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On Rich Hill's Experimental Elbow Surgery and Previous Injury History


The Minnesota Twins entered the 2020 offseason with big plans, building a roster capable of springboarding off the success of the 2019 season — one of the single greatest seasons in team history — being at the forefront.While the team may have struck out on acquiring their top-tier starting pitching targets — Zach Wheeler, in particular — the acquisition of slugging third baseman and former league MVP Josh Donaldson helped freshen the bad taste left in the mouth by the beginning stages of free agency.

 

However, one acquisition that has the potential to further cast the Twins’ offseason in a positive light is the signing of starting pitcher Rich Hill. Hill, a 15-year veteran who has split time between the bullpen and starting throughout his career, spent the previous three years and change with the Los Angeles Dodgers where he posted an ERA of 3.16 and struck out 427 batters in 361 1/3 innings.

 

Hill, who signed a one-year, $3 million contract laiden with performance incentives, largely resurrected his career during his stint with the Dodgers. Prior to joining L.A., Hill’s career was defined and marred by injuries and inconsistency. Other than four semi-successful seasons with the Chicago Cubs to begin his career — he posted a 4.37 ERA across 337 2/3 innings — Hill never threw more than 76 innings for any of the other six teams he made appearances for. and those productive 76 innings came while he was with the Oakland A’s in 2016, who went on to trade Hill to the Dodgers later in the season.

 

The majority of the injuries Hill has suffered during his career (see photo above) have occurred on the left side of his body, something that would be expected for a left-handed thrower; the throwing arm is subjected to an immense amount of force with each pitch and the muscle contractions within the push-off leg is the source of the power — itself a great amount of force — that serves as the foundation for every throw.

 

The two most significant of Hill’s injuries both involve his left elbow.

 

In 2011, Hill underwent Tommy John surgery to reconstruct the ulnar collateral ligament (UCL) in his left elbow. The UCL — along with the bony configuration of the elbow and the wrist flexor muscles — helps stabilize the elbow against valgus forces. A valgus force causes stress to the medial — or inner — elbow; if the soft tissue structures in the arm are unable to compensate for the vast amount of force placed through it while throwing a baseball, the UCL is usually one of the first structures to be injured. The UCL can be injured acutely - failure after one subjection to a high force — or chronically — a build up of “wear and tear” over the course of many throws.

 

Just like any other ligament in the body, the degree of injury of the UCL can vary. A grade 1 sprain of the ligament is analogous to a simple “over stretch”; these injuries aren’t usually severe and heal on their own over the course of a few weeks. The main treatment for grade 1 injuries is rest and ice.

 

Grade 2 and 3 sprains of the UCL involve tearing of the ligament, with grade 3 sprains being full ruptures. Grade 2 injuries may be able to heal on their own due to the UCL’s relatively good blood supply, so the first line of treatment usually involves targeted strengthening of the wrist flexors, a gradual return to throwing, and perhaps a platelet-rich plasma (PRP) injection or two. PRP injections involve removing some of the athlete’s blood, spinning the collected blood very rapidly to separate the red blood cells from the plasma, then injecting the plasma back into the elbow; the thought is that the plasma will boost the healing of the UCL, though the true efficacy of PRP injections is up for debate.

 

If conservative treatment for grade 2 and 3 tears fails, Tommy John surgery is ultimately required. Tommy John surgery — also known as ulnar collateral ligament reconstruction — involves creating a new UCL by grafting a piece of tendon - often from the hamstring or palmaris longus of the forearm - into the elbow. The physiological process of the body turning the tendon into a new ligament is, appropriately, known as ligamentization, and this combined with the amount of rehabilitation that is required for the athlete to return to game action can take some time. It isn’t uncommon for a major league pitcher to miss 9-18 months after undergoing Tommy John surgery.

 

However, this is where Hill’s latest injury needs to be discussed.

 

Hill underwent a largely experimental though highly encouraging procedure this past October to repair a partial tear of the UCL in his left elbow, known as a primary repair with internal bracing and was conducted by renowned orthopedic surgeon Dr. Jeffrey Dugas(Dr. Dugas studied under and now works with Dr. James Andrews in Alabama and, interestingly enough, is the Associate Medical Director for the WWE!). To my knowledge, pitchers Seth Maness and Jesse Hahn as well as outfielder Brandon Guyer are the only other professional baseball players to undergo this procedure as of this writing.

 

involves using biotape — a relatively thick-stranded surgical “thread” dipped in collagen (the substance that comprises all connective tissue) — to increase the strength of the repaired UCL. In essence, the torn portion of the UCL is reattached to the bone and the biotape is woven within the UCL, which, in turn, increases its strength. (Quick surgical terminology aside: “Repair” means that the existing structure has been reattached during surgery; “reconstruction” means that the existing structure has been removed and a “new” structure has been put in its place.)

 

Not all UCL injuries are eligible to undergo Dr. Dugas’ procedure, however; the tear has to be relatively clean with defined edges. The biggest difference — besides the surgical differences outlined above — between traditional Tommy John surgery and the procedure Dr. Dugas performed on Hill is the typical recovery timeline. Athletes who undergo the primary repair with internal bracing procedure

, whereas they have to wait until at least week 16 with traditional Tommy John surgery.

 

When asked recently about his recovery timeline, Twins’ President of Baseball Operations Derek Falvey relayed that Hill will soon resume throwing. Said Falvey, “Rich will begin a throwing program or process here going into spring training ... Our hope is that he’s pitching in some rehabilitation games in June.” This would place Hill’s return to play at about 8-9 months, at least a full month, or likely much more, sooner than he would have had he undergone traditional Tommy John surgery.

 

However, as Falvey stated, Hill’s return and rehabilitation process isn’t set it stone. “[Hill’s return] is all going to be somewhat dependent on how he responds at each juncture. Could [his return-to-play timeline] speed up? Sure. Could it slow down a little bit? Absolutely it could. We just need to see how he is once he gets to a more aggressive part of his throwing program.”

 

That last clause is the most important aspect of Hill’s recovery; it would be wise for the Twins to bring Hill along slowly, making sure that his surgically repaired elbow responds positively (i.e. doesn’t hurt and is producing sufficient amounts of force) prior to progressing him in his throwing program; Hill’s starts in September, and hopefully beyond, are much more important to the Twins than his potential starts in June.

 

According to Baseball Savant, Hill has primarily utilized a two-pitch mix over the past four seasons; Hill’s four seam fastball and curveball usage percentage ranged between 44.9-55.4% and 36.0-49.2% respectively from 2016-2019. This is important as higher pitch velocities place greater amounts of stress on the inner elbow. It is important that Hill have adequately strong rotator cuff and wrist flexor muscle strength and endurance to help attenuate the forces placed on the inner elbow with repeated throws greater than 90 miles per hour.

 

If Hill is able to rehab without any hiccups it wouldn’t be out of the realm of possibility for him to return to his Los Angeles Dodger-levels. Perhaps the biggest obstacle to returning to prominence, however, would be Hill’s relatively advanced age — he’ll turn 40-years-old in March. All baseball players experience a decline in performance at some point and few have been able to carry high amounts of success into their 40s. However, with Hill’s contract being heavily performance-based, his signing was a low-risk, high-reward move for the Twins. If he returns healthy, Hill could be an extremely viable Game 3 starter behind Jose Berrios and Jake Odorizzi; if he doesn’t, the Twins still have Michael Pineda.

 

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To my knowledge, pitchers Seth Maness and Jesse Hahn as well as outfielder Brandon Guyer are the only other professional baseball players to undergo this procedure as of this writing.

This is what has bothered me about the high expectations some have for Hill. The procedure has been around a little while now, and yet the only player I could find a mention of (when I looked, after Hill was signed) was Maness. Glad to learn of the other two; but none of these three has "made it all the way back", in my estimation.

 

IOW, Hill would be the first.

 

Worth a try, but I'm not banking on him in the slightest.

 

The article's is great, by the way - a deep dive into a topic few of us are capable of judging independently.

 

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This is what has bothered me about the high expectations some have for Hill. The procedure has been around a little while now, and yet the only player I could find a mention of (when I looked, after Hill was signed) was Maness. Glad to learn of the other two; but none of these three has "made it all the way back", in my estimation.

 

IOW, Hill would be the first.

 

Worth a try, but I'm not banking on him in the slightest.

 

The article's is great, by the way - a deep dive into a topic few of us are capable of judging independently.
 

 

Same, but at this point I'd be surprised is he pitches more than 25 innings for them.

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I hesitate to ask as it's an unfair question, and a very new procedure with little track history, but what would be the best "guesstimate" for success?

The research that has been done on the procedure seems to indicate that it is just as successful as regular T.J. surgery. I believe one of the articles I linked in the article stated that players have a 90% return to play rate; at the very least it was something high like that.

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Thanks for the article. I love this stuff, and you made it very understandable.

 

Interesting that the Twins consider $3 million for Hill to maybe essentially flush down the toilet a low risk, but ponying up the $375 K to keep Berrios happy becomes an issue and something to fight over. Baseball is a weird business.

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The research that has been done on the procedure seems to indicate that it is just as successful as regular T.J. surgery. I believe one of the articles I linked in the article stated that players have a 90% return to play rate; at the very least it was something high like that.

One important difference here is that Hill had a repair not of his own UCL, but of a previously reconstructed UCL. This makes him different from Manness, into another category altogether. I am not aware that this has been done successfully at the major league level. Also, you can't compare Hill to a typical UCL reconstruction for purposes of return to play percentage. He is, at best case, comparable to a revision UCL reconstruction, which has a MUCH lower rate of return to MLB-level play. Most studies I have seen put that number around 40-50%. 

 I hope I am wrong on this front, and Hill doesn't need to return to throwing 97 mph to be effective (i.e. less stress on elbow), but I would put his odds for returning to meaningful contribution to the Twins this year around 50%. 

 Great review- thanks for a well-done article.

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One important difference here is that Hill had a repair not of his own UCL, but of a previously reconstructed UCL. This makes him different from Manness, into another category altogether. I am not aware that this has been done successfully at the major league level. Also, you can't compare Hill to a typical UCL reconstruction for purposes of return to play percentage. He is, at best case, comparable to a revision UCL reconstruction, which has a MUCH lower rate of return to MLB-level play. Most studies I have seen put that number around 40-50%. 

 I hope I am wrong on this front, and Hill doesn't need to return to throwing 97 mph to be effective (i.e. less stress on elbow), but I would put his odds for returning to meaningful contribution to the Twins this year around 50%. 

 Great review- thanks for a well-done article.

Very good points. In all reality, I'd even take it a step further and say the likelihood lies somewhere between the 50% you stated and the 90% I stated. I think what tips in closer to the 90%, however, is that the collagen-dipped biotape is (theoretically) much stronger than the revised UCL would be, due to it being a synthetic material while the revised UCL would be a repaired/reconstructed version of a tissue that wasn't a ligament to begin with.

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Very good points. In all reality, I'd even take it a step further and say the likelihood lies somewhere between the 50% you stated and the 90% I stated. I think what tips in closer to the 90%, however, is that the collagen-dipped biotape is (theoretically) much stronger than the revised UCL would be, due to it being a synthetic material while the revised UCL would be a repaired/reconstructed version of a tissue that wasn't a ligament to begin with.

This is getting fairly 'into the orthopedic weeds', but this internal brace construct (which is the general term for the biotape) is designed to be load-sharing, not load-bearing. Essentially, it is designed to provide time zero strength to the construct to allow for healing without plastic deformation/elongation of the repaired tissue. This does allow for a faster return to sport (in an ideal scenario), but it is yet to be determined if this provides greater strength to failure when compared to a UCL graft once ligamentization of the graft is complete. Lab/cadaver studies can simulate the time zero condition. They are unable to account for healing of the graft over time which certainly has an effect on the construct strength. Being that there have been so few of these done on major league players, I don't think there is enough available data to say that the biotape would result in such an improved likelihood. It may, but I don't think there is enough data to support it at this time. 

 Another point to consider is that in this case, I believe it's likely that Hill was presented the option of repair of his UCL graft with this internal brace versus revision reconstruction, with the difference being that repair MAY allow a quicker return to play. Given his age and stage of career, my best guess is that he opted for the repair to give him a shot to pitch again, as undergoing reconstruction with 1.5 year timeline would likely put him out of baseball. As a result, I don't think even the limited results of UCL repair (which is typically done in young players on an otherwise normal ligament with a focal injury) can be extrapolated to Hill. 
You're certainly welcome to disagree- I would absolutely not advertise my opinions as fact. I also hope I'm being pessimistic and Hill knocks everyone's socks off this year. But from my end of the microscope, I'm skeptical. 

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