Heezy1323

Yes, it is essentially a worker's comp situation. The parent club pays for minor leaguers. Of course, this is assuming injury was incurred while playing baseball, not mowing the lawn or something.

Happy to answer questions as best I can. Your question re: Perkins conditioning is a good one, though obviously difficult to answer with much certainty. I would say in general that MLB pitchers are in less 'good shape' than position players, though obviously there are exceptions. In many ways, being overly muscular can be detrimental to hurling a ball 95 mph. Also, I would say there is a difference between a pitcher keeping his arm in shape but perhaps gaining some weight in the midsection, and neglecting an offseason throwing/strength program altogether. To me, the latter is more likely to be problematic than the former. All of that being said, it seems reasonable to me that significant weight gain (not sure how I would define significant) has the possibility to change mechanics, which could in turn lead to injury (I am not aware of any studies that have specifically looked at this). Another possible explanation is that the cumulative 'wear and tear' on Perkins shoulder simply became too much, and would have been problematic if he had shown up to spring training in the shape of his life. Personally, I have come to believe that every thrower's shoulder/elbow has only so many 'bullets'. For every MLB pitcher, there are 100 who were great in HS or Legion ball, but simply ran out of bullets much sooner. Sometimes the gun is just empty.

I thought I might add just a little bit to this discussion, as it is likely I look at more shoulder MRI's than most on TD (I am an orthopedic surgeon). Alarp is correct, these are difficult to diagnose. Sometimes it is because they don't show up on MRI. In other cases it is because nearly every pitcher's shoulder (particularly by the time they reach the professional level) shows signs of 'wear and tear' on MRI. So trying to differentiate 'normal' wear and tear from 'troublesome' wear and tear is also very difficult. Also, I thought a brief discussion of shoulder anatomy may be helpful for some. Many times while discussing the throwing shoulder, people lump the rotator cuff, labrum, and SLAP tears together, while in fact they are really separate (though potentially related) issues. I like to use the analogy of a golf ball sitting on a golf tee when discussing the shoulder with my patients. The shoulder is a ball and socket joint, and in many ways similar to the golf ball analogy. The rotator cuff is a group of muscles/tendons that comes off of the shoulder blade and attaches to the ball. It's job is mainly to pull on the golf ball to keep it in the center of the golf tee as the larger muscles move the arm around in space. The labrum is cartilage that runs around the circumference of the golf tee. It's job is to act as a 'bumper' to keep the golf ball centered on the golf tee. It also serves as an attachment point for ligaments that help to keep the golf ball on the golf tee (the muscles and ligaments work in concert to do this). The top of the socket is where your biceps tendon attaches and becomes confluent with the labrum. Anatomically, we call this the 'superior labrum'. So a SLAP tear (which stands for 'superior labrum anterior to posterior') is an injury where the labrum has become separated from the rim of the golf tee at this area where the biceps tendon attaches. One can also get a labrum tear at other points around the rim of the golf tee (that don't involve the biceps tendon attachment area). These injuries can commonly be in the front (anterior) or back (posterior) of the shoulder, thus often being referred to as 'anterior labrum tears' or 'posterior labrum tears' which are different than SLAP tears. However, certainly a thrower can (and often does) have more than one of these issues at a time. To add to the confusion (as if all of this wasn't confusing enough already, right?), different people can pitch with different amounts of damage/injury in the shoulder. I have seen shoulder MRI's that look TERRIBLE, and the player is still pitching at a near All-Star level. I have conversely seen MRI's that look essentially normal, and a pitcher is completely unable to throw. I hope this was helpful to some, and I apologize if it is covering known material for others. I really enjoy this site and like to pitch in here and there where some of my medical knowledge may be helpful to others. I know I have certainly learned a lot from many here- just trying to return the favor. https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjD7KGjvLHNAhWF8z4KHeiuDJMQjRwIBw&url=https%3A%2F%2Fwww.shoulderdoc.co.uk%2Farticle%2F1399&psig=AFQjCNFMBoj1JIDKkxv2TwQBWh7JPROf-w&ust=1466335474059527

This is a somewhat complex explanation, so hopefully I can make it make some sense. In a normal, healthy elbow during a pitch, the stress generated at the inside part of the elbow is actually greater than the measured tensile strength of the UCL. So essentially you are exceeding the capacity of the UCL with every pitch- a phenomenon Dr. Andrews calls 'red-lining' the UCL. So why doesn't the UCL snap with every pitch? Some of this force is dissipated by the use of other structures in the kinetic chain. These would include the forearm flexors, biceps, shoulder musculature, bony anatomy of the elbow and others. So in theory, the rehab angle seeks to 'protect' the UCL by strengthening these other contributors, and thereby dissipate the stress seen by the UCL itself. In addition, there is probably some limited capacity of the UCL to head in certain situations- something we are trying to augment with PRP and/or stem cell injections. Unclear at this point if these are truly helpful or not. The time resting from throwing allows (perhaps) for some healing.

Also absolutely correct. There are dozens of variables in play when you are trying to analyze this data, thus making it difficult to draw solid conclusions about any one aspect. To the 'soured on therapy' comment, I would say that there are certainly cases where this is true. There are also cases where a player successfully recovers with rehab without the public ever knowing what the specific injury was. That may not be easy to believe, but you'll just have to trust me- I've seen it happen a number of times. I wish that patients would come in with a blinking light on their elbow indicating it is time to operate. Unfortunately, more often it seems to be challenging decision that needs to be made on a case-by-case basis. Very astute comments- I appreciate and enjoy the conversation.

Absolutely! I suspect that data will be forthcoming as time allows from this initial study. But we don't really have that data yet. Another way you could interpret this data is that surgery is more successful for incomplete tears than it is for complete tears... so should we be quicker to operate on partial/incomplete tears before they become complete? Difficult to answer because we really don't know how frequently incomplete tears progress to full tears over time. It seems like every time we answer a question, it is replaced with 5 more.

Daily browser, infrequent poster here. I am in the medical field and have read several threads over the past couple of years on TD that discuss Tommy John surgery and related topics. In these threads, there is often a sentiment that a pitcher should undergo TJ surgery sooner than later, and that non surgical treatment is rarely successful. Certainly, there is not an abundance of data to argue this either way. However, in the March issue of the American Journal of Sports Medicine (probably the most highly respected sports medicine journal) there is an article which discusses precisely this. I found the results interesting, and I thought others on this site may, too. It was done in Colorado in the Rockies organization. They looked at all UCL injuries from 2006-2011. In all, they came up with 43 elbows which met their criteria. 8 were complete tears on MRI, and underwent surgery. 35 were incomplete on MRI (which is the much more common finding). Of these, 28 were treated non operatively and 7 were treated operatively. Of the 28 non operatively treated elbows, 18 were pitchers. They were treated with a program including e-stim, mobilization, massage, ultrasound, laser therapy, cuff and periscapular strengthening. No PRP injections were used, as far as I can tell. They defined success as return to the same level of play for at least 1 season. Of these 18 pitchers, 94% were able to return to play for at least 1 season at the same or higher level of play. Those with incomplete tears treated operatively had a return to play rate of 86% at the same or higher level. Those with complete tears that had surgery initially had a return to play rate of 63% at the same or higher level. Overall, I believe this is a well-done study that may answer some questions posters on this site have had in the past. Obviously, those treated non-operatively had less severe injuries, so I don't think you can draw the conclusion that non-surgical treatment is better than surgery in all cases. But this does lend some support to non-surgical treatment in many cases. I hope some find this helpful. Happy to try to answer any questions folks may have. I'm sure there are other health care professionals or performance specialists on this site that will likely have an opinion as well. Below is a link to the study abstract: http://ajs.sagepub.com/content/44/3/723.abstract

Trust me, if this were as simple as plugging numbers into a mathematical equation, we would've solved this problem a long time ago. I can tell you with 100% certainty very few things about this issue, but one of them is this: no one knows exactly how well rest works for this problem. It is very difficult to study on a large scale. Several questions arise including1) how do you define a 'qualifying' injury? Is a guy who has one elbow twinge and skips a bullpen session taking a 'rest'? Two? One start? Two starts? 2) how do you define 'rest'? 1 day? 5 days? 10? 3) how do you define success? Is it returning to normal pitching duties for 10 appearances? 20? If someone needs TJ two years later, is it success? Or failure? How about 5 years later? 4) how do you factor in those who receive PRP or stem cell injections versus those who don't? 5) do you count 'flexor strain' as a UCL injury? Triceps strain? Elbow 'inflammation'? Do all of these count the same? Also realize this- surgeons like to do surgery. 'To cut is to cure' is something I have heard countless times in my career. If surgery was the answer, that's what we would do. Do you HONESTLY believe that despite the tremendous amount of research that has gone into this subject, that surgeons would continue to frequently recommend conservative treatment if it didn't work? Finally, I can recall seeing at least a dozen pro pitchers during my time with Dr. Andrews with shoulder/elbow issues that had inaccurate information reported the press. Trust me, the public story is not always the 'real' story. I'll get off my soapbox now.

As far as the MRI's go, their utility is overestimated for this injury. The same MRI findings in two different players may mean two widely disparate things. Serial MRI's, particularly a week apart almost never add anything to the discussion unless there has been an increase in symptoms or a new 'pop' or something of the like. The 10% or less is not definable. There is no classification system for UCL tears that measures them this way. Coincidentally, the annual meeting of the American academy of orthopedic surgeons is this upcoming week and there is a paper being presented (that I worked on- shameless plug) that proposes a classification system, but it's utility is far from clear. Bottom line, the decision for when to proceed to surgery is often difficult and approached individually on a case by case basis. Some guys can pitch at a high level with a partial tear- others can't. Only way to find out is to let them try.

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.

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.

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.

I don't have exact numbers, but my intuition is that you are correct. The hard part is going from 'excellent theory' to 'data-driven fact'. The example I use with patients is a paper clip. If you straighten out a paper clip and bend it back and forth 50 times, it will eventually break, right? Well, was it the 50th bend that did it? Or was it the combination of all the bends leading up to (and including) the 50th bend that did it? I would say about 40% or so of UCL injured pitchers have an acute 'pop' and the rest have a more vague onset of elbow pain with throwing without a specific injury. The hard part is that even those that have a 'pop' probably didn't have a completely normal ligament one pitch and completely torn the next. It's proving that concept with specific data that is difficult.

Couldn't agree more. Certainly there is more awareness about the injury now than 10-15 years ago- which I think is mostly a good thing. The focus on velocity is also a big one. When I see these kids with throwing injuries I ask them how hard they throw- and they ALWAYS know exactly. From a data standpoint, there is still debate about breaking pitches contributing to injury, but I think it's likely it has some importance. Overall, I think as athletes have gotten bigger/stronger over the years, these injuries are some of the side-effects. The increase in number of 'hard throwers' (however you want to define it) has been well documented. And we also know that when pitchers reach about 90 mph the amount of force placed on the UCL nears the tensile strength of the ligament. Add it all up and you get more injuries.

I don't think it is the weightlifting specifically, but the fact that all the weightlifting makes you stronger- allowing you to throw harder which places more stress on the elbow/shoulder. There is pretty good data that fastballs place the most stress on the elbow, followed closely by sliders. I agree that pitchers probably throw less today than years ago. This is where the idea of a cumulative effect of throwing comes from. Nolan Ryan wasn't pitching 12 months a year on 4 different teams as a youngster.

I agree 100%- that would be extremely valuable research. Unfortunately it is almost impossible to do... (this idea is similar to an idea for a project I was working on that I just wasn't able to get off the ground). 10-20 years ago very few people were paying attention to pitch counts (even less to the type of pitch). Today, most youth leagues have pitch counts, but few if any keep track of type of pitch. I think one difference is that years ago pitchers were more likely to throw more pitches in an outing (importance of pitch counts was not as well understood) but also less likely to play year-round baseball. It would be difficult to get an 'apples-to-apples' comparison. During my time with Dr. A, about 35% of the TJ's we did were on high schoolers. Crazy.

I'm certainly not a frequent poster on TD, but really enjoy the site/commentary/etc. There was a nice article today on ESPN.com that many have likely already seen regarding the incidence of Tommy John surgery this year. I thought it had a nice discussion of factors that come in to play and the current research in the area. There had been some discussion in the forums previously regarding this topic and I thought others may find the article interesting as well. http://espn.go.com/mlb/story/_/id/10831700/is-mlb-midst-tommy-john-epidemic

My experience with this has been that most commonly there is an open discussion between the surgeon(s), player, agent and the team. Every situation is a little bit different in terms of the quality of player, significance of injury, contract status, time of year, previous injuries or surgery, prior treatment, goals of the player (both short and long term), goals of the team (same), age of the player, and probably a half dozen other things I haven't listed. Often times in cases of a premier player, they will see multiple surgeons who will frequently communicate with each other. Ultimately, the responsibility of the surgeon is to serve the best interests of the player, but there is frequently input from the team as to their preference in treatment. In the majority of cases all parties are able to come to an understanding regarding the best way to proceed. At the end of the day, it is the player's decision.

I'm an orthopedist yes. I trained with Dr. Andrews recently so I have a fairly decent understanding of some of the thought processes in play for these guys. I certainly don't have all the answers but am happy to put my two cents in here and there if it helps. Was born and raised in MN and a lifelong twins fan so kind of a bummer to hear about Sano. Sure hoping things go well with his surgery and recovery.

They likely did do serial mris. The issue is not interpretation of the MRI, it comes down to the player's ability to play with what he has. Nearly all elbow mri's done on baseball players show some abnormality, even if they are symptom-free. So unless the MRI shows progression of a tear to a full thickness tear (most do not) the decision on when to operate is difficult. In most cases, the player is allowed to attempt to return to play after a period of rest, rehab and potentially PRP. If they can play pain-free, great. If not, depending on a multitude of factors, surgery is considered. Hope that helps explain the thought process.

Thats exactly correct. Many times it is not necessarily that it takes so long to make a diagnosis of UCL injury- it is deciding how long to try to treat it non operatively before resorting to surgery. Most guys that have UCL reconstruction don't have a completely torn ligament on MRI. The vast majority (probably 80% or more) have a partial tear. Some can play with a partial tear... some can't. Many variables in play including mechanics, degree of partial tear, condition of shoulder/elbow musculature, etc. Many lay people (as well as many baseball people) assume the success rate of UCL reconstruction is 100%. Not true. It is a highly successful operation, but most literature puts success rate around 85-90%. So that means one out of ten is unable to return to the same level of play. This is the main reason for trying conservative treatment (rest, rehab, PRP) prior to proceeding with surgery. It is true some position players can play without an intact UCL, but these are usually not players at positions requiring hard throws (3B, RF). As far as the W and inverted W position, that is one of probably a dozen or more current theories about predisposition to UCL injury. The issue is far from understood.

I think it's interesting that some people enjoy the human element to calling balls and strikes and yet lose their mind over plays like the Arizona State vs. Wisconsin ending in the football game last weekend. Bottom line- we need to get the calls right. Many games (in many sports) are played at such a high level and the difference between a win and loss is minuscule. To have the outcome decided by someone other than the players seems wrong. Just my two cents...

To our discussion, a link from today on grantland.com: How Concern Over Pitcher Usage Can Actually Give College Coaches a Recruiting Edge - The Triangle Blog - Grantland

Keeping in mind I'm in the medical field and not on the baseball side, I will give you my impression/opinion. There is not to my knowledge a current 'rule' for relievers- I believe teams differ in their willingness to use relievers back-to-back days, extended innings, etc. I do believe (again, this is my opinion) that teams are generally more conservative with starters and to a certain extent view relievers as more replaceable. I believe a 'rule' for relievers would be in the best interests of both the player and the teams, but exactly what that rule should be is very tough to know. Pitching back to back days is probably hard on your arm, but many pitchers do this for a career and never have a problem. Great question and a good area for some well done research (though perhaps there is some out there that I'm not aware of).

Yes the things I noticed were some minor operative details. The remaining info was pretty sound I thought. I think one thing to consider about the increasing incidence is that our understanding of the problems and ability to diagnose injuries using advanced MRI techniques has improved to where we are picking up more injuries than we were able to in the past. Also, the public's knowledge has improved and as a result they are more likely to recognize the issues and seek appropriate care.