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Could a 2-inch ligament stand between Rays and a possible World Series?

The rate of Tommy John surgeries is skyrocketing in baseball, and no AL team has suffered as much as Tampa Bay when it comes to elbow problems.
 
Rays starting pitcher Jeffrey Springs looks at his hand before leaving an April 13 game in the fourth inning against the Red Sox. He was lost for the season after it was determined he would need Tommy John surgery.
Rays starting pitcher Jeffrey Springs looks at his hand before leaving an April 13 game in the fourth inning against the Red Sox. He was lost for the season after it was determined he would need Tommy John surgery. [ IVY CEBALLO | Times ]
Published June 30, 2023

ST. PETERSBURG — In books and on Broadway, the desperate ballplayer is forever willing to make a deal with the devil in exchange for on-field glory. This is fantasy, of course. In the real world, every pitcher knows the most reliable path to riches is to make a deal with the surgeon.

As we near the 50th anniversary of the most consequential medical procedure in all of sports, Tommy John surgery is more relevant than ever as a safety net for pitchers who are constantly pushing their arms to unnatural extremes.

In what would seem to be a cruel and counterintuitive twist of fate, cutting-edge technology isn’t keeping pitchers safer in the 21st century. Instead, it has seemingly put them more at risk. With advanced biomechanics and high-speed video teaching pitchers to throw harder and push the anatomical envelope, elbows are blowing out at an increasingly rapid pace.

And no one should understand that better than a Tampa Bay Rays fan.

In the past three calendar years, the Rays have had an alarming number of well-known pitchers succumb to the surgery, and you could make a case that Tampa Bay’s hopes in the 2020 World Series were dashed by a late-season elbow injury. No American League team has had as many Tommy John procedures that, depending on the timing, will wipe out at least one and sometimes significant parts of two seasons.

Rays catcher Michael Perez looks on as relief pitcher Jalen Beeks is looked at after an injury sustained against the Orioles at Tropicana Field on Aug. 25, 2020. Beeks was one of three Rays pitchers who ended up in surgery that season.
Rays catcher Michael Perez looks on as relief pitcher Jalen Beeks is looked at after an injury sustained against the Orioles at Tropicana Field on Aug. 25, 2020. Beeks was one of three Rays pitchers who ended up in surgery that season. [ DIRK SHADD | Times ]

The Rays have seen an ace (Tyler Glasnow) and a phenom (Shane Baz) go down. An All-Star reliever (Andrew Kittredge) and a breakthrough starter (Jeffrey Springs). In one particularly harsh stretch in the summer of 2020, they had three pitchers (Colin Poche, Yonny Chirinos and Jalen Beeks) land in the operating room in consecutive months.

“Conditioning, as well as mechanics, have been optimized to get maximum fastball velocity,” said Glenn Fleisig, a longtime consultant for Major League Baseball and the research director at the American Sports Medicine Institute in Birmingham. “The muscles can do it, the bones can do it, but the ligaments and tendons in the elbow and shoulder are getting pushed beyond what they can handle.”

Before Game 3 of the 2008 World Series, Fox Sports TV analysts raved about Rays starter Matt Garza being a “power pitcher.” And when he threw the only no-hitter in Tampa Bay history a couple of years later, Garza’s fastball averaged a formidable 93.6 mph.

That fastball would be below the league average in 2023.

‘Weakest link along the chain’

There have been a handful of memorable, wondrous nights this season when the Rays have looked unstoppable. As if walls can’t contain them, and opponents don’t frighten them. A deliciously diverse group of ballplayers built for both the grind of the regular season and the intensity of the playoffs.

On nights when Yandy Diaz is ripping, Shane McClanahan is dealing and fans in Randy Land are shouting, it can seem as if every hazard has been considered and every pitfall addressed.

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Except, maybe, for a 2-inch ligament in the wrong pitcher’s elbow that could wipe out everything.

The ulnar collateral ligament is every pitcher’s kryptonite and every team’s worst nightmare. It is a triangular band of tissue that connects the upper bone (the humerus) in your arm with a lower bone (the ulna) in the forearm.

“That ligament ends up being the weakest link along the chain, right?” said Rays reliever Pete Fairbanks, 29, who had Tommy John surgery as a high school junior and then again as a Rangers minor-leaguer in 2017. “It’s just the nature of throwing a ton of pitches and the stress that gets put on the arm. That little thing that holds your elbow together is bound to go.”

Everyone remembers Game 6 of the 2020 World Series as the night Rays manager Kevin Cash removed Blake Snell with a 1-0 lead on the Dodgers in the sixth inning. What many don’t recall is that he was replaced by Nick Anderson, who had been as electric as any reliever in the game the previous 14 months. But that October, Anderson bore little resemblance to his once-dominant self. He blew the save, the Rays lost the Series and, a short time later, it was discovered Anderson had a partially torn elbow ligament that would wipe out his 2021 season.

After reliever Nick Anderson pitched, and blew a save, in Game 6 of the 2020 World Series against the Dodgers, his elbow issue was discovered.
After reliever Nick Anderson pitched, and blew a save, in Game 6 of the 2020 World Series against the Dodgers, his elbow issue was discovered. [ DIRK SHADD | Times ]

Prior to 1974, nobody fretted about the ulnar collateral ligament because tears usually went undiagnosed in the days before the MRI was invented. Pitchers were said to have sore arms or tired arms or, in the infamous case of Sandy Koufax, traumatic osteoarthritis. Pitchers would use ice, heat and painkillers to combat the loss of velocity or bite on their pitches. And when that didn’t work, they just faded away to become salesmen or civil servants.

Surgery wasn’t an option because inspiration had yet to catch up with technology. It took a former World War II medic who returned home and went to college on the G.I. Bill before becoming a team physician for the Los Angeles Dodgers to envision the possibilities. Doctors had recently begun using a largely useless muscle in the wrist as a replacement tendon for patients with hand injuries, which led Dr. Frank Jobe to ponder whether the palmaris longus tendon could be a substitute for the ulnar collateral ligament.

So when Dodgers ace Tommy John ruptured the ligament at age 31 in July of 1974, Jobe offered reconstructive elbow surgery as a longshot alternative to early retirement. In his exquisitely researched book “The Arm,” author Jeff Passan said Jobe did not want to give John false hope and told him there was a 1% chance the surgery would work. In reality, Jobe believed there was a 90% chance of success.

John had surgery in September of 1974, missed the entire following season, and returned as a 33-year-old in 1976. He would go on to make three of his four All-Star appearances and garner Cy Young Award votes in four consecutive seasons in his post-surgery career.

Jobe’s initial optimism turned out to be fairly accurate. Current estimates suggest roughly 80% of Tommy John patients resume their careers with similar levels of success. And considering the number of patients, the surgery is not just career-saving; it is game-changing.

Dodgers left-hander Tommy John, whom the infamous elbow surgery is named for, delivers a pitch against the Braves during an opening day game in Dodgers Stadium.
Dodgers left-hander Tommy John, whom the infamous elbow surgery is named for, delivers a pitch against the Braves during an opening day game in Dodgers Stadium. [ AP (1978) ]

Including players on the injured list, the Rays had 20 pitchers with lockers in the Tropicana Field clubhouse earlier this month. Those 20 had a combined 13 Tommy John surgeries between them, including a handful who have had it twice.

Since the most accurate predictor of future ligament problems is a past Tommy John surgery, the Rays are aiming for the 2023 World Series from a particularly vulnerable position. Glasnow, McClanahan and Drew Rasmussen all have had the surgery. Fairbanks, Poche, Kittredge, Chirinos and Beeks, too. It’s a roulette wheel of risk, and everyone is hoping their number isn’t called.

“This is not a mystery. And these guys are realists,” said former New York Mets team physician Dr. Joshua Dines, who has coauthored medical journal reports on elbow ligament injuries. “I don’t think anyone goes into this wanting to have surgery, but they all have friends and colleagues they’ve seen get hurt very frequently. So it’s not a surprise when it does happen to them. And with the treatment available, just because somebody gets injured, it doesn’t mean their career is over.

“It’s the rare — very, very, very rare — pitcher at this point who goes through an entire career without being injured or disabled.”

In recent years, observers have estimated that 25% of MLB pitchers have had Tommy John surgery. That number appears to be woefully low.

On June 28, we compared the 26-man active roster and 15-day and 60-day injured lists for every major-league team against a Tommy John database meticulously created and updated by baseball writer Jon Roegele. With more than 570 pitchers accruing major-league service time on that day, 39.7% had undergone Tommy John surgery at some point in their careers.

It is not an exaggeration to say the procedure has changed the trajectory of baseball by giving more than 2,000 pitchers since 1974 a shot at resuming their careers.

It also has served as a quasi-catastrophic insurance policy allowing pitchers to push their bodies to even greater extremes.

Leading the league in surgical scars

In early June, when the Rays acquired Pittsburgh reliever Robert Stephenson and his unsightly 5.14 earned run average, some fan caustically suggested on a message board that Stephenson’s ERA would be down to a sparkling 1.50 by August. And he would be on the injured list by September.

This is not an uncommon perception.

The Rays are notorious, and justifiably envied, for finding nondescript pitchers and turning them into quality relievers and starters in rapid fashion. But Tampa Bay’s growing list of injured hurlers has raised eyebrows around the game.

Is there a connection between the Rays’ success and their crowded injured list?

If there is, the evidence is only circumstantial. Players in Tampa Bay’s clubhouse are adamant that the team’s training and coaching staff are among the best in the game. And if the improvements pitchers have made to their repertoire while in Tampa Bay have somehow contributed to injuries, it is a price they are willing to pay. And a choice that each of them has made willingly.

Colin Poche throws during a team scrimmage on July 16, 2020. Five days later he was diagnosed with a torn ligament in his elbow.
Colin Poche throws during a team scrimmage on July 16, 2020. Five days later he was diagnosed with a torn ligament in his elbow. [ MIKE CARLSON | AP (2020) ]

“If you can throw a slider at 92 mph, it’s probably the best pitch in baseball,” said left-hander Colin Poche, 29, who had his first Tommy John surgery going into his sophomore season at Arkansas in 2014 and then again with the Rays in 2020. “It’s weighing that risk/reward. Maybe I got hurt trying to throw hard, but if I don’t throw hard, I’m not going to be pitching in the big leagues.

“If you can pitch in the big leagues for five years, you’re talking about a winning lottery ticket. I think a lot of kids would say that’s worth the potential risk and they’re willing to sell out to increase their (velocity).”

Pitchers are not the only ones seeking to unlock the secrets of higher velocity and better spin rates on breaking pitches. Fleisig, who was a past chairman of USA Baseball’s Medical & Safety Advisory Committee, estimates that two-thirds of major-league teams now employ biomechanists to maximize player ability.

The Rays, naturally, were among the first teams to journey down that road.

Because their revenues are well below the league average, the Rays must outsmart their richer rivals in the American League East. That means searching for competitive advantages in underutilized concepts like biomechanics and analytics.

Erik Neander, the team’s president of baseball operations, is confident the Rays have done their best to keep pitchers healthy, almost to the point of being too conservative when it comes to workloads and usage. Still, he says, the team has been reevaluating pitching philosophies to look for better methods, which is not necessarily tied to the recent problem with elbow injuries.

“In any part of our organization, whether things are going well or not as well as we’d like, we are always asking whether there is something we can be doing better,” Neander said. “Is there something others are doing better than we are? Is there something else to be learned? These questions permeate all that we do.

“And these questions are not unique to this particular topic. That is a constant in our effort to be better tomorrow than we are today.”

Drew Rasmussen has had two Tommy John surgeries and is currently sidelined hoping to avoid a third.
Drew Rasmussen has had two Tommy John surgeries and is currently sidelined hoping to avoid a third. [ MARY ALTAFFER | AP ]

So how have the Rays fared when it comes to avoiding elbow ligament tears? Better than some, but not as well as most.

Ultimately, the answer depends on how you parse it. Roegele’s database includes surgeries for minor-leaguers, as well as active Major League Baseball rosters. If you look at the total number of procedures since 2020, the Rays are fifth overall with 15, but have far fewer surgical scars than the Padres (23), Mets (21) and Guardians (21).

If you limit it to players who are either on the 40-man roster or recently removed or added, however, the Rays are second to the Padres with eight Tommy John surgeries among their most valuable commodities in the past three years. That’s the most in the American League.

Yet none of those numbers seem alarming to players in the Rays clubhouse.

“The level of play on the field is higher than it’s ever been,” said Rays starter Drew Rasmussen, 27, who had two Tommy John surgeries before he came to Tampa Bay and is sidelined with a flexor strain that is dangerously near that ulnar collateral ligament. “As that continues to grow, something has got to give because it’s still the same human body. I mean, we can train to be stronger; we can train to move more efficiently. And now, with technology, we have the ability, through grips and finger placement, to change how we manipulate the baseball to make it move more and be thrown at a higher velocity.

“But the ligament itself is still the same, right? So as guys continue to perform at higher and higher and more elite levels, that’s the tradeoff. Everyone in this room knows that.”

Chasing velocity and courting danger

Andrew Kittredge had Tommy John surgery last season but appears to be closer to a return to form.
Andrew Kittredge had Tommy John surgery last season but appears to be closer to a return to form. [ IVY CEBALLO | Times (2022) ]

He pitched for a half-dozen minor-league teams across seven different seasons. That doesn’t include the summer he spent in the Cape Cod League, the winter in the Dominican League, the fall in the Arizona League or that stint with Adelaide in the Australian Baseball League.

Andrew Kittredge was 27 and nine years removed from being the 1,360th player selected in the 2008 draft by the time he made his major-league debut with the Rays in 2017. He had thrown countless pitches in wildly different environments for a variety of pitching coaches and managers and never once had an elbow problem.

It was while he was back at Triple-A Durham in 2019 that Bulls pitching coach Rick Knapp made a minor adjustment to Kittredge’s lower body mechanics that changed the course of the relief pitcher’s career. He was now throwing 94-95 mph consistently and, just as important, his arm felt great. No soreness, no weariness, no worries.

A year later, he was in the Dallas office of surgeon Dr. Keith Meister, discovering he had a tear in his ulnar collateral ligament.

There’s your smoking gun, right? A change in mechanics that led to increased velocity that led to a torn ligament.

Except, that’s not how it happened.

After cranking, turning and manipulating the elbow without any complaint of pain from Kittredge, Meister was convinced the tear had occurred years earlier. The problem Kittredge had encountered in 2020 was instead diagnosed as a flexor strain that could be treated with intense rehab.

“He told me, ‘If you give an MRI to every pitcher in the majors you’re going to find half of them have partial tears like this in their elbow,’ " Kittredge said.

The next summer, Kittredge made the American League All-Star team.

And the summer after that, he blew out the rest of his elbow and had Tommy John surgery. Just past the one-year anniversary of his surgery, Kittredge has resumed throwing and could rejoin the team in another month.

The point is there is no simple answer. No catch-all explanation. No two cases that are exactly alike. Sometimes, the injury is caused by an accumulation of wear and tear. Sometimes, it snaps on a single pitch. Sometimes, the doctor can’t give a definitive answer.

Twenty years ago, renowned orthopedic surgeon Dr. James Andrews strongly suggested pitchers be limited to around 100 pitches per outing to limit stress and prevent injuries. Most teams adhere to that arbitrary number, yet injuries continue to pile up. There have been white papers written that blame the epidemic of ligament tears on overuse by youth league players. Others say increased velocity definitely has caused surgeries to soar. Some say it is the quantity of max effort fastballs per outing. More recent theories are questioning long periods of rest in the offseason as a potential culprit.

Shane McClanahan throws a seven-pitch bullpen session under the watchful eye of pitching coach Kyle Snyder, left, on June 25. McClanahan ended his previous game after four innings with back tightness.
Shane McClanahan throws a seven-pitch bullpen session under the watchful eye of pitching coach Kyle Snyder, left, on June 25. McClanahan ended his previous game after four innings with back tightness. [ STEVE NESIUS | AP ]

“Regardless of what we know now versus what we knew 10 years ago, I don’t think anybody has an answer to why (increased surgeries are) happening,” Rays pitching coach Kyle Snyder said. “And anybody who tells you they do, I honestly wouldn’t believe them. There’s more that we don’t know than we do know, and that will probably still be the case 10 years from now.”

That doesn’t mean the baseball community will stop trying. Snyder says technology and modern indicators can help identify detailed changes in a pitcher’s mechanics in real-time on the mound, which can alert a manager of a potential injury about to occur. That is why Cash pulled Shane McClanahan from a start June 22 when the left-hander’s lower back pain was causing him to make slight adjustments to his delivery.

That is progress and that is promising. But it doesn’t change the reality that the human body was not meant to throw an object over and over again with maximum force and torque and speed.

NASCAR put restrictor plates on cars when excessive speeds on the biggest tracks put more and more lives in danger. The NFL has changed kickoff rules, helmet-to-helmet tackling and implemented equipment changes when it was discovered that repeated concussions were causing serious brain damage.

But an elbow ligament? That can be fixed in an operating room. And most pitchers, thus far, have been willing to risk that procedure when the tradeoff is more velocity, which begets more success, which translates to more money and fame.

“You want to help these guys take care of themselves and their families and have the best career possible and optimize themselves as pitchers. Well, some of what comes with them getting better is the chance of them getting hurt,” Snyder said. “My job sucks more often than it used to because of all these physical things. And I think every pitching coach in the game would tell you the same thing.”

John Romano can be reached at jromano@tampabay.com. Follow @romano_tbtimes.

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