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  • The Twins and Tommy John

    When we heard the sad and unfortunate news on Monday afternoon that Miami Marlins starting pitcher Jose Fernandez has an elbow sprain, it made me feel awful. The assumption (true or not) is that sometime in the near future, he will have Tommy John surgery and miss the rest of this season and likely some of the 2015 season. If you’re a real, true baseball fan (and let’s face it, if you’re reading this web site, you are), you want to see the best performing. Jose Fernandez, despite being just 21 years old, is one of the best.

    Fernandez is just the most recent example of what has become an epidemic over the last couple of years. “Everyone” is having Tommy John surgery. No team, including the Twins, is immune to this surgical procedure. Fifteen Major League pitchers have already had Tommy John surgery in the last two months.

    Jose Fernandez photo by Steve Mitchell

    IT CAN HAPPEN TO ANYONE


    The Atlanta Braves have long been touted as an organization that develops pitching talent, and they are. This year, they have had no fewer than four Tommy John surgeries including a couple of big leaguers and a top prospect. Brandon Beachy and Kyle Medlen both had their second Tommy John surgeries this spring.

    Many like to tout the Tampa Bay Rays organization as the one to emulate, and they certainly do a lot of things well. They are said to have some special things that they do medically to study how to keep players healthy. Jeremy Hellickson hasn’t had Tommy John surgery, but he has missed a lot of time the last couple of seasons. Matt Moore, another one of baseball’s best young pitchers, had Tommy John surgery last month.

    Baseball America’s JJ Cooper tweeted last night that from 2010 through 2012, 15 high school pitchers were drafted. If Fernandez has Tommy John Surgery, he will be the sixth in that group. Two others on currently on the DL with elbow or forearm issues, and one had hip surgery. Count Dylan Bundy and Jameson Taillon among those who have already had the surgery. The two that are on the DL right now with elbow issues are Top 50 prospects Archie Bradley and Max Fried. Max Fried’s high school teammate, Lucas Giolito, had Tommy John while still in high school and still was a first-round pick.

    Two possible Top 10 2014 draft picks, Jeff Hoffmann (East Carolina) and Erick Fedde (UNLV), have or soon will have Tommy John surgery. And both still could get drafted in the first round.

    TOMMY JOHN AND THE TWINS


    Tommy John was a Minnesota Twins TV broadcaster from 1994 through 1996. Unfortunately, that is not the only connection to the Twins. The Twins have been affected in one way or another by Tommy John surgery over the past decade. I went back ten years of Twins and Twins minor league rosters and here is a list of guys who have had Tommy John surgery before, during or after their Twins career (This is not necessarily complete):


    • Brian Duensing – in College at Nebraska
    • Mike Pelfrey – with Mets before coming to Twins as free agent.
    • Kyle Gibson – in minor leagues, in September 2011
    • Lester Oliveros – in September 2012
    • Samuel Deduno – in 2008 with Rockies
    • Corey Williams – on April 1, 2014
    • Alex Wimmers – in minor leagues, in August 2012
    • JT Chargois – in minor leagues, in August 2013
    • Dallas Gallant – in minor leagues, 2011
    • Andrew Ferreria – in college at Harvard
    • Jeff Manship – in college at Notre Dame
    • Francisco Liriano – with Twins in November 2006
    • Pat Neshek – with Twins in November 2008
    • Scott Baker – with Twins in April 2012
    • Carlos Silva – with Cubs in 2012
    • Andrew Albers – with Padres in 2009
    • Joe Mays – with Twins in 2003
    • Kyle Waldrop – with Pirates in 2013
    • Matt Maloney – with Twins in July 2012
    • Carl Pavano – with Yankees in 2007
    • Joe Nathan – with Twins in March 2010
    • Bobby Korecky – in minors with Twins in 2005
    • Matt Bashore – in minors in 2010
    • Tom Stuifbergen – in minors in July 2013
    • Carlos Gutierrez – in minors in college
    • Jhon Garcia – in minors in April 2013
    • Dan Sattler – in minors in August 2012
    • Brian Kirwan – in minors in 2006


    This list also does not include a couple of hitters. Remember Matt Macri? He made his Major League debut with the Twins in 2008 after coming to the team from the Rockies organization. They had drafted him in 2001 out of high school, but he went to Notre Dame. A shortstop, he had Tommy John surgery in 2004.

    And, of course, the big news this spring in Ft. Myers came when the Twins announced that Miguel Sano would have Tommy John surgery and miss most, if not all, of the 2014 season.

    WHY, OH WHY?


    So many fans seem to have a solution to this problem or what they would do to try to keep players from needing Tommy John surgery. That’s funny, of course, since the medical profession has not yet determined any preventative measures to avoid Tommy John surgery.

    Aside from not becoming a baseball pitcher, there are several theories out there right now about why there seems to be this influx of Tommy John surgeries. However, I’m not going to pretend to know with any certainty.


    • I happen to agree with those who say that some pitchers do too much upper body weight lifting which creates less flexibility and more stress on the ligaments.
    • I wouldn’t be surprised if specialization in high school (playing one sport year-round rather than playing two or three sports) has some correlation too. Of course, you will find examples on both sides of this as well.
    • I don’t necessarily think pitch counts alone determines if a pitcher will eventually require Tommy John surgery.
    • We have seen pitchers with “perfect” mechanics have Tommy John surgery, and we have seen pitchers with “poor” mechanics have long careers.


    TNSTAAPP – There’s No Such Thing As a Pitching Prospect. Eerily, that acronym is becoming more and more true.

    I do have one overriding belief in my head at this time on pitchers and Tommy John surgery. Here’s how you can determine whether or not a pitcher will have Tommy John surgery at some point in his career: Grab a coin and flip it. If it’s heads when it lands, he might have Tommy John surgery. If it’s tails, well, he might not have Tommy John surgery.
    Comments 24 Comments
    1. Sconnie's Avatar
      Sconnie -
      Well said Seth. I think there may be something to the notion of improved diagnosis techniques and improved success of the surgery. There's more TJ surgeries in part because the medical staffs at all levels of baseball diagnose the issue better, are more willing to prescribe the surgery, and those that opt to have it done are more successful afterward than ever before. I wonder how many players in the past played until they couldn't, and retired early.
    1. crarko's Avatar
      crarko -
      It will be interesting to see if this research provides any help:

      http://www.drmagaziner.com/stem-cell...ndon-injuries/
    1. Kirby_Waved_At_Me's Avatar
      Kirby_Waved_At_Me -
      Man, Joe Mays. I wonder if Joe had had the benefit of today's understanding of Tommy John Surgery and rehab if he would have lasted longer in the majors post surgery. He was pretty much done after (though the season leading up to the procedure was not going all that well, either).
    1. nicksaviking's Avatar
      nicksaviking -
      Velocity and strikeouts are up in the league while guys are throwing fewer pitches and going fewer innings.

      It would seem that guys are exerting more effort these days to try to miss batas. I would think if a guy is exerting max effort on each pitch to keep the ball out of play instead of pacing himself, he would have a higher likelyhood of needing reconstructive surgery. We're not that far removed from the days when a 5.5 K/9 was above aveage and 91 MPH fastballs were impressive.

      Of course that would make most of the current Twins pitchers safe from the procedure.
    1. ND-Fan's Avatar
      ND-Fan -
      I think the weight training programs are leading to this sudden rise in elbow injuries and shoulder problems this extra strength has put more strain on both elbow and shoulder more than they are capable of handling over period of time. Also the emphasis on big tall pitcher I believe has led to elbow problems with weight training has created velocity that arms can not tolerate this torque that is generated. Just 15 years ago it was considered you had power arm that reached into the 90's and now that is required norm and now its become common to have pitchers reach middle to upper 90's. Also number of pitchers are reaching 100's but the problem is very few now have seen there arms stand up to this pitching. I would believe if Tommy John surgery hadn't come along baseball teams would be training their pitchers differently to protect their arms. Also some of smaller pitchers would have been looked at more seriously to see they could have developed into major league pitcher. I look at Greg Maddux today would he have been given a job today and given time to develop into the pitcher he became. A lot of this has been reaction to change in strike zone in MLB with strike zone shrunk to try to help bolster the offense and see more home runs hit. I think were coming to critical point where baseball may have to revaluate how they are training and developing players with cost they are incurring because of all the injuries. At some point its going effect numbers of players being developed and players organizations demanding something be done about all these injuries.
    1. Brandon's Avatar
      Brandon -
      When I first started following baseball in the late 80's rotator cuff surgery was a lot more common place. I don't see that as much anymore. Does anyone know why?
    1. Kirby_Waved_At_Me's Avatar
      Kirby_Waved_At_Me -
      I couldn't find a specific study showing the frequency of rotator cuff injuries, but some recent notable players that had the operation:

      Jessie Crain
      Mark Mulder (twice!)
      Johan Santana
      Roy Halladay

      Here's an interesting article on Rotator cuff injuries from January of this year- Tommy John surgery seems to be the bigger headline right now, but Shoulder injuries that require surgery are still plaguing pitchers:

      http://www.philly.com/philly/sports/...MLB_teams.html
    1. twinsfan34's Avatar
      twinsfan34 -
      Great question Brandon.
    1. ScrapTheNickname's Avatar
      ScrapTheNickname -
      oops
    1. ScrapTheNickname's Avatar
      ScrapTheNickname -
      I was watching a Dodgers' broadcast and Orel Hershiser was asked about the rash of Tommy John surgeries over the past years and first of all he said he didn't know, but he thought maybe it had to do with specialization - as Seth said may be one of the reasons - at younger and younger ages; that is, in his day kids plays multiple sports and by doing so used all or many parts of their bodies, while nowadays a pitcher will only pitch and thus over-tax his arm and not really develop the rest of his body. I'm saying it crudely, but that was his general point.
    1. Lefty74's Avatar
      Lefty74 -
      The whole TJ issue seems to be a mystery, even to those who perform the surgery. Last week I had a chance to meet and talk with Dr. David Altchek for a few minutes. Altchek performed surgery on Sano, Santana and tons of other MLB guys. He said he was on a panel on MLB network the previous day with Costas, Kaat, Smoltz and Verducci talking about TJ. He said Smoltz was very much against blaming it on pitch counts. Altchek's personal opinion is specialization and kids throwing at early ages off a mound and with radar guns logging speed. He said kids will tend to overthrow due to the guns and that the mound creates a tremendous amount of lag in the elbow which multiples the forces on the joint. He thinks these 2 things cause damage over time and believes that in youth baseball the mound should be removed.

      There is also a lot of tracking being done by Boyds World and Baseball Prospectus. They track Pitcher Abuse Points (PAP) for college and professional pitchers. The basic premise is that when college or pro pitchers exceed a threshold of around 125 pitches they are in greater danger of injury--in particular if they exceed it frequently. I haven't studied their conclusions in detail, however they do seem to have data supporting the theory that high pitch counts tie to problems for many pitchers.
    1. KOHG's Avatar
      KOHG -
      Quote Originally Posted by ScrapTheNickname View Post
      I was watching a Dodgers' broadcast and Orel Hershiser was asked about the rash of Tommy John surgeries over the past years and first of all he said he didn't know, but he thought maybe it had to do with specialization - as Seth said may be one of the reasons - at younger and younger ages; that is, in his day kids plays multiple sports and by doing so used all or many parts of their bodies, while nowadays a pitcher will only pitch and thus over-tax his arm and not really develop the rest of his body. I'm saying it crudely, but that was his general point.


      I agree with the idea of specialization and specific weight training is the cause. Looking at stats of inning of pitchers in the 20-40s its amazing how much throwing they did. The thing is - those players also worked for a living. They had jobs on the farm in the off season giving their body more of an overall workout especially when they where young. Now a days a kid goes to school and all he does is throw a baseball once every 5 days. Weight lifting is "specific" it targets one group of muscles. However, the other muscles, ligaments, bones aren't keeping up strength wise because they are not being strengthened at the same rate because they are not being targeted. Its like building a brick house and using wood glue for the motar..eventually its going to break. Also, they used to throw alot more when they where younger building up arm strength targeting the exact muscles, bones, and ligament that they would be using - the key was constantly and consistently. Another way to look at it...My dad was a sheet metal worker for 25 years he would lift and adjust a sheet metal slab for his lazer cutter he never had back problems or muscle problems he would come home and then work in the yard. I did that one time along time ago for a couple of weeks and I thought my legs and back where on fire and I couldn't move the next day. Its about consistency over a long period of time, its about an "overall" workout which strengthens all parts of the body at the same rate. Its also about some of these justin beiber, metro sexual kids who spend all of there time with there face in a tablet or pc not really doing any type of physical labor work over along period of time, when all of the sudden they have too and things break. Also, they just don't throw enough early and often, they should throw more not less. These guys just aren't as tough as the greatest generation because they don't have to be. This is my theory anyway
    1. spycake's Avatar
      spycake -
      Quote Originally Posted by Kirby_Waved_At_Me View Post
      Man, Joe Mays. I wonder if Joe had had the benefit of today's understanding of Tommy John Surgery and rehab if he would have lasted longer in the majors post surgery. He was pretty much done after (though the season leading up to the procedure was not going all that well, either).
      Mays also saw his K/9 drop by an average of almost 1 K/9 per year, for each of the 4 years prior to his surgery.
    1. Heezy1323's Avatar
      Heezy1323 -
      Quote Originally Posted by Brandon View Post
      When I first started following baseball in the late 80's rotator cuff surgery was a lot more common place. I don't see that as much anymore. Does anyone know why?
      Great question. The answer is because the results of cuff repair in pitchers have been miserable in regards to return to play. In fact, the results of surgery to address ANY shoulder pathology in pitchers (SLAP tears, partial or full-thickness cuff tears) are quite a bit worse in terms of return to play than elbow surgery. Currently, most sports surgeons ascribe to the 'only operate on the shoulder when you have no other choice' school of thought. There is quite a bit of controversy as to how to handle cuff tears once it becomes clear that a pitcher is unable to continue without surgery. Most surgeons would probably lean toward just cleaning up the cuff (debridement) without doing an actual repair even if a full-thickness tear is present due to the poor results of return to play after a cuff repair. Hope this answers your question.
    1. mike wants wins's Avatar
      mike wants wins -
      From what my doctor friends tell me, no one wants to to shoulder surgery for anything for anyone anymore, if it can be helped. Just too hard/not effective enough for the risk.

      As for TJ......I would never presume to opine on why there is more TJ, or how to avoid it, since teams are probably spending more time and resources and expertise to solve for this than I ever could....
    1. Brock Beauchamp's Avatar
      Brock Beauchamp -
      Quote Originally Posted by Heezy1323 View Post
      Great question. The answer is because the results of cuff repair in pitchers have been miserable in regards to return to play. In fact, the results of surgery to address ANY shoulder pathology in pitchers (SLAP tears, partial or full-thickness cuff tears) are quite a bit worse in terms of return to play than elbow surgery. Currently, most sports surgeons ascribe to the 'only operate on the shoulder when you have no other choice' school of thought. There is quite a bit of controversy as to how to handle cuff tears once it becomes clear that a pitcher is unable to continue without surgery. Most surgeons would probably lean toward just cleaning up the cuff (debridement) without doing an actual repair even if a full-thickness tear is present due to the poor results of return to play after a cuff repair. Hope this answers your question.
      Interesting. Thanks for explaining that to us non-doctors.
    1. Heezy1323's Avatar
      Heezy1323 -
      Quote Originally Posted by KOHG View Post

      I agree with the idea of specialization and specific weight training is the cause. Looking at stats of inning of pitchers in the 20-40s its amazing how much throwing they did. The thing is - those players also worked for a living. They had jobs on the farm in the off season giving their body more of an overall workout especially when they where young. Now a days a kid goes to school and all he does is throw a baseball once every 5 days. Weight lifting is "specific" it targets one group of muscles. However, the other muscles, ligaments, bones aren't keeping up strength wise because they are not being strengthened at the same rate because they are not being targeted. Its like building a brick house and using wood glue for the motar..eventually its going to break. Also, they used to throw alot more when they where younger building up arm strength targeting the exact muscles, bones, and ligament that they would be using - the key was constantly and consistently. Another way to look at it...My dad was a sheet metal worker for 25 years he would lift and adjust a sheet metal slab for his lazer cutter he never had back problems or muscle problems he would come home and then work in the yard. I did that one time along time ago for a couple of weeks and I thought my legs and back where on fire and I couldn't move the next day. Its about consistency over a long period of time, its about an "overall" workout which strengthens all parts of the body at the same rate. Its also about some of these justin beiber, metro sexual kids who spend all of there time with there face in a tablet or pc not really doing any type of physical labor work over along period of time, when all of the sudden they have too and things break. Also, they just don't throw enough early and often, they should throw more not less. These guys just aren't as tough as the greatest generation because they don't have to be. This is my theory anyway
      I have spent a lot of time thinking about this question of 'are kids throwing too much nowadays or not enough?' What I have come to think is this: the main difference between the situation you describe above and throwing injuries (specifically UCL injuries) is that in the scenario above you are mainly talking about exercise of muscles. Muscles have the ability to hypertrophy (get larger) when worked out. This helps protect them from future injuries. In fact, this is exactly what is happening when someone lifts weights- the muscle is being partially broken down and subsequently repaired along with the muscle cells increasing in size. Ligaments, however, are different. They do not hypertrophy in response to repetitive loading and do not have the same capability to heal themselves as muscle does. This has to do with many different factors (which I won't pretend to completely understand) but some include blood flow (excellent for muscle, much less so for ligaments) and composition (primarily protein for muscles, mainly collagen for ligaments).
      In sum, I do not ascribe to the argument that kids now do not throw enough. I'm certainly not saying I'm absolutely correct, just stating my opinion. I fall more in to the camp that believes kids throw too much. Too many innings, too many different teams, not enough time off to recover between seasons. IMHO a ligament has a finite life span (which is different for everyone) and once this is reached, the ligament is no longer able to do its job. For some people, this may be a few seasons in middle school, for others (elite pitchers) their ligament is inherently stronger and can take more punishment. Some go an entire career without ever having a problem; many do not.
    1. Heezy1323's Avatar
      Heezy1323 -
      Quote Originally Posted by Lefty74 View Post
      The whole TJ issue seems to be a mystery, even to those who perform the surgery. Last week I had a chance to meet and talk with Dr. David Altchek for a few minutes. Altchek performed surgery on Sano, Santana and tons of other MLB guys. He said he was on a panel on MLB network the previous day with Costas, Kaat, Smoltz and Verducci talking about TJ. He said Smoltz was very much against blaming it on pitch counts. Altchek's personal opinion is specialization and kids throwing at early ages off a mound and with radar guns logging speed. He said kids will tend to overthrow due to the guns and that the mound creates a tremendous amount of lag in the elbow which multiples the forces on the joint. He thinks these 2 things cause damage over time and believes that in youth baseball the mound should be removed.

      There is also a lot of tracking being done by Boyds World and Baseball Prospectus. They track Pitcher Abuse Points (PAP) for college and professional pitchers. The basic premise is that when college or pro pitchers exceed a threshold of around 125 pitches they are in greater danger of injury--in particular if they exceed it frequently. I haven't studied their conclusions in detail, however they do seem to have data supporting the theory that high pitch counts tie to problems for many pitchers.
      Very interesting stuff. Certainly hard to discount anything Altchek says (he is a giant in the profession) but I was at a conference recently (Altchek was also there, but not sure if he was at the particular session I am talking about) where a study was presented stating that the stresses on the elbow when pitching from flat ground were nearly identical to the stresses seen when throwing off the mound. This was a biomechanics study and was, in my opinion, very well done. Because of that study, I have some questions about the mound issue. It makes sense intuitively, but I'm not sure the science backs it up at this point. Personally I think specialization and radar guns are much more influential.

      I think the pitcher abuse points thing is very interesting, and can help give some guidelines, but ultimately my belief is that every pitcher is different. Their mechanics are different, as is the inherent strength of their UCL. Things like this can be helpful, but at the end of the day a single set of guidelines is unlikely to be universally applicable. My (perhaps foolish) dream is to find a way to somehow measure the strength of an individual's UCL and be able to monitor this over time so the we could tell when the ligament is beginning to break down and perhaps catch some of these injuries before they get to the point of requiring surgery. We certainly know a lot more about these injuries today than we did ten years ago, but also have LONG way to go.
    1. Thrylos's Avatar
      Thrylos -
      I'd add a couple of notables to the list:

      Scott Erickson
      Joel Zumaya (2 Spring Trainings ago.)
    1. LaBombo's Avatar
      LaBombo -
      Nice writeup. Amazing that a third of the 1st round high school pitchers from 2010-12 have already had TJ when you consider that probably the oldest would be 23 by now, with the average age probably 21 or a little less.

      But possibly even more disturbing is the fact that those those 2010-12 HS pitchers blew out their elbows at a rate 5 times what HS pitchers drafted in the top 30 from 2002-2009 did. That's probably at least partly small sample anomaly, but if it represents even a modest increase in injury frequency then it's a very alarming trend.

      SI's Tom Verducci has a good writeup about the subject. He ends it with a plug for lowering the mound, and it will be interesting to see if the debate about mound height effect on pitcher mechanics and stress intensifies as the injuries mount.
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