handled with injections or, in an extreme case, surgically. If Darvish needs even minor spinal surgery, such as a microdiscectomy, he would miss two to three months. If it’s something minor, it’s more about how he responds to the treatment and when he can get his arm ready to come back.

There are several pitchers who have had similar injuries. The comparable that makes the most sense to me is Clay Buchholz, who missed much of the last half of the season with a similar-sounding neck injury. Buchholz’s is more serious, in that it moved into his shoulder due to nerve impingement. Other pitchers with similar cases are Shaun Marcum and Ted Lilly. The range of days lost to these goes from 16 to 84, according to my injury database.

There’s another sports comparable that NFL fans will note: Peyton Manning. While Manning eventually had to have a single-level fusion, where the disc was removed and two vertebrae were locked together with a titanium cage, he’d previously had two microdiscectomies, plus a number of other minor treatments, and was able to play at a high level for at least five years.

With Darvish out for the Opening Day game with the Philadelphia Phillies—which just sounds odd, doesn’t it?—the Rangers are left scrambling. They will already be without Derek Holland for the first half of the season after knee surgery, and without Matt Harrison for at least a few weeks, if not more, after his three surgeries with Dr. Dossett last year. 

That leaves Martin Perez as the likely Opening Day starter, with no clear favorite for the now-open No. 5 slot. The Rangers may be forced to convert another reliever to the rotation, with Tanner Scheppers now possibly the No. 2 starter and Robbie Ross in the lead for the No. 5 spot. That will leave the pen thin in front of as many as four starters who are coming off injuries or just converted to the rotation. Mike Maddux has his work cut out for him to be sure.

The Rangers do get a little help from the schedule. With two off days in the first two weeks, the team could elect to go with a four-man rotation for the first two times through, but that would leave them needing a fifth starter in an important divisional series with the Seattle Mariners

The Rangers start the season in a very tough spot. They’re down three of their expected five starters as well as Jurickson Profar and Geovany Soto. Elvis Andrus isn’t feeling so well, either. Ron Washington is going to have to rally a team that’s going to look very unfamiliar for the first few weeks of the season in order to not fall behind an improving AL West.

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Under the Knife: More Spring Training Injuries

The story this week has been pitching injuries, but while the outbreak of Tommy John across the league got headlines, it’s not unusual. Tommy John surgery is happening more and more. Remember, David Wells, a player from the not-too-distant past, may have been one of the first 10 MLB players to have the surgery.

The acceleration has come to the point where we’ll likely have 10 this week. It’s more than just the MLB players as well. There are several minor leaguers who will head to Birmingham, Ala. or Los Angeles for surgery and more college and high school pitchers alongside them. 

I asked Dr. Tim Kremchek of the Reds how many Tommy John surgeries he did last year, and it was nearly 100. Add in the other surgeons that do the bulk of MLB Tommy John procedures, and we’re looking not at a problem but an industry.

We’ve accepted it, to some extent. There’s a moment of sadness when we see a pitcher like Jarrod Parker lose another year to an injury, but we forget about it quickly.

This week’s outbreak hasn’t led to any discussion of changes. Bud Selig isn’t announcing a bold research initiative. Some team spent more money on a computer than the whole league will spend on sports medicine. If that’s how baseball is going to be, we’re going to have a lot more weeks like this and a lot more pitchers missing years. That’s bad for baseball.

For now, let’s look around the league…

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What MLB Must Do to Change Philosophies, Stop Wave of Pitching Injuries

In 2006, I wrote an article about developing pitchers. I was frustrated that there was no reduction in injuries after years of watching pitch counts and innings workloads drop. The promise of Pitcher Abuse Points was starting to fade as the orthodoxy of Dr. Rany Jazayerli and Keith Woolner’s work became book. Pitchers were no longer going 168 pitches, like Al Leiter had just before injuring his arm. In fact, pitchers were barely going 120 pitches anymore.

But the injuries weren’t reducing. You can imagine how I felt this week. Several pitchers, including Kris Medlen, Brandon Beachy, Jarrod Parker, Cory Luebke and Patrick Corbin, were all checked for elbow injuries. More, like Cole Hamels, Taijuan Walker and Anibal Sanchez, were behind schedule due to shoulder problems. 

Last year, in the course of writing a piece on Frank Jobe’s work, I asked Tyler Brooke to go through the list of current pitchers to see how many of them had undergone Tommy John surgery. I was stunned when he came back with the one in three figure. Remember, that’s just elbows! Pitchers hurt shoulders, backs, knees and everything in between, so the “health rate” we have is abysmally low.

Yet, teams do next to nothing. I’m not maligning the hard work of medical staffs here, who do their best despite being overworked and underpaid to keep their players on the field. Nor am I ignoring the work of people like Stan Conte of the Los Angeles Dodgers, who has tried to quantify injuries, or the biomechanical work of Dr. Bill Raasch in Milwaukee. The problem is that these are exceptions.

Baseball has a problem. At the major league level alone, MLB has taken billions of dollars and burned it over the last decade. In just the last five years, pitching injuries alone have cost owners more than $1 billion in salary for players who are on the disabled list.

MLB owners are titans of industry with successful businesses in everything from real estate to software. In any of those businesses, a billion-dollar loss would be quickly addressed and remedied. In baseball, they seem to shrug their shoulders and collect frequent-flyer miles to Birmingham.

It’s time that changed. I interviewed several pitching coaches, researchers, doctors and other experts in the pitching field looking for suggestions about what might work. While none of them would commit to the suggestions actually working, they all believed there was a chance they were on to something. In some combination, I do believe these suggestions to be among the best possibilities for saving pitchers. 


Tandem starters

Several teams have used a tandem system in the minor leagues and we’ve even seen some variations in the major leagues. The basic idea is to pair two “starters” into one starting pitcher and use a strict pitch or inning count to manage fatigue. 

At the minor league level, the tandem system appears to have both reduced injuries and developed pitchers, but there is resistance. It is tougher for the starter to get wins, a meaningless stat that my colleague Brian Kenny has done his best to kill. Team wins are important and the tandem system doesn’t reduce that. 

The downside of the tandem is that it does limit pitchers very strictly and requires eight “starters.” At lower levels where teams are shotgunning their pitchers, this isn’t an issue, but at the major league level, it’s more of a problem.

No team that I am aware of has used a tandem above the Double-A level, so a test at Triple-A would be interesting and easily handled. Teams have used a “shadow” system at times, where a pitcher coming back from injury or being inning-limited has a second pitcher come in early, showing that a tandem setup could work at least in the short term.


Six-man rotation

There are many calls for adding a man to the rotation or going to a so-called Japanese rotation. The problem is the sheer lack of pitchers. The quality of the fifth man in most rotations is significant and takes starts away from the ace. In a four-man rotation, the best pitchers get more starts.

In a six-man rotation, the ace would get 28 starts if healthy all year, limiting someone like Justin Verlander to between 160 and 170 innings a year and handing them off to…well, for the Detroit Tigers, that would be trading 50 innings of Verlander for 50 innings of Kyle Lobstein. The loss there could well counteract any value from reduced injuries. 

As for the Japanese, there is a reduced rate of Tommy John surgery there, but it is more cultural. American baseball might be better off looking at their training methods and obsessive throwing, as well as their rejection of pitch counts, than their rotation.


Progressive development

Progressive development is a simple system that would call for individual limits for each pitcher based on demonstrated ability to pitch and recover. Detailed in this article from 2006, a progressive-development system would need to be paired with a tandem system. 

We use progressive development in many other areas. No one tries to bench 225 on their first try. No one tries to run a marathon on their first run. You work up to it, slowly and steadily. My 2006 article goes into the system in more detail, but it’s simply a baseball version of what we’re already doing. Instead of tossing a ball to a kid and saying “go 100 pitches, full go,” it’s worked up.

This is already done to an extent in spring training, but this is a much more organized system that builds a pitcher and discovers his limits as much as it prepares him for pitching to the point of failure. Indeed, the system could find pitchers that could safely and regularly go 150 pitches, something I feel is reasonable but is lost in the modern game.

Shifting to a progressive model would take a long-term commitment since it would need to start at the lower levels. That alone would make it difficult for most organizations who cannot commit to anything over a decade. For this to work, we’ll need ownership-level commitment. I think a team like the Los Angeles Angels, with an involved owner and a struggling minor league system, could be the one to try this. The Toronto Blue Jays also fit, but I’m unsure how their corporate owner could be brought on board.


10 starters

In football, there’s a defensive formation where the players all stand up, milling about to create confusion about their position and function to confuse the quarterback pre-snap. It’s been called “11 Angry Men” and one MLB front-office type suggested a variation that he called “10 Starters.” 

Basically, it’s a full-season equivalent of a “kitchen sink” game where every pitcher is available. Instead of having a division between starters and relievers, the suggestion is that all 10 would be able to go as starters and could be mixed and matched as needed. While there would be a defined rotation, it wouldn’t be as simple as going one through five and then rinse-repeat. 

Instead, the rotation would be adjusted based on availability. There are already days where a reliever is designated as out due to previous workload, so this 10-starter system would be a variant of that. On any given night, a manager should have no less than six pitchers, not far off from what is available in a standard system. 

Several of my experts had objections to this system. The first is that “pitchers like roles.” Pitchers might, but we’ve taught them those roles and could teach them new ones. The second is stronger and implies that pitchers would have a hard time shifting from starter to reliever and back.

However, throughout baseball history, we’ve had swingmen, pitchers who did exactly this. Earl Weaver was famous for his use of them, especially for young pitchers breaking into the league, but he was hardly the first. This is difficult to research, but there’s no cursory sign that swingmen broke down at a rate any higher than other pitchers. 


Quantification of fatigue

We are seeing a vast expansion of the so-called quantified self. Devices like the Nike FuelBand and various flavors of Fitbit have given people some measure of their activity level. It would be easy to extrapolate a similar system into quantifying fatigue. Direct measures of fatigue could come through simple physical tests or a more direct high-tech measure like this device

Being able to quantify exactly how a pitcher is dealing with both a start (pure fatigue) and recovery at any given time should be able to let baseball teams individualize programs. The downside here is that with set roles and expectations, it’s difficult to individualize anything from a management standpoint. Maybe newer managers and new data will change that.


Quantification of injury

Many on the medical side are excited about the possibilities offered by new imaging and diagnostic tools. It’s perhaps more realistic to think that we could monitor injuries more proactively than doing a complete change of how baseball manages its games. 

New technology is making ultrasound imaging hand-held. Many soccer teams, including most of the MLS, have some of these portable scanners on the sidelines for quick checks. The same could be done in the dugout or locker room. Between innings or at least between starts, a doctor could do a quick, noninvasive visualization of the elbow and shoulder so that we’d know the player is intact. 

What we do with that information is an unknown, but with more data, we could find patterns and predictors for when a pitcher is about to break down. A red flag raised prior to the injury could trade a 12-month rehab for a couple days of extra rest.

As of yet, no major league team is using this kind of technology regularly, despite a very reasonable cost and ability to use it. One team official said the pitchers themselves were very resistant to this, feeling like it reminded them of their mortality and could be used against them in negotiations. I think that’s silly and could be altered and explained to make it a major positive, especially for early adopters.

This is hardly an exhaustive list. There are certainly other approaches that could work. Even in the broken current system, some teams like the Tampa Bay Rays and Seattle Mariners have had better success than most in avoiding the most serious pitching injuries. Trying to copy that approach might work, but it would be better to build a solid scientific foundation through research.

Worse, all of these systems would only work at the professional level. We know that much of the damage on arms is coming at lower levels. Dr. Glenn Fleisig often compares pitching arm injuries to smoking, saying that kids don’t get lung cancer on their first puff nor Tommy John after their first curve. However, we know enough to discourage kids from smoking at all. We don’t do the same for pitching. In fact, in many cases, parents and coaches are doing the opposite. MLB can be a thought leader and let their research (and dollars) trickle down.

The team that builds a better mousetrap will have a Moneyball-style advantage that could be huge. Think injuries don’t take a toll? Just watch where the Atlanta Braves end up this season after losing two of their five expected starters. The simple cost is a $14 million deal for Ervin Santana, but it’s likely more, especially if you consider the cost of a win or a playoff appearance.

Baseball teams have had 40 years since Frank Jobe developed Tommy John surgery and 15 since the Pitcher Abuse Points system was developed to figure out how to reduce pitching injuries. Now, it’s time to demand change and to drive it. Maybe it’s time to rewrite the book

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Kris Medlen, Jarrod Parker Can Still Be Same After Second Tommy John Surgery

Atlanta Braves pitcher Kris Medlen is headed for Tommy John surgery, according to The same is true for the A’s ace, Jarrod Parker. It’s also true for Brandon Beachy, who follow Corey Luebke and Daniel Hudson.

While this is all too common among pitchers at all levels, all of them are headed through the process for a second time.

He previously had the surgery after rupturing his ulnar collateral ligament in 2010. Medlen made it back and excelled both in the rotation and the bullpen. His ascension to dominant starter was surprising and occasionally attributed to his Tommy John surgery, though there is absolutely no evidence that he or any other pitcher has seen a performance gain from the procedure.

Facing a second procedure, Medlen faces the same year away from the game and grueling yearlong rehab. Many Braves fans are asking whether or not he faces the same sort of potential when he returned. Second replacements are called revisions by surgeons and are rare in terms of surgery. Only a handful of specialists like James Andrews, Neal ElAttrache, and Tim Kremchek will do more than a few of these.

Medlen is hardly alone. Brandon Beachy is also headed for a second Tommy John surgery, adding to the long list of Braves trekking from Atlanta to Dr. James Andrews’ office. Add in Patrick Corbin from the Arizona Diamondbacks and Jarrod Parker, who would also be having a second surgery and had his first while with the Diamondbacks, to the list of recently injured pitchers. 

There’s not much in the way of evidence or even anecdote, but what we know gives us a good look at Medlen’s future. He should be able to return sometime in early 2015 and there’s no physical reason why he couldn’t return to the Braves rotation and even return to his previous level of performance.

While Tommy John surgery allows a player to come back, it doesn’t make them invulnerable. In fact, it’s the coming back that is likely the problem. Pitchers, especially mature and successful pitchers, aren’t likely to make significant mechanical changes. Do the same thing and you’ll get the same result, which, for these pitchers, was a ruptured ligament. 

It’s important to note that this is not a failure of the surgery, the rehab or even the pitcher. This is like blaming the car for a tire going bald. It’s a recurrence of a problem with a known etiology. Calling this a failure demonstrates a fundamental misunderstanding of the procedure.

It’s easy to suggest biomechanics should be changed, that hip and shoulder strength and flexibility could be augmented, but it’s much harder to tell a multi-million dollar pitcher to change what has made him successful. 

On top of that, the use of biomechanics is spotty at best in the major leagues. Even with the use, teams don’t have a perfect prediction system.

One of the teams that uses biomechanics extensively is the Baltimore Orioles. In spite of this and several other factors, the Orioles lost prize pitching prospect Dylan Bundy for a year after he injured his elbow last season. He had Tommy John surgery and should be back this summer. Most teams ignore biomechanics altogether, including the Braves.

So even if we don’t know the force that Medlen, Bundy or many individual pitchers are exerting on their elbows on each and every pitch, we do know that there’s clear evidence that the ligament broke down, either insidiously or traumatically. Given the same tasks, similar force and any other significant changes, a transplanted ligament is likely to break down again after a period of time. 

One thing we do not know for any pitcher is how much their ulnar collateral ligament can handle. There’s simply no way to know this, though we know that it will be significantly different for every pitcher, just as they exert different forces in their pitching motion. Some pitchers are likely to have “weak” ligaments and some have strong, making the same force give different results.

There is a “Tommy John honeymoon,” a period after the surgery where it appears there is a significantly lower risk of damaging the replaced ligament. Studies have shown that over a period of four to five years, the transplanted tendon becomes a ligament. However, remember that there’s at least a chance that the pitcher’s ligament was structurally unable to handle the load of pitching. A strong harvested tendon helps, but at a cellular level, will change.

Medlen was inside the normal “honeymoon” period, so it would be interesting to know what Dr. Andrews will find inside his elbow. Was the transplanted tendon fully ligamentized? Was his natural ligament weaker? No pitcher is going to let a surgeon open up the non-dominant side to check. 

The surgery for a revision is different as well. It’s not substantially different in technique, but requires some changes. The bone has already been drilled for the previous ligament replacement, but new holes are required. There’s less space for that, as well as further damage and “mileage” on the elbow. 

The upside is that the player has been through the process before. He’s not likely to be surprised by anything in the rehab and understands the effort and patience necessary. As long as the player is not struggling on a performance level and is not advanced in age, there’s little to show currently that a revision is less successful than an original.

A recent study published in the American Journal of Sports Medicine and conducted by the Kerlan-Jobe Orthopaedic Clinic focused on the rate of return from Tommy John surgery. Previous studies peg the number anywhere from about 75 percent up to 87 percent. This recent study shows that only five players out of 179 did not return to play. 

Dr. Neal ElAttrache, a Kerlan-Jobe surgeon and team physician for the Los Angeles Dodgers, told me in a phone conversation that the return rate doesn’t surprise him. “The surgery itself isn’t the problem any more. It fixes something that was previous career ending and gives the player a chance to come back and play at the same level.” 

The study is clear that there is no performance boost and there may be a bigger cost. Currently, there are no pitchers in the Hall of Fame that have had Tommy John surgery. John Smoltz is likely to be the first in the next couple years, but behind him, there’s not much coming.

Adam Wainwright is the most likely, with almost no one else “on pace.” Pitchers like Chris Carpenter, AJ Burnett and Joe Nathan simply don’t have Hall of Fame numbers and little time to accumulate them.

I spoke with Jay Jaffe from, who has done extensive work on quantifying Hall of Famers. Jaffe believes that there are three factors holding back Tommy John pitchers (including Tommy John himself!) from being inducted. The first is that the BBWAA has been stingy in electing pitchers, putting in only 15 since 1981.

The second is that durability is key to getting to huge numbers, like 300 wins. Of the pitchers that have hit major milestones, few have had major surgeries, with only Roger Clemens having a major surgery, though he missed almost no time after it.

Finally, Jaffe believes that because the operation was done so seldom into the mid-1990s, there were fewer opportunities. I agree, but I’m focused on the second with the dearth of likely Hall of Famers coming.

There are a number of players that have had two Tommy John surgeries, or even more. The “record” is five, but Jose Rijo is a special case and several of the failures were caused by external forces rather than being an actual redo. Nine current players, including Brian Wilson, Joakim Soria, Chris Capuano, Jason Frasor and Kyle Drabek have had two. 

While it may appear that there are few starters that have returned after a repeat Tommy John, it’s still a small sample size. Since relievers tend to be max effort pitchers, one theory is that they are more likely to do a traumatic sprain of the repaired ligament. There simply haven’t been any studies done, though anecdotally this matches up with surgical findings. 

As more pitchers have the surgery when they are younger, the two will collide and could open up the possibility that we see an explosion of second and third revisions. How baseball as a whole deals with this could be one of the most important sports medicine decisions they make in the next decade.

Medlen’s revision will not make him invulnerable any more than the first surgery did. If he continues to put too much force on the elbow, it will break down again. However, there’s no reason to believe that he will not be able to return. The last decade of sports medicine research shows us that. 

As a symbol, Medlen and the other pitchers headed to operating tables remind us that as a whole, baseball doesn’t know how to prevent arm injuries. A decade plus of pitch counts, cautious progressions and long toss have not reduced pitching injuries one iota. It’s time to step back and maybe even start over, or else get used to seeing the best pitchers heading to surgery time and again.

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