Tommy John Surgery: The Epidemic

His career ended when he walked away from the game at age 30. Winner of the Cy Young Award in three of his final four seasons, some regard him as the greatest left-hander in the history of the game. If only Tommy John surgery had been available to Sandy Koufax, perhaps there would be no debate about who the best lefty ever was... 

Thanks to the surgery pioneered by Dr. Frank Jobe on hurler Tommy John - hence the name of the procedure - scores of pitchers have been able to extend their careers long past the point that could have been expected for the overwhelming history of the game of baseball. Dr. Jobe found a way to harvest a tendon from another part of the body, transplant it in the elbow and relocate the ulnar nerve to allow pitchers to resume their careers. Whereas the odds of a return were at one point miniscule, upwards of 80-85 percent of players who undergo Tommy John surgery are able to resume their professional careers. Thanks to the procedure, ball fields are littered with arms that went under the knife to repair their elbow. A short sampling of those hurlers would include Adam Wainwright, Jordan Zimmermann and Stephen Strasburg. Not limited to just the realm of pitchers, hitters such as Shin-Soo Choo and Matt Wieters have undergone the procedure. Some players have even had the procedure done twice—Jarrod Parker, Kris Medlen, Joakim Soria and Brian Wilson come to mind—showing the power of modern medicine. 

In what follows, we will look at the surgery, the path to recovery, the number of hurlers who are undergoing the procedure and the performance of pitchers once they return to the bump.

WHAT CAUSES THE INJURY THAT LEADS TO SURGERY?

There is no definitively established reason as to why some players end up needing the surgery while others do not. Some possibilities that can be considered would include (a) the physical structure of the player, (b) throwing mechanics, (c) wear and tear, i.e. heavy or long term usage, (d) extreme exertion while throwing, i.e. throwing at 100 percent, (e) throwing too many pitchers at a young age, (f) year round training and throwing. All of these factors likely have some bearing on whether or not a player ends up having to make an appointment at the hospital.

Noted surgeon Dr. James Andrews had this to say last April to MLB Network Radio. He has noticed a trend toward ever younger arms needing the surgery, with pitchers in high school inundating him with surgical requests. His guess is that hurlers are so big and strong, and throw with such velocity while young, that they simply overpower the elbow ligament (if they throw over 85 mph, they are especially at risk). He sees the biggest risk factor as year-round baseball with no time for recovery. This is especially true for youngsters. 

Some athletes believe that the procedure should just be done either (a) because they fear it will eventually be required or (b) because they believe they will be able to throw harder when they return. No doctor would perform an unnecessary procedure. There's also always the possibility that the surgery doesn't work. Just ask Ryan Madson. Second, and this is one of the biggest misnomers about the procedure, it does not directly lead to an increase in velocity. “But Ray, guys throw harder after the procedure.” The most likely reason for this is overall conditioning. Pitchers are diligently trained through the process as they strengthen all parts of their bodies. Something can be said for the new ligament helping the arm to be stronger, but it's most likely any increased velocity is the result of overall physical training. 

THE SURGERY

When the ulnar collateral ligament is damaged, Tommy John surgery is often indicated to resolve the issue. A tendon is most frequently harvested from the wrist, but there are times when the tendon is taken from the forearm, hip or hamstring of the patient. In rare instances, the tendon is taken from a cadaver. 

The operation is a simple procedure that can take anywhere from an hour to an hour and a half. The surgeon drills two holes in the ulna and humerus. A graft of the tendon is passed through the holes and weaved into a figure eight pattern. The ulnar nerve is often relocated so as to avoid any irritation in the future.

THE PATH TO RECOVERY

The recovery period continues to recede as medical procedures and training regimens improve (there is a widely accepted, almost codified recovery plan that results in a return to throwing off the mound somewhere in the 8-10 month time frame). Generally speaking, athletes can return in under a year, but for pitchers it's best to guesstimate 12-18 months for a return to action, though it often takes up to two full years before the arm fully responds. 

THE INCREASING VOLUME OF PROCEDURES

According to Jon Roegele (@MLBPlayerAnalys) as of mid-December 2014, there had been 92 recorded Tommy John surgeries in the majors and minors in 2014. How does that number stack up to recent years? Let's take a look at his database. 

2005: 49
2006: 47
2007: 58
2008: 41
2009: 57
2010: 63
2011: 50
2012: 87
2013: 63
2014: 92

Some salient facts.

(1) Over the last 10 years, there have been between 41 and 92 Tommy John procedures per season, a pretty massive spread.

(2) The average number of procedures per year over the last decade is 60.7.

(3) The average number of procedures the last three years has climbed to 81. 

(4) The only two years that included more than 65 procedures in a calendar year over the last decade have occurred in two of the past three years. Both of those efforts are over 85, a massive jump from the recent past. 

UNDERWENT THE PROCEDURE IN 2013

The following players of note underwent Tommy John surgery in 2013. Listed is the date of their procedure. Remember, it usually takes 12-18 months of time before a hurler is ready to perform up to the point that a team will trust him with significant innings.

            * Hitters in bold.

Which of these 2013 arms did anything in 2014? Yep, none of them did anything fantasy worthy. 

UNDERWENT THE PROCEDURE IN 2014

The following players of note underwent Tommy John surgery in 2014. Listed is the date of their procedure.

            * Hitters in bold.

Check the previous section real quick. None of the 2013 options did anything to note in 2014. Does that mean this list of '14 arms won't do anything in 2015? The most likely outcome is that all of them will struggle to offer anything of substance until the second half of the 2015 season (hitters excluded). 

PERFORMANCE IN YEAR ONE AFTER SURGERY

The case of Kris Medlen is instructive. 

Medlen had his first Tommy John surgery in August of 2010. 
In 2011, he pitched 2.1 professional innings.
In 2012, he threw a total of 151.1 innings between Triple-A and the majors. 

Here's how his 2012 effort broke down. Medlen made 38 appearances out of the bullpen and only 15 starts on the year. What the Braves did was to bring him along very slowly. Medlen began the year in the bullpen and didn't make his first big league start until the 31st of July, some 23 months after his surgery. Will teams use their returning arms in the same manner, easing them into things, or will they throw them back into the fire as starting pitchers if that is their long-term role?

What follows is a random sampling of the first year of performance from hurlers who made their way back from Tommy John surgery.

Danny Duffy (Date of Surgery: 6-13-2012)

In 2013, he threw a total of 99.1 innings with a 4.04 ERA and 1.39 WHIP in the minors before making five successful starts with the Royals. It wasn't until 2014 that he regained his velocity, and form, two years after the procedure.

John Lackey (Date of Surgery: 11-1-2011)

He didn't throw a big league pitch in 2012. In 2013 he was a new man with a 3.52 ERA after posting a mark of 5.26 in the two years before he hurt his arm (2010-11). Note that the 2013 season started 17 months after be went under the knife. 

Adam Wainwright (Date of Surgery: 2-28-2011)

Threw an impressive 198.2 innings, but with a 3.94 ERA and 1.25 WHIP in 2012. The ERA was the worst of his career and the WHIP was a six year worst. Also walked 2.36 batters per nine. The mark has been under 2.00 the last two seasons. 

(Date of Surgery: 9-3-2010)

He threw 44.1 innings in 2011 making a quick return to the mound. In 2012, 19 months removed from surgery on Opening Day, Strasburg threw 183 innings and performed well with a 3.00 ERA and 1.05 WHIP, right on his career marks of 3.02 and 1.09. His K/9 rate was down a full batter from his career mark, however, and his BB/9 rate was a career worst, albeit by a small margin. 

Joe Nathan (Date of Surgery: 3-26-2010)

After seven years of at least 67 innings pitched, Nathan returned to throw 44.2 in 2011. He was wildly ineffective with a 4.84 ERA and 8.66 K/9 mark. His career marks are 2.89 and 9.48. He rebounded to excel in 2012 with a 2.80 ERA, 1.06 WHIP, 10.91 K/9 and 37 saves.

Jordan Zimmermann (Date of Surgery: 8-19-2009)

Jordan threw 39.2 innings in the minors and 31 innings in the bigs in 2010. Let's just say he didn't impress with a 4.94 ERA, 1.32 WHIP and 2.70 K/BB ratio. His career marks are 3.24, 1.15 and 4.06. 

Tim Hudson (Date of Surgery: 8-8-2008)

Threw 23.1 innings in the minors and then 42.1 in the big leagues in 2009. In 2010, nearly two years removed from the surgery, he was back to his old self, going 17-9 with a 2.83 ERA and 1.15 WHIP. 

Shin-Soo Choo (Date of Surgery: 9-25-2007)

Was limited to a total of 106 games in 2008 but he performed exceedingly well at the big league level, with a .309/.397/.549 slash line over 94 games.

Josh Johnson (Date of Surgery: 8-3-2007)

He tossed 116.2 innings in 2008 with 87.1 coming at the big league level. Though his K/9 was a five year low (2007-2011) and his BB/9 was a three year high (2008-2010). He was still an effective hurler with a 3.61 ERA and 1.35 WHIP, though the WHIP was a five-year high (2008-2012). He's had the surgery twice.

Chris Carpenter (Date of Surgery: 7-24-2007)

He only tossed 15.1 big league innings after throwing 9.2 innings in the minors. In 2009, he was back to full strength, throwing 192.2 innings and going 17-4 with a 2.24 ERA, but it took the second year after the surgery for him to get "it" back.

Francisco Liriano (Date of Surgery: 11-6-2006)

He didn't throw a professional pitch in 2007. In 2008, he tossed 123.1 minor league innings and 76 big league frames. Oddly, that total of 199.1 innings is the most he has ever thrown in a season. His performance wasn't very impressive though with a 3.91 ERA, 1.39 WHIP and 7.93 K/9 mark (career 9.16). 

PLAYERS TO WATCH IN 2014

Remember, it takes at least 10 months for these guys to return to action and 12-18 is a nice area to place your expectations in for a return to prominence, though as we have seen, it can often take upwards of 24 months or a full season of work after the procedure to recapture past glory. History strongly suggests that any pitcher who had the surgery in the 2014 calendar year will struggle to live up to expectations in 2015.

Tyler Skaggs (Date of Surgery: 8-13-2014)

It would be shocking if he did anything other than make a couple of late-season appearances.

Bronson Arroyo (Date of Surgery: 7-15-2014)

Given his age (38 in February), it's likely he will struggle to have any positive outings in 2015.

Matt Wieters (Date of Surgery: 6-17-2014)

Hitters can obviously return much quicker than pitchers, but Wieters has the disadvantage of playing catcher. It's likely he will be spending some time at first base or DH early on as he continues to build arm strength. 

Martin Perez (Date of Surgery: 5-19-2014)

The hope is that he will be ready to return around the All-Star break. Perez owns a career 4.13 ERA, 1.39 WHIP and 6.07 K/9 so you shouldn't be wasting your time on him in 2015.

Jose Fernandez (Date of Surgery: 5-16-2014)

A best-case scenario would likely see Fernandez back in June or July, making him very difficult to draft in mixed leagues. Realize that he's never thrown 175 innings in a a season and would be only 14 months removed from surgery in July. He's a huge risk at the draft table. 

A.J. Griffin (Date of Surgery: 4-30-2014)

Doesn't depend on velocity but location for success. Given that many hurlers struggle with control early in their return from surgery... pass. 

Ivan Nova (Date of Surgery: 4-29-2014)

Could return to the starting ranks in the first half, but will he have all the sink he needs to be effective right away?

Matt Moore (Date of Surgery: 4-22-2014)

His best pitch is that curve ball and the curve certainly puts more strain on the elbow than the heater. Can't count on anything from him until the second half. 

Bobby Parnell (Date of Surgery: 4-8-2014)

Being a reliever, his path to a return is likely to be much shorter than starting arms. Not likely to have a roll of significance in 2015, though. 

Patrick Corbin (Date of Surgery: 3-25-2014)

Won 14 games with a 3.43 ERA and 1.17 WHIP in 2013. He didn't throw a professional pitch in 2014, leaving his 2015 outlook muddled.

Jarrod Parker (Date of Surgery: 3-24-2014)

Parker also had Tommy John surgery back on the 28th of October in 2009. Given that fact, it would be wise to proceed with extreme caution with the righty. 

Brandon Beachy (Date of Surgery: 3-21-2014)

Like his former Braves' teammate Medlen, Mr. Beachy had his second Tommy John operation last year. Just a year removed from surgery at the start of the 2015 season, it would be wise to only look at Beachy as a league-specific option on draft day.

Miguel Sano (Date of Surgery: 3-12-2014) 

The 21-year-old should make an appearance in the big leagues in 2015, though it might be very late in the year. The term "prodigious power" was invented to speak to players with Sano's ability to send the pelota into the stratosphere. 

Matt Harvey (Date of Surgery: 10-22-2013)

The dumbest thing I've ever heard was the idea that Harvey was going to pitch at the end of the 2014 season for a sad sack Mets club. Let's just say I'm pleased that they showed that they acted like they had an IQ over 85 and held out their franchise arm. It's not reasonable to expect Harvey to throw more than 180-innings in his first season back and it's unclear how the Mets will limit his workload, though they have announced that they plan on him opening the season in the rotation. He could skip a couple of starts here and there or have his starts cut short in terms of innings or pitches. Don't expect an ace in 2015.

Dylan Bundy (Date of Surgery: 6-27-2013)

Still one of the best pitching prospects in baseball, Bundy has been a top-10 prospect in each of the last three years. He should be ready to contribute early on and will be two years removed from surgery by mid-season. Watch the early reports on his velocity, as he was having a hard time hitting 90 mph consistently at the end of last season after thrown 41.1 innings in the minors.