Nationals Arm Race

Jose Fernandez was (arguably) the biggest name to go down to TJ surgery in 2014. Photo via thestar.com

When we hit 20 MLB pitchers going under the knife for blown Ulnar Collateral Ligaments (UCL) on the 2014 season, I posted on possible reasons for the epidemic.  By the time the season was over, more than 90 players in professional baseball (and a handful of marquee amateurs, including two first round picks and our own) had gone under the knife for blown UCLs/Tommy John surgery.  2014 was the year of the elbow ligament, no question, in terms of volume and awareness.

This post lists all the major league pitchers who had the surgery this year, with links to the announcements as they happened, along with stills of the pitchers’ mechanics to do a quickie thumb nail analysis of mechanics and whether there’s a relationship to the injury. At the bottom i’ve captured any significant news related to the surgery, MLB being proactive in preventing the injuries, and other TJ news.

First, here’s the complete Tommy John fall-out for the year for major league arms.  According to the great injury tracking links below, no less than 91 players in all levels of pro baseball had the surgery in calendar year 2014, of which 29 were MLB-experienced pitchers.

(data from baseballheatmaps.com, which has detailed Disabled List data).

• Jonny Venters, recovering from his 2nd TJ surgery, re-tore the ligament and is going for his THIRD.
• Jeremy Hefner, already on the shelf from a TJ surgery *last* year, suffered a big set-back and may have to have a 2nd procedure (announced 8/11/14)
• Tyler Skaggs was diagnosed on 8/10/14 with needing the surgery.
• Nate Jones: diagnosed 7/31/14.
• Tyler Chatwood: diagnosed 7/17/14
• Masahiro Tanaka, diagnosed with torn UCL 7/10/14; a huge blow, nearly as big of an announcement as Jose Fernandez’ if he has to get TJ surgery.  No announcement yet though that he’s having the surgery.  But, as of 8/5/14 he’s re-habbing and experiencing no pain while throwing, and eventually was able to avoid the surgery.  For now.
• Bronson Arroyo diagnosed 7/8/14, a surprise considering his durability and soft-tossing nature.
• Trevor Bell, diagnosed 4/23/14 but finally getting the surgery 7/16/14.
• (… we go more than a month without another diagnosis after getting them nearly daily in April and May.  Odd).
• Sean Burnett: diagnosed 5/28/14 (would be his 2nd)
• Chris Withrow: diagnosed 5/29/14 (though technically he’d been optioned to AAA; not sure if this should count as a MLBer)
• Martin Perez: diagnosed 5/15/14
• Jose Cisnero: diagnosed 5/14/14.
• Jose Fernandez: diagnosed 5/13/14.  Wow, biggest name to fall yet.
• AJ Griffin: getting the surgery 4/27/14
• Pedro Figueroa: diagnosed 4/24/14 (his 2nd, first in 2010)
• Ivan Nova: diagnosed 4/25/14
• Josh Johnson: diagnosed/announced 4/23/14, surgery 4/24/14.  His 2nd (first in 2007).
• Matt Moore: surgery 4/22/14
• Cory Gearrin: diagnosed 4/8/14
• Bobby Parnell: diagnosed 4/2/14
• Erik Davis: diagnosed 4/2/14
• David Hernandez: diagnosed 3/31/14
• Peter Moylan: diagnosed 3/22/14 (his 2nd)
• Bruce Rondon: diagnosed 3/21/14
• Patrick Corbin: diagnosed 3/17/14
• Jarrod Parker: diagnosed 3/17/14. (his 2nd)
• Brandon Beachy: diagnosed 3/17/14 (his 2nd)
• Kris Medlen: diagnosed 3/9/14. (his 2nd)
• Luke Hochevar: announced 3/7/14
• Cory Luebke: surgery in 2/4/14 (his 2nd)

10 of these 29 pitchers are getting the surgery for the 2nd time.  Wow.

Here’s links to other notable non-MLB pitchers who have gotten the surgery as well in 2014:

• Jamison Taillon: the Pirates #1 pitching prospect and one of the best pitching prospects in the game.  Diagnosed 4/6/14, surgery 4/9/14.
• Danny Rosenbaum: Nats AAA starter and long-time farmhand.   Surgery 5/8/14.  Tough for Rosenbaum because he’s a MLFA this coming off-season, now facing a very uncertain future.
• Miguel Sano: one of the best prospects in the minors, had the surgery 3/12/14.  He’s not a pitcher, and he initially injured his arm playing in the Dominican Winter League, but it still costs Minnesota one of its best prospects.
• Jeff Hoffman, ECU’s right handed starter and consensus top 5 pick in the 2014 draft, hurt his arm and was diagnosed on 5/8/14.  He dropped 5 places from his likely drafting spot by the Cubs at #4, which cost him about $X in slot dollars.   We talked about whether the Nats (picking at #18) were a likely suitor for him at the time of the injury in early May.
• Erick Fedde, UNLV’s friday starter and projected mid-1st round pick, was diagnosed two days after Hoffman on 5/10/14.  He dropped perhaps 8 places from his estimated drafting spot of mid 1st round and was picked by Washington.  His injury didn’t really cost him much in slot money thanks to the Nats paying over-slot.
• Our own Matthew Purke, diagnosed and set for TJ surgery 5/29/14 after really struggling out of the gate this year for Harrisburg.   Purke may face an options crunch by the time he’s done re-habbing, thanks to his MLB deal signed on draft-day.  (Update: the Nats never let him get there, releasing him on 11/14/14).
• Chad Billingsley having flexor tendon surgery while trying to recover from his 2013 TJ surgery.    This isn’t counted as a TJ, but is noteworthy.
• Not a pitcher, but key Orioles player Matt Wieters had to have TJ surgery on 6/18/14.
• Matt Cain dodged a bullet by just being diagnosed with elbow chips, but still had season-ending elbow surgery on 8/5/14.
• Padres uber-prospect and 2012 first rounder Max Fried went under the knife in mid-august.
• Yu Darvish didn’t fall victim to the TJ surgery, but an elbow issue is shutting him down in late August, just the latest nail in the coffin of the Rangers’ season.
• Jonathan Mayo discussion on elbow surgeries and prospects from Mid-Late August.

Here’s quickie images of every MLB starter diagnosed this year as they land to make a quick judgement about their mechanics:

Quick and Dirty Mechanics analysis (images in same order as list of pitchers above, which is chronological in order of diagnosis in 2014):

• Inverted W: Hefner, Skaggs, Withrow, Griffin, Nova, Gearrin, Beachy, Hochevar
• Sideways M: Ventors, Chatwood, Bell, Burnett, Fernandez, Johnson, Davis, Moylan, Rondon, Parker, Medlen
• Inverted L: Jones, Tanaka, Arroyo, Perez, Cisnero, Figueroa, Moore, Parnell, Hernandez, Corbin, Luebke

Conclusions? None.  They’re all over the road.  TJ injuries this year happened to those thought to have “dangerous” mechanics and clean mechanics.  TJ injuries happened to the league’s harder throwers (Rondon, Ventors, Fernandez) and its softest throwers (Medlen and Arroyo, both of whom are usually at the absolute bottom of the league in terms of fastball velocity).  Starters and relievers, no discernable pattern.

I think all you can conclude is this: if you throw a lot of innings, you’re more prone to injury.  I know, ground breaking analysis.

Other notable/interesting links I’ve collected on the topic over the length of the season:

• Yahoo’s Tim Brown interviewed Zack Greinke (published 5/15/14)who says he made a conscious decision to throw fewer sliders, noting that he could really feel it in his elbow after starts where he threw too many.  This tends to support the notion that sliders make a difference.
• Jerry Crasnick interviewed commissioner Bud Selig on 5/15/14 and Selig said he’s “concerned.”  Great!  On a scale of “Resolve Oakland/San Jose territorial rights” concerned to “Resolve MASN dispute” concerned, I wonder where he falls?  Maybe he’ll form a blue-ribbon committee that can meet for several years without arriving at any solutions.
• Stephania Bell‘s articles on the spate of TJ injuries: from April and again in May.
• Nate Silver‘s new blog 538 chimes in in mid-may.
• Neil Weinberg from Peter Gammons‘ website posts his own theory on 5/16/14 that is basically related to the rise in youth/showcase events.
• Shawn Anderson from the blog HallofVeryGood.com posts his theory (overuse).
• An older link to Will Carrol from July 2013 talking about the surgery, how its done, who’s had it and some other great stuff.
• The American Sports Medicine Institute (led by Dr. James Andrews) released a statement on 5/28/14 on the issue of Tommy John surgeries (as pointed out by David Schoenfield and/or Craig Calcaterra in late may and/or Jerry Crasnick on the same day).  Their basic point: don’t throw with max effort.
• Dr. James Andrews announced that he’s releasing an app to help keep pitchers healthy.   Per screen shots, it will be relatively simple and will have pitch counts, age and rest days calculate a max number of pitchers that a player can throw today.
• An interesting analysis of Kansas City’s Yordano Ventura after he was diagnosed with a non-UCL related elbow injury in May.
  
• Thoughtful piece from Dirk Hayhurst about the quest for velocity and the value of soft-throwers like Mark Buehrle.
• Danny Knobler special piece to the BleacherReport in June 2014 discussing “child abuse” of kids over-throwing, throwing too much, too hard, too soon.
• A sleeve has been announced that may help prevent TJ injuries (its called the Motus Pitcher Sleeve).  Dirk Hayhurst subsequently did some research and interviews about the sleeve and offers some thoughts.
• CBS’s Jon Heyman breaks the news that #1 overall pick Brady Aiken may have an “elbow ligament issue,” thus holding up the signing.  Wow.  As we all know, this turned into a big-time stalemate, the non-signing of Aiken (which cascaded down and cost the Astros their 5th round pick too), possible grievances, possible lawsuits, all sorts of NCAA eligibility concerns, and a whole big black-mark for the Astros organization.  All over $1.5M.  Remember; this is the same team that gave $30M last off-season to 5th starter Scott Feldman.
• There was a two hour special on the injury on MLB Radio Networks on 7/17/14 that I hope they replay or transcribe to the internet.
• Bud Selig still awaits the Tommy John study in Mid July 2014.  If its anything like his other blue-ribbon panels, he’ll be waiting a long time.
• Discussion about youths with UCL/TJ injuries in USA Today on 7/23/14.
• Study from USA Today on how prep pitchers are avoiding TJ.
• MLB unveils “Pitch Smart” guide in Mid November to help youth’s understand workloads.  Also discussed by Jeff Passan.

Hope you’ve found this trove of TJ links as interesting as I have.

Jose Fernandez is (arguably) the biggest name to go down to TJ surgery yet. Photo via thestar.com

Its the biggest story in baseball so far in 2014.   We’ve had nearly 20 MLB pitchers get diagnosed with torn elbow ligaments so far this calendar year.  All of them have or are set to undergo “Tommy John” surgery (also known as ulnar collateral ligament/UCL replacement surgery).  That’s nearly as many as who got the surgery ALL of 2013 and we’re just 6 weeks into the season.  There’s an alarming trend upwards over just the past few seasons of pitchers getting this surgery.  There’s been plenty more minor leaguers (two Nats farmhands in Erik Davis and Danny Rosenbaum have already gotten it in 2014) and already a couple of very high-profile draft prospects as well (including as discussed in this space potential 1st rounders Jeff Hoffman and Erick Fedde just in the last week).

Lots of people are talking about this story, especially some heavy-weights in the baseball world.  A sampling:

• Dr. James Andrews, perhaps the most famous sports doctor in the world, attributes the growing trend to the rise in year-round baseball competition in the US.
• SI.com’s Jay Jaffe reviews Dr. Andrews comments and had other excellent stats about the trend in this April 2014 piece.
• The Washington Post’s Dave Sheinin did an excellent piece in the paper a few weeks ago about the injury, which he attributes to youth usage.
• Tom Verducci (he of the “Verducci effect”) proposed a solution in a column this week after the Jose Fernandez announcement.  His idea?  Lowering the mound across all levels of the sport.  He draws this conclusion after hosting a very interesting round-table on MLB Network.
• Jayson Stark teamed up with ESPN injury analyst Stephania Bell and former player Alex Cora to discuss the rise in arm injuries in this ESPN.com video, and they follow Andrews’ theory of year-round pitching.
• Chris O’Leary, king of the Inverted-W (whether you believe his theories or not, I’ve included this link here) has his own theories as discussed here.  He doesn’t really have much in the way of explanation, just more whining about how every pitcher’s mechanics has something you can complain about.
• Jeff Passan basically calls out baseball executives for not having any answers.
• If you want an index of all of ESPN.com’s stories on the topic, click here.  It will have columns, analysis and press releases for individuals getting the surgery.

Some interesting stats about Tommy John surgery:

• Per a Will Carroll 2013 study, roughly 1/3 of current MLB pitchers in the majors have had the surgery.
• Per a study by the American Journal of Sports Medicine, of those pitchers who have the surgery, about 83% make it back to the majors and 97% returned to pro pitching.  Only five of 179 pitchers in the study failed to return to their craft.
• The number of pitchers getting TJ surgery has risen dramatically in just the past few years, from a couple dozen in the early part of last decade to nearly 70 a couple of years ago.

So what the heck is going on??  Lets talk about some theories.  I’ll highlight them in Blue.

The new “hot theory” is essentially this: Over-throwing at Showcase events, which have become crucial scouting events for kids raised in the United States, are to blame.  Thanks to the rise in travel leagues and select teams, scouts spend less time sitting at high school games and more time at these all-star events.  To prescribers of this theory, it isn’t so much about the amount of innings or pitches that kids throw … its the nature of the “showcase” events and the high pressure situations that those events put kids under.  Kids are throwing year-round, and they’re ramping up max-effort pitches at national competitions multiple times per year, and in some cases out of “season.”  This leads to serious damage to kids’ arms done as 16 and 17 yr olds, which then manifests itself over the years and results in blown ligaments in pro ball.

Do you buy this explanation?  It certainly makes sense to me, but how do you prove this?  And, it doesn’t explain the similar rise in elbow injuries to non-American pitchers.

Is it less about the showcase events and more about the Larger Increase in Youth pitched innings thanks to the rise in Travel Leagues?   This theory also makes some sense to me: thirty years ago kids played an 18-20 game spring Little League season, at best would pitch half those games and that was it.  Maybe they played in the fall too, but there were specific innings limits in place that protected kids.  Now instead of playing limited spring and fall seasons, kids are playing AAU travel teams that play 40-50 games a summer, plus weekend tournaments, plus (eventually) the above showcase events as they get closer to matriculation.  This theory certainly is supported by a startling rise in youth arm injuries, as noted in this 2010 study by the American Academy of Orthopaedic Surgeons.

But, if its “bad” to play more baseball … then shouldn’t we be seeing even MORE injuries from players who grew up in third-world baseball hot beds like the Dominican Republic or Venezuela, where by all accounts kids play baseball from sun-up to sun-down 12 months out of the year in tropical climates?

Interestingly, of the list of 19 MLB players so far who have been diagnosed with a torn UCL (see next section), there’s 4 non-American developed pitchers (Rondo, Nova, Figueora, Cisnero).  4 of 19 = 21%, whereas about 22% of MLB pitchers are non-American developed (my 22% figure comes from this quick study that I did; I grabbed every active MLB pitcher as of early May 2014 and did a quick-and-dirty player upbringing analysis to determine that about 78% of players “grew up” in the current American system of player development).  It is small sample size … but the percentage of american versus foreign developed players are so far exactly in line with the total percentage of each type of player in the larger pool of MLB pitchers.  This doesn’t seem to support either of the two above theories.

We’ve all heard horror stories about pitch counts and pitcher abuse at  high school events in Japan (this came to light over the winter as we looked at Masahiro Tanaka and learned about these Japanese showcase events; this article here at thebiglead.com talks about one Japanese prospect’s 772 pitches thrown over 9 days, and Jeff Passan talked about Tanaka’s own pitch count abuse stories and his average pitch counts as a Japanese-league pro).   Unfortunately there’s not a ton of data available about this TJ theory and Japanese pitchers.  I can find a couple of instances of Asian pitchers getting the surgery (Kyuji Fujikawa in 2012 being the most recent example), but not enough to establish any trends.

But lets state it this way: you can’t have things both ways.  Both these stereotypes about player upbringing cannot be true:

• Latin American poor youth plays baseball from sun up to sun down 12 months a year, building arm strength constantly, therefore his arm is “stronger” and he’s less suceptible to injury
• American little leaguer plays limited schedules (18 games in the spring, perhaps fewer in the fall), has closely monitored pitch counts, therefore does not abuse his arm as a youth and thus his arm is “stronger” later in life as a result.

Here’s a list of the 19 MLB pitchers who have already gone under the TJ knife so far in 2014 (data from baseballheatmaps.com, which has detailed Disabled List data).

• Jose Cisnero: diagnosed 5/14/14.
• Jose Fernandez: diagnosed 5/13/14.  Wow, biggest name to fall yet.
• AJ Griffin: getting the surgery 4/27/14
• Pedro Figueroa: diagnosed 4/24/14 (his 2nd, first in 2010)
• Ivan Nova: diagnosed 4/25/14
• Josh Johnson: diagnosed/announced 4/23/14, surgery 4/24/14.  His 2nd (first in 2007).
• Matt Moore: surgery 4/22/14
• Cory Gearrin: diagnosed 4/8/14
• Bobby Parnell: diagnosed 4/2/14
• Erik Davis: diagnosed 4/2/14
• David Hernandez: diagnosed 3/31/14
• Peter Moylan: diagnosed 3/22/14 (his 2nd)
• Bruce Rondon: diagnosed 3/21/14
• Patrick Corbin: diagnosed 3/17/14
• Jarrod Parker: diagnosed 3/17/14. (his 2nd)
• Brandon Beachy: diagnosed 3/17/14 (his 2nd)
• Kris Medlen: diagnosed 3/9/14. (his 2nd)
• Luke Hochevar: announced 3/7/14
• Cory Luebke: surgery in 2/4/14 (his 2nd)

Of these 19 pitchers, they are evenly split between being starters (10) and relievers (9).  So that doesn’t seem to lend itself to any Starter vs Reliever usage conclusion.

How about Pitching Mechanics?  We’ve all heard ad-naseum about the “Inverted W” and people talking about pronation and timing and elbow lift and etc etc.  Here’s a quick attempt to analyize the mechanics of each of these 19 guys (all photos grabbed as thumbnails from google images for the purposes of demonstration; no copyright infringement intended).

Quick and Dirty Mechanics analysis (images in same order as list of pitchers above, which is choronological in order of diagnosis in 2014):

• Inverted W: Griffin, Nova, Gearrin, Beachy, Hochevar
• Sideways M: Fernandez, Johnson, Davis, Moylan, Rondon, Parker, Medlen
• Inverted L: Cisnero, Figueroa, Moore, Parnell, Hernandez, Corbin, Luebke

But I’ll immediately add a caveat to these classifications; at various stop-points in a guy’s delivery, he may exhibit “good” or “bad” trends.   Maybe some of these “sideways-M” guys are actually “inverted-W” guys.  Maybe some of these inverted-W guys are ok and the stills make their mechanics seem worse than they are.

Nonetheless; there’s no trend among the 19 guys in terms of their mechanics.  In some cases they’re “bad” (Griffin and Gearrin’s look awful) but in some cases excellent (nobody should look at Moore’s mechanics and say they’re anything but clean, nor with Parnell or Corbin).  These pitchers are overhanders, 3/4-slot guys and even side-armers/submarine guys (Gearrin and Moylan).   These guys include hard throwers (Rondon had the 3rd highest velocity of *any* pitcher in 2013) and softer-throwing guys (Medlen had one of the lowest fastball velocities in the majors in 2013).  There’s starters and relievers almost equally represented in this list.

Conclusion; there’s no conclusions to draw from pitching mechanics analysis.  I think all attempts to look at guys’ mechanics and make judgements are useless.  I think (as does Keith Law and other pundits in the field) that the “Inverted W” is nonesense and that “research” posted online by concerned-fathers-turned-self-appointed-mechanics-experts is not exactly trustworthy.  The fact of the matter is this: throwing a baseball over and over is hard on the body.  Throwing a ball is an unnatural motion, and throwing a ball at max-effort will eventually lead to pitching injuries, no matter what your mechanics.  They can be “good” or “bad” according to someone’s pet theory on bio-mechanics and it has nothing to do about whether a pitcher is going to throw 10 seasons without injury or have two tommy johns before they’re 25.

Some historical context for pitching mechanics arguments: the pitcher who has the 2nd most innings thrown in the non-knuckleballer modern era (behind Nolan Ryan) was Don Sutton.  Sutton displayed absolutely *classic* inverted-W mechanics, never hit the D/L in his career and threw nearly 5,300 innings over the course of 23 seasons.   Walter Johnson‘s mechanics were awful; he slung the ball sideways as he literally pushed backwards away from the hitter at the end of his delivery.  If someone saw Johnson’s mechanics today they’d talk about how over-compensated he was on his shoulder and how he lost velocity thanks to landing stiff and having zero follow through.  Johnson only threw 5,900 innings in his pro career; yeah those mechanics really held him back.  Nolan Ryan was a freak of nature, throwing at that velocity for as long as he did.  The point?  You just don’t know.

Maybe there’s something to the “showcase abuse” theory for some players.   Maybe there’s something to the travel-ball overuse theory for some kids.  But I think the answer may be a bit more simple.  We all know there’s been a rise in the average MPH of fastballs in the majors, both on starters and especially with relievers.  My theory is simply this: kids who “can” throw upper 90s spend all their time trying to throw upper 90s/max effort fastballs 100% of the time, and human arms just cannot withstand that kind of abuse over and over.  In prior generations, kids who “could” throw that hard wouldn’t, or would rarely try to throw that hard, and thus suffered fewer elbow injuries.

Side note: I also firmly believe that we’re “victims of our own success” to a certain extent with respect to modern medicine; 30 years ago would someone have just “blown out their arm” instead of being diagnosed specifically with a “torn ulnar collateral ligament?”  Would some kid in the low minors who hurt his harm even bother to get an MRI?  How much of the rise in these injuries is simply the fact that we’re better at diagnosing injuries in the modern sports world?

Why are these kids trying to throw so hard these days?  Because velocity is king, and that’s what scouts look for.   A kid who “only” throws mid 80s as a 17-yr old is dismissed, while the kid who can throw mid 90s at the same age is fawned over.   Guys like Greg Maddox, Mark Buehrle, and Tom Glavine probably don’t even get drafted in the modern baseball climate thanks to the over-focus on pure velocity.

You can talk about upbringing and showcase events and pitch counts and mechanics all you want, but I think it comes down to Pitcher over-exertion thanks to the rising trend of fastball velocity and the human nature urge of prospects and farm-hands to show more and more velocity so they can advance their careers.

What do you guys think?  Do you dismiss the “inverted-W” arguments like I do?  Do you think its all about showcase events?