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Under The Knife has always been about more than just listing the injuries around baseball. Sure, the focus is explaining the injury status of players like Albert Pujols, Derek Jeter and Ryan Howard, among others. But, it’s also been about updating the injury status of MLB in general and taking opportunities to find ways to reduce or prevent injuries. 

I like to take the intro to highlight some larger concept or an article from the last week that caught my eye on the topic of sports medicine. Today, you won’t get that here. I started work on it, but when it gets close to 1,000 words, it’s not an intro—it’s another article.

So later this week, I’ll show you what I was working on. The focus of the article is innings limits for young pitchers, specifically Matt Harvey, who is likely to add an inning of work at the All-Star Game (probably the first inning!) and how the Mets could handle him in the second half. With the counter-example of Stephen Strasburg and the attack on the Verducci Effect out there, this is something I’ve been discussing all season, but we’re no closer to any big answers for the game of baseball.

For you panicking Mets fans, I’ll ease your mind. They seem to be doing things the right way, using more of a checklist approach to when they’ll shut Harvey down. Again, I’ll have lots more on this later in the week. 

Until then, let’s take a look around the league at some big-name injuries as we head into the All-Star break.

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As you look at the next 10 slides, think about how much value each of these players have to their respective teams. Not just salary, but value. Even just the names tell you a lot—Bryce Harper, Alex Rodriguez, Jose Reyes and more. Teams can overcome injuries, but they cannot replace value in most cases and if you add in the value of time lost, it’s pretty clear that teams need to be doing more. 

That’s easy to say, but if injuries are “part of the game,” as some will try to infer, and since all injuries can’t be prevented, then finding solutions is rendered moot in their mind. That’s defeatist. If a team can’t hit, the hitting coach is going to be asked why. More and more teams have hired assistant hitting coaches for the major league team in addition to coaches at every level. Some teams even have a bunting coach!

For injuries, which has as demonstrable an effect on a team as a hitting coach, the simple solution would be to add one more assistant trainer. The ratio of two trainers to a roster of 25 seems manageable until you see how many man-hours are required per injury, and that’s before we talk about how much is required for immediate care, rehab and the administrative tasks. 

Another assistant trainer would add one-third more man hours immediately and, if a team simply called up its Triple-A trainer, there would be very little change since they should be familiar with many of the players and procedures. The reason teams do this simply can’t be cost. It can’t be availability either, since finding a competent athletic trainer for short-season ball could be done in an afternoon. 

Baseball is seeing a significant increase in injuries this season and I believe it’s the result of being penny wise and pound foolish. Lack of manpower in the medical staff, a lack of knowledge about biomechanics and predictive measures and little to no research on sports science is going to leave teams exactly where they are now, or worse, and that’s not a good place. 

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About a decade ago, I got a text from Peter Gammons. “When did baseball players start having obliques?” Peter knew that players had always had the muscle, but it did seem that we were suddenly seeing more of them injured about that time. This year, it seems to be rib injuries that are the hot new thing in training rooms around the league.

But why?

Anatomically, there’s no difference. Ribs are ribs, and we have to assume that in almost all cases, MLB players have normal ribs in structure and strength. The game is also much the same—at least in terms of the stresses that it places on the ribs. 

We then have to look at the method of injury in context. For Troy Tulowitzki, he was injured on a diving stop of a grounder while at shortstop. Ian Kinsler injured himself twisting away from an inside pitch at the plate, though many point to an awkward headfirst slide earlier in the game as a possible injury point. Pitcher Jake Peavy of the White Sox is a bit tougher to pin down, as he was lifted early but showed poor velocity all through the last start he made before heading to the DL.

One interesting point on all these is that the diagnosis wasn’t simple. In each case, an MRI was necessary, and in both Kinsler and Peavy’s case, X-rays were negative. Simple rib fractures—the result of collisions—tend to be very visible on X-rays, so that fact tells us that the fractures are either small or in an unusual location.

There are other rib injuries around the league, with Edwin Nunez of the Yankees and Josh Kinney of the Mariners also listed, but those go less noticed, in large part because they’re not All-Star-caliber players like Tulowitzki, Kinsler and Peavy.

In other words, this may well be a cluster of injuries that is noticeable due to the player’s visibility and notoriety rather than an increase in the incidence of the injury itself. Looking through my database of injuries, there is only a slight increase over previous seasons. This seems to be random variation, which is typical of traumatic injuries like this.

Last season, there were six ACL sprains in MLB, but this year only two (and one of those was a flukish recurrence). There is almost no known way of preventing these kinds of injuries, so the focus is on reducing the rehab time necessary.

It appears to be much the same way for rib fractures.

Injuries will happen, on dives, odd pitches or strange swings, but it’s up to the medical staff to minimize the time lost. Getting Kinsler, Tulowitzki and Peavy back just a week early could have huge implications for their team.

For example, Kinsler has been worth about a win every 20 games played, so a week is worth around one-third of a win. All you have to do is think back to last season’s AL West finish to know how valuable that can be.

There is no answer to why there are more rib injuries because, simply put, there really aren’t more. Traumatic injuries are inconvenient and unpredictable, even for big stars like these. 

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Stephen Strasburg and Bryce Harper were drafted not so long ago, but the health questions they face now were also brought up at that draft. People seem to be putting more importance on the draft since players do seem to be coming up more quickly. There are five already in the big leagues from last year’s draft.

That makes assessing future health as much a key as assessing any other skill—and yes, health is a skill. 

The downside is that there’s no real way to capture this information. Scouts are left guessing at biomechanics, talking to coaches and travel teams to dig up any injury history and hoping that there’s nothing that was missed. They do a great job, but not having a combine process, the way every other professional league does, leaves them at a disadvantage.

There are always tales about pre-draft workouts, how a team fell in love with a player over one workout, but ignored an injury history.

We’ll likely see players fall some due to injury, but looking back over the past few drafts, it’s clear that injuries should be at or near the top of the list. Players fail on injury much more often than they fail on talent, especially for pitchers. At best, there are lost years or delays, not to mention how much a pitcher leaves on the table after a significant injury or surgery.

Risky players can be successful; no one is going to knock the White Sox for drafting Chris Sale, even if his career ended today. He made the majors and he won games, which is the definition of success for the scouts.

This weekend, we’ll see more players taken and a lot of talented, risky ones in the bunch as well. Taking risks is part of how teams win, but taking smart risks and understanding those risks is how teams win consistently.

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One of the greats has passed. Dr. Lewis Yocum, one of the top sports surgeons in the world, died on Tuesday according to Mike DiGiovanna of the Los Angeles Times. Long the team physician for the Los Angeles Angels and a consulting surgeon to hundreds of major league players, Yocum‘s work at the Kerlan-Jobe Clinic in Los Angeles placed him on a high pedestal. While no sports surgeon is in any Hall of Fame, Yocum deserves consideration, along with his mentor, Dr. Frank Jobe.

The esteem he was held in was manifest in two ways. The surgeons he trained and the medical staffs he consulted with often identified themselves as “Yocum guys.” The orthopaedic fellows from Yocum‘s Kerlan-Jobe program, along with those from James Andrews’ ASMI fellows make up the majority of sports surgeons today. The legacy Yocum built through his mentorship is strong, with some of the top names in sports medicine today amongst them.

Yocum was also honored by his own team. The Angels’ training room was named on May 5th for Dr. Yocum, an honor to be sure, but one even more than most realize. The training room is the holy of holies in most locker rooms, a place where no one enjoys going, but within those walls, the trust that must be shared takes on an element of the confessional. That everyone in an organization would agree that one man, one doctor, was worthy is truly notable.

The list of Yocum‘s patients is extensive. Returning players in recent years like Stephen Strasburg, Dustin Pedroia and Daniel Hudson barely scrapes the surface. Just the list from the last few years would be enough to fill out the rosters of a couple All-Star teams (the list is below). 

Yocum‘s research was also groundbreaking. His work on the rotator cuff, along with Dr. Frank Jobe, led to the near universal use of the “thrower’s ten” exercises which helped reduce the number of shoulder injuries. His work on shoulder impingement also led to a much greater understanding of what could be done to help baseball pitchers. His work went beyond the shoulder, with key papers on the knee and elbow to his credit as well. 

Dr. Tim Kremchek, the team physician for the Cincinnati Reds worked with Yocum and sums up how so many in the industry feels. Kremchek told me “I got to know Lew over the last 15 years and taking care of high profile athletes, there was no one better. He was always calm, straight up, experienced. Always invaluable assistance. Great doctor, great human being, and a better friend. In this business, too many people are trying to keep the case. Lew was there to help the player.

The loss of Dr. Yocum is one not just for the Angels, for whom he served so long and well, but for all of baseball. As yet, there is no doctor enshrined in the Baseball Hall of Fame, but when it does, Dr. Yocum should be noted alongside the giants of his profession and the best of baseball. 

Patient List:

Major patients:  Stephen Strasburg, Dustin Pedroia, Jacoby Ellsbury, Jordan Zimmermann, Kendrys Morales, Ted Lilly, Robb Nen, John Lackey, Randy Wolf, CJ Wilson, Francisco Liriano, Billy Wagner, Joakim Soria, Jake Westbrook, Cal Eldred, Scott Erickson, Daniel Hudson

Others: Chris Narveson, Cory Luebke, Joe Wieland, John Lamb, Ryan Kalish, Sergio Santos, David Riske, Tsuyoshi Wada, Trevor Crowe, Anthony Reyes, Danny Duffy, Felipe Paulino, David Aardsma, Hector Ambriz, Carlos Gutierrez, Mike Aviles, Zach Miner, John Franco,  Lucas Giolito, Daisuke Matsuzaka, Jeremy Bonderman, Jose Arredondo

Special thanks to Dan Wade for his research assistance on this piece.

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Injuries have continued to plague some of the biggest names in baseball. With David Price the latest Cy Young contender to come up with a sore arm, Bryce Harper bouncing his head off an unprotected section of fencing and Ryan Howard limping again, we can only wonder about the hours that the medical staff is putting in.

And while those good men and women work 18-hour days, we’re left wondering if anyone else seems to care. I’ll pass on stepping back up on my normal soapbox here. You know the next stanza on your own by now. At some point, some team will realize the advantage it can gain.

In the meantime, we’re left trying to find where the advantages are in our own fantasy world. You’ll know if your favorite team is serious about managing injuries, but on a fantasy team, it’s a game of minimization and prediction. The simplest way to gain an advantage is to understand the severity and effects of the inevitable injuries, so let’s get to it.

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On Thursday night, Yu Darvish beat the Detroit Tigers and threw 130 pitches. It wasn’t his best performance this year or even this month, but it may end up the most scrutinized. 

As Darvish’s pitch count climbed, everyone—including announcer Matt Vasgersian and analyst Tom Verducci—had something to say about it. Vasgersian called Darvish’s deep pitch count a “Herculean feat.” 

Unfortunately, Rangers CEO Nolan Ryan wasn’t in his customary seat just to the left of the Texas Rangers dugout, so the camera couldn’t cut to him. Ryan, who pitched in the major leagues for over two decades and was inducted into the Hall of Fame in 1999, was as well known for his durability as he was for his fastball.

While I don’t know what Ryan thought about Darvish pitching the eighth inning with a six-run lead or giving up the ball in the ninth, we can look back and see what Ryan the pitcher did in similar situations. It’s food for thought when considering whether more pitchers could go as long as Darvish, if only their managers would let them.

Even the amazing Baseball Reference doesn’t have pitch-count data before 1988, but that doesn’t mean we can’t make solid estimates. Stats analyst Nate Silver, known for his work with Baseball Prospectus and The New York Times, created a pitch-count estimator that uses the known data, such as batters faced, walks and strikeouts, to tell us what a pitcher likely did on a given day in history.

The estimator was able to be tested against the pitch counts kept by Allan Roth, the statistician hired by Branch Rickey to track the Dodgers throughout the 1950s. It proved to be very accurate.

I had my stats guru, Dan Wade, run Nolan Ryan’s career starts through the pitch-count estimator, and here is what he found:

> 200: 3

190-200: 1

180-190: 3

170-180: 8

160-170: 14

150-160: 37

140-150: 67

130-140: 85

120-130: 80

110-120: 85

100-110: 72

If 130 pitches is “Herculean,” then Ryan was that almost 300 times in his career. That means of his 773 career starts, almost 38 percent of them ended up with a pitch count north of 120, and 28 percent were at Darvish’s level or greater.

Of course, Ryan pitched in a different era. It wasn’t that long ago that pitchers went deeper into games, coasting against the weak hitters and saving their best stuff for when they needed it. Today, pitchers go all out all the time, putting stress and fatigue on their arms. 

It’s also important to remember that Ryan pitched the last decade of his career with an elbow ligament that was hanging by a string. In his last start it popped, and he walked off into the sunset.

Darvish’s outing is notable not only in the amount of pitches he threw, but also that he was even allowed to throw them. Pitching coach Mike Maddux focused on his pitch effectiveness, not his pitch count.

While this is likely the discussion of two outliers—Darvish’s start and Ryan’s career—we do have to remember that outliers are what make the game great. Darvish’s durability and ability to go deep into games is what makes him one of the top pitchers in MLB. There are likely more out there if managers would stop relying on a stat and start relying on what they know.

Pitchers’ fatigue levels and durability should be measured and maximized not by fear, but by ability.

Statistics courtesy of Baseball Reference.

Will Carroll has been writing about sports injuries for 12 years. His work has appeared at SI.com and ESPN.com, and he wrote the book “Saving The Pitcher.”

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There are a lot of pitchers close to comebacks. With Zack Greinke making a quick comeback from his collarbone fracture and Jered Weaver not far behind him, not to mention Johnny Cueto’s return, we will see a lot of pitching coming back to the mound. The problem is that there are just as many heading out with injury. 

It’s been 15 years since Pitcher Abuse Points was debuted by Dr. Rany Jazayerli, and it may be the most influential piece of baseball research in the history of the game.

When it came in, 150-pitch games were a regular occurrence—not common, but regular—and today, the media freaks out when Yu Darvish goes 127. Managers, even the ones that say they’re not sabermetrically minded, are managing by a stat, just like they are handling their bullpens by the save. 

The issue is that while Jazayerli‘s research was intended as a warning against regular overuse and gave teams a tool by which to measure the risk of an extended outing, teams decided against measuring and largely abandoned the practice. Adding to the issue was the contemporary La Russization of bullpens, increasing the size and changing the usage of the pen. It allowed managers to pull their starter at 100 pitches or less.

I’m not advocating a return to the days of complete games and huge pitch counts. Those aren’t coming back. Pitchers have to throw too hard to today’s power-filled lineups and don’t have the ability to “coast.” (Though I do think they have the ability to try and force hitters to act more quickly in counts, but that’s a story for another day.) 

I do think that another shift in pitching usage could help—a progressive approach to development and usage, a data-driven approach or maybe something I haven’t thought of. There are a full complement of smart people inside the game and more pitching wisdom than I can catalog. Plus it’s impossible for these people to say that change isn’t possible since the game has changed drastically already! 

It’s going to take one smart team with the guts to take some risk that wins with a new plan before everyone else will follow. We’ll see who wants to be the kind of team the Cardinals were over the last decade. You know—winners.

For now, let’s get to the injuries… 

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Just look at the names in this week’s UTK and you’ll see the issue. Giancarlo Stanton, Zack Greinke, Troy Tulowitzki, Stephen Strasburg—these are big-time stars, with most making big time money or carrying the hopes of a franchise on their back.

Instead of being on the field, these players and more are in the training room or worse. The inability of Major League Baseball to keep even their biggest stars healthy is a true indictment of the last decade. Some can’t be helped, but some can, and those opportunities to save money and keep the talent on the field are often being missed.

Let’s take a look around the league to see what’s going on with the biggest names and biggest injuries in another week of Under The Knife:

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Giancarlo Stanton looks like Superman, but injuries have been his kryptonite. On a hustle play in extra innings Monday night, Stanton racked up another injury. This time it is a hamstring strain that could cost Stanton a month or more, depending on the severity.

The Marlins pushed Stanton to the disabled list on Tuesday morning, even before an MRI could be taken. The Marlins medical staff needs to have clear indication that this is a significant strain.

Manual testing, as well as Stanton’s assertion that he heard a pop, indicate at least a Grade II strain. That type of injury will leave what doctors call a “palpable defect,” which means that someone with their hand on Stanton’s leg would be able to feel the hole that the tearing has left in the muscle.

The injury is to his right leg, which is his “power leg” when hitting and the same one he had knee surgery on last season. Stanton was able to come back from that minor knee surgery and showed no issues with his power, so there’s a positive in his ability to return to production. 

If this is a normal Grade II strain, the time frame is usually four to six weeks for a return. Stanton isn’t a speed player and has enough power to deal with a minor deficit in push when he returns. 

However, if this turns out to be a more serious injury, such as a Grade III strain or even just one in a bad location, it could end up effectively ending Stanton’s season. An MRI is scheduled for later on Tuesday to determine just how bad this is, giving us a more distinct timeline soon.

Stanton is joined on the DL by Joe Mahoney, also with a hamstring issue. While Stanton’s injury is the clear, traumatic result of a hustle play, any cluster of injuries has to be noted. The Marlins have often been among the bottom 10 in injury statistics, largely because they use a lot of replaceable players who cycle through. They have also had substantial injuries to major stars, including Stanton, which have hurt them in terms of days, if not dollars. (Stanton makes just over the major league minimum for a player with his service time.)

The state of the Marlins does have to be taken into account. The team is out of the playoff race already, but it has Stanton as about its only gate attraction. Moreover, many around baseball expect Stanton to be traded before he hits arbitration after this season. The haul of prospects he could bring back would kick-start the latest rebuilding effort by Larry Beinfest. 

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