Are the Mets mismanaging Matt Harvey?

— -- Matt Harvey returns from the ligament protection program on Sunday. And gee, it'll be great to see him, even if his pitch-count buzzer goes off in, say, the third inning.

But where he goes from here is one of those topics that matters to more than just the New York Mets, or the people who live and die with them and dream those wacky October dreams.

We know what the Mets are trying to do in an attempt to preserve this man's elbow. But is this what they should be doing? Running him out there for a bunch of tuneup mini-starts every five days?

This is a biggggg topic for another chunk of the population, too. To doctors and surgeons who perform Tommy John surgery for a living. To trainers. To the entire sports-medicine community. To people who have devoted their lives to trying to determine when pitchers are being abused.

So we thought we'd do something that's practically unheard of at a time like this. We're taking a step back from the hysteria to ask some actual experts whether the Mets are handling Matt Harvey correctly. We delved into questions like this:

? In an age that offers us so much information, aren't there better ways to measure pitcher abuse than good old-fashioned "innings"?

? Even if Harvey stays below the magical 180-inning threshold (he's at 171 2/3 innings now), can anyone be sure he'll stay healthy?

? Where are the scientific studies that tell us exactly how much a pitcher like this should or shouldn't be pitching, 23 months after his Tommy John surgery?

? Since trying to win a World Series is kind of a big deal, too, how should a team balance the importance of winning against the long-term health of its pitchers?

Their answers were fascinating and compelling. But before we start running through them, there's something you need to understand:

We'll never know.

We'll never know whether the Mets are doing the right thing or the wrong thing. And no matter what The Dark Knight does in his career from here on out, no matter how healthy Harvey stays (or not), we'll never know whether it all would have happened anyway. Sorry. Even medical science can't tell us that.

"No one absolutely knows," said Dr. Michael Ciccotti, the leader of MLB's elbow-study group, the head team physician for the Philadelphia Phillies and the director of sports medicine at the Rothman Institute in Philadelphia. "There's no crystal ball, unfortunately."

Yeah, that's unfortunate, all right. But since every crystal ball on earth is apparently on the fritz, let's ask some of the smartest people in baseball what they do know.

Why are we still focusing on innings?

We should begin by agreeing on this: If the goal is to protect Harvey, to keep him healthy for the next 15 years, that's a beautiful thing. We're glad we live in an age where teams actually try to do that. But here's a question that people in sports medicine ask all the time:

Are we sure that counting innings is really going to accomplish that?

"At this point, there is nothing in our scientific literature to guide us as far as innings pitched," said Dr. Christopher Mazoue, associate professor of the University of South Carolina's Department of Orthopedic Surgery, and a man who first began performing Tommy John surgery as a fellow under Dr. James Andrews.

"So that's one of the questions," Mazoue said. "What does 'innings pitched' mean? Innings can mean a lot of different things. A pitcher can have a very easy inning, where he throws 12 pitches. Or he can have a very difficult inning, where he's throwing 30 pitches an inning. So ... there really is nothing in our scientific literature to guide us, in terms of the difference between 150 innings and 180 innings, versus 230 innings. That's just not out there scientifically."

OK, everyone got that? We're talking about innings limits. And there's no scientific evidence behind them. Oh, there's definitely some logic behind them, which we'll get into later. But Rany Jazayerli, who first devised a system for pitcher abuse points for Baseball Prospectus in 1998, says he can no longer see even that logic. Not in the 21st century.

"I feel like innings are a terrible, terrible way of measuring pitcher abuse," Jazayerli said. "There's a much better way."

And what is that way? How about a more detailed look at those innings themselves, and perhaps how stressful they really were? So guess what: We did that for Matt Harvey. Here's what we found:

? ESPN's Stats & Info group defines a stressful inning as one in which a pitcher throws 30 pitches or more. Harvey has had only three of those innings all season. That's half as many as Noah Syndergaard and eight fewer than the MLB leader, Boston's Joe Kelly.

? Or we could look at Harvey's efficiency in general. Turns out he's about as efficient as it gets. He has averaged just 14.8 pitches per inning this season. Only seven qualifying starters in the whole sport average fewer than that.

? Jazayerli suggested looking at how often Harvey has had the stress of pitching with runners on base. So we did that, too. According to baseball-reference.com, a whopping 95 different pitchers have faced more hitters with men on base than he has.

? We also had multiple suggestions to look at the number of "high-leverage" situations Harvey has had to pitch in. We learned that, according to baseball-reference.com, Harvey has faced only 107 hitters in those situations. That's 62 fewer than Carlos Martinez, 51 fewer than Zack Greinke and 49 fewer than Dellin Betances, who isn't even a starting pitcher. FanGraphs ranks Harvey among the top 13 in the sport on its Leverage Index leaderboard.

So obviously, not all innings are created equal. And by any definition, Harvey's innings would appear to be less taxing than those of all but a handful of starters in the game. Why, then, is anyone still using his innings total to determine how much more he's physically able to pitch?

Well, here's where that old-fashioned "logic" comes in that we referred to earlier: Only because nobody has figured out a better way -- yet.

"As we make decisions like this, in territory that's a bit unchartered, we look back at the history of that pitcher," said Ciccotti, who works with both Andrews and Mets medical director David Altchek as part of the elbow-study group. "And we say, 'OK, how much did that pitcher pitch prior to the onset of their symptoms, in a way that was pain-free and effective?' So we kind of use [innings] as a barometer. That's an imprecise barometer, but it's about the most precise that we can be."

In other words, here's the deal: Harvey had never thrown more than 178 1/3 innings in his professional career (in 2013). So the goal this season was to keep him in that range again. Never mind that he threw 320 fewer pitches in 2013 than Bud Norris, who got five fewer outs than Harvey recorded. Never mind that there are technological advances like the Motus "mThrow" sleeve, which measures stress on the ulnar collateral ligament with every pitch thrown. 

For now, baseball is still counting innings. And that count hovers over Harvey's every move these days.

What does scientific research tell us?

One of the first questions we asked the people we spoke to was this:

Is there any scientific evidence that if a pitcher who has had Tommy John surgery throws more than a certain number of innings, he would need a second Tommy John surgery or it would cause any sort of lasting damage?

Pretty basic question, right? But shockingly, it's still one that medical science can't answer.

"We don't have substantive evidence," Ciccotti said, "that absolutely defines, or draws a line in the sand, and says that if you pitch over a certain number of innings, then you have a certain increased risk of incurring an ulnar collateral ligament tear, or re-tear."

Amazing, isn't it? Four decades after Tommy John himself underwent the first of these surgeries, neither Major League Baseball nor medical science has been able to determine, with any scientific precision, the relationship between workloads and this astoundingly frequent procedure. Even the surgeons themselves find that frustrating at times.

"I would think," Mazoue said, "that part of the thought process for orthopedic surgeons at this point, given the Stephen Strasburg situation and now the Matt Harvey situation, is that we, as orthopedic surgeons, have to look at that more closely. And look at the numbers. Look at innings pitched. Look at the number of pitches. Look at types of pitches thrown. And use that to guide us for recommendations to give our athletes. ... That probably needs to be something that is looked at."

At least Andrews and Glenn Fleisig, who work together at the American Sports Medicine Institute, have done extensive research on excessive workloads by younger pitchers. And those studies have brought pitch counts to pretty much every form of youth baseball known to humankind. But at the professional level? Not there yet.

Stan Conte, the Los Angeles Dodgers' vice president of medical services, declined comment on Harvey's situation because it doesn't involve his team. But he did refer us to a recent study by a group that included him, Altchek and the Dodgers' head team physician, Neal ElAttrache.

That study, which has been accepted for publication by the Journal of Shoulder and Elbow Surgery, looked at 235 major league pitchers who had Tommy John surgery between 1999 and 2014. It found that 31 of them -- a remarkable 13.2 percent -- needed to undergo that surgery a second time. And that's enough reason for caution in and of itself. But while that study analyzed recovery time and recovery rates, it didn't delve into the specific causes for all those repeat surgeries.

That job is on the radar screen of MLB's elbow-study group, which is in the midst of an extremely ambitious look at virtually every factor contributing to all elbow injuries in professional baseball. But unfortunately for the Mets and Harvey, the results won't be available between now and Game 1 of the NLDS. Sorry about that.

"We're getting closer," Ciccotti said. "And with Major League Baseball, and the past commissioner and the current commissioner so focused on it, and with the players' association understanding the importance of it, this is a really exciting time. These next two, three, five years, I'm really optimistic."

So maybe in 2020, when the next Matt Harvey faces a similar mess, we won't have to write a story like this, because we'll have so much more info to work with. But in the meantime, the Mets have a postseason they're about to play -- and a dominating pitcher they'd love to invite to that party.

How should the Mets handle the postseason?

We did an informal survey of a group of sports-medicine professionals, a couple of whom would not agree to be interviewed about a player who isn't their patient. By and large, they liked the Mets' plan to pitch Harvey in shorter outings on regular rest over the last two weeks of the season. Their only concern was how those shorter outings would affect Harvey's ability to pitch deeper into games in the postseason.

But October presents a whole new set of challenges. It once seemed absurd for a team to consider not using one of its best pitchers in the games that define its season. But that was before Stephen Strasburg, before the 2012 Washington Nationals, a team with a real chance to win the World Series, decided one pitcher's future was more important than the group's chances of winning in the present.

So now ... here we are again, as the Mets weigh where Harvey fits in their October plans.

"What bothers me," Jazayerli said, "is the Mets are doing everything they can to protect him, within the confines of trying to win baseball games. ... So I side more with the teams that are saying the point of pitching is to win championships. And if an injury occurs that affects the ability to win championships in the future, that has to be weighed against the effects that not pitching now affects our ability to win a championship now. I don't think that cost-benefit will ever work out for the Nationals from the Strasburg [situation]. And with the Mets, it's been what, nine years since they went to the playoffs? It would be kind of crazy for them not to take advantage of this opportunity."

Yeah, it seems crazy in the Citi Field bleachers, too. But is it also medically crazy? Wow. Tough call.

Every team physician understands the meaning of postseason baseball games. So when those games arrive, there's usually no debate. Players always push themselves past normal workloads, to potentially dangerous levels of fatigue, in the name of winning. It happens every October. It's always been part of the deal. And there's a reason doctors don't step in to stop it -- because under almost all conditions, everyone accepts it.

"Players understand -- not all of them, but most of them -- how fleeting this sometimes is, like, 'Gosh, am I going to have this opportunity again?'" Ciccotti said. "And that's intoxicating. That's a big part of it, too. And that's where you have to balance short-term goals with long-term goals. As a medical profession, you'd like to give a player everything. ... But with this player, who's also a patient, you have to balance what's best for them short term against what's best for them long term.

"And the emotional part of this -- that's a big part to consider, too," Ciccotti said. "And not just the player's emotion. It's the coaches. It's the management. It's the clubhouse. And it's the millions of fans that are out there, too. And that's the hard part as well."

He's got that right. So whatever decision Harvey and the Mets make, they need to consider everything. This is about more than one ligament in one elbow. This is a decision that will hang over all of them for a lifetime.

Can modern medicine assure Harvey he'll stay healthy?

Here's our rule of thumb about all pitchers: They will get hurt. They will wind up on the disabled list. And that's especially true of pitchers who have had Tommy John surgery, no matter how cautiously their team handles them.

Want to guess what percentage of pitchers who have had that surgery wind up going back on the DL with some type of shoulder or elbow problem? That would be 57 percent, according to a study written by New York Yankees head team physician Christopher Ahmad, which was published last year in the American Journal of Sports Medicine. Yessir, 57 percent.

That doesn't mean they'll need a second surgery on their ligament. It doesn't even mean they're in for a long stay on the DL. It just tells us that Harvey is already on the Most Likely to Get Hurt list, no matter how many innings he pitches over the rest of this year.

His agent, Scott Boras, has done his own research on this topic, naturally. He told The New York Times that his study found four pitchers in the past decade who returned from recent Tommy John surgeries, had never previously thrown 200 innings and endured especially heavy workloads in their first full season back: Josh Johnson, Shaun Marcum, Kris Medlen and Jarrod Parker.

All four pitched more than 180 innings. And all four had more elbow problems after that heavy usage, Boras said. So he's done the math. And it makes a lot of sense -- except that, as we've mentioned, why are we still talking about innings in the year 2015?

Look at those four. Look at Harvey. You'll see their innings weren't created equal. Here is how their workload -- and total pitches thrown -- compare to Harvey's:

Get the picture? Harvey's innings total might be approaching their level if he keeps working through a long postseason. But he's also throwing significantly fewer pitches per inning and per start than the other names on that list.

So let's say we set his bar at 3,000 pitches instead of 180 innings. At his current pitches/IP rate, he could throw 203 innings -- not 180 -- before he reaches 3,000 pitches. And that would give everyone involved much greater flexibility.

But that still brings us back to the gazillion-dollar question: Can anyone promise Harvey that he'll stay healthy, even if he pulls the plug on his season at 180 innings? We bet you know the answer.

Ciccotti's reply: "No. No. No. No."

Mazoue's response: "Absolutely not. No one can give you a very scientific assessment on what his percent risk is if he throws 185 innings or 190 innings or 200 innings. That information is not out there at this point."

So if that information is not out there, let's recognize this for what it really is -- for all concerned: a big guessing game. For Matt Harvey. For that team he pitches for. For Scott Boras. And even for modern medical science.

If he pitches fewer than 180 innings, can they be sure he'll stay healthy? If he pitches more than 180 innings, can they be sure he won't?

No. No. No. No.

"There you go. Bingo," Ciccotti said, laughing. "When you figure that out, will you let me know?"