Tommy John surgery 'epidemic'?

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As he watched Kris Medlen walk off the mound in mid-inning last month and head straight for the trainer, Frank Wren already had that "sickening feeling" in his stomach.

Unfortunately, it's a feeling the Braves' GM knows all too well.

Within days, Medlen and Brandon Beachy would become the third and fourth Braves pitchers to visit their friendly neighborhood Tommy John surgeon since May. Only a few weeks later, reliever Cory Gearrin would become the fifth.

Now, you don't need to graduate from Harvard Medical School to know a pitcher can't catch that Tommy John surgery bug the way he would, say, the measles. There's no vaccine to prevent it, no pill you can pop to stop it, no room you can quarantine yourself inside to avoid contracting it.

But yikes. Something seems to be going on here -- and not just in Atlanta, either.

According to research by Jeff Zimmerman and Jon Roegele for the invaluable website Baseballheatmaps.com, we've already seen 14 major league pitchers undergo Tommy John surgery just this year. And two others are scheduled to have surgery next week: Yankees starter Ivan Nova and Rangers reliever Pedro Figueroa.

And this is happening in a sport that averaged fewer than 16 of those surgeries per year between 2000 and 2011.

So, everywhere you turn, somebody is asking probing questions about this stunning proliferation of trips by all these elbows to the ligament-reconstruction repair shop. And the group asking those questions, naturally, includes the beleaguered Atlanta Braves.

"We've taken a step back and looked at everything," Wren said. "We've talked to our doctors. We've talked to [Dr.] Jim Andrews. We've talked to our medical staff. And from everything we can tell, nothing would indicate that what's happened to us is anything other than fate."

But is this just fate? Is this an official "epidemic" that has mysteriously afflicted the entire sport? And whether it is or not, what can baseball do to keep all those elbow ligaments off the operating table?

Let's examine those questions, with the help of people who have studied this topic in exhaustive detail.

Is this a true 'epidemic'?

OK, so this isn't an epidemic in the same way the swine flu was an epidemic. But when you start to see something in the medical sphere that begins happening with greater and greater frequency, doesn't that still qualify as some sort of epidemic?

"It's not an epidemic -- yet," said Stan Conte, the Dodgers' vice president of medical services and a man who probably has done more injury research than anyone else in baseball. "But I think I see the storm clouds gathering.

"Hopefully," he said, "the storm will miss us. But I'm still going to grab an umbrella."

Sounds like an excellent idea. But it's still too early to determine whether this year's Tommy John surgery outbreak is part of a trend or just One of Those Years. So see what you think:

The stage seems to have been set for a record year, when you consider that, in the past, March and April have been relatively light months for these surgeries. They've tended to increase as the season goes on -- with June and July as the peak months.

So, if that trend continues, baseball could be headed for an unprecedented number of Tommy John surgery patients. But this just in: We don't know that yet.

"What you have to remember is that all these surgeries are mutually exclusive," Conte said, "because they happen to individuals. Therefore, to say, 'We could have 15 by the end of April, so we'll therefore have 40 by the end of the year,' that's not necessarily true."

But where we go from here is a subject of major interest to the sports-medicine community. Why? Because right now, the TJ spike of 2012 -- when the number of Tommy John surgeries more than doubled the previous average -- is regarded as a fluke year. But what happens if this year's total mushrooms right back to 30-plus, 40-plus or beyond?

"An epidemic is a long-standing issue," Conte said. "Not a short blip. ? So, as we appraise what's happened this year, it may be closer to 2012. And if it is, it makes 2012 maybe not an anomaly. It could be the beginning of something."

Why are more pitchers needing a second TJ surgery?

To those of us who just follow baseball orthopedics as a "hobby," it's merely the long list of names on the disabled list getting our attention. But to people who actually practice sports medicine, it's a second burgeoning trend that's arousing their curiosity -- and concern.

That would be the increasing number of pitchers who are having Tommy John surgery for a second time. Consider this:

  • In the dozen seasons from 2000 to 2011, according to Baseballheatmaps.com, an average of 15.8 major league pitchers per year had Tommy John surgery -- peaking at 20 in the 2007 season.

  • Then, in 2012, that number spiked to 36 -- only to confuse everyone by boomeranging back down to 19 in 2013.

  • From 2000 to 2013, the average number of Tommy John surgeries performed before Opening Day was only two per year. This season, there were seven -- followed by four more just in the first nine days of the season.

  • From 1996 through 2011, the total number of pitchers who needed to repeat TJs came to 18 -- in 16 years.

  • But from 2012 to 2014, we've seen 14 of those "revision" surgeries in three years -- including six just in 2014 (Medlen, Beachy, Jarrod Parker, Josh Johnson, Cory Luebke and Peter Moylan).

So, what does this mean? Even folks who study this sort of thing for a living aren't totally sure.

"It's the ones that are recurrent ? that are more of a challenge to understand," said Dr. Michael Ciccotti, the leader of MLB's elbow study group, the head team physician for the Phillies and the director of sports medicine at the Rothman Institute in Philadelphia. "And, in some ways, they're also more alarming."

The sports-medicine community is dividing these repeat TJ patients into two groups. One includes pitchers such as Brian Wilson and Joakim Soria, who had their first surgery while they were still in their teens, then needed a second operation after a long period of post-operative success.

But the second group includes pitchers such as Medlen, Beachy and Daniel Hudson, whose comebacks from TJ led to a second elbow blowout within two seasons (or, in the cases of Beachy and Hudson, basically zero seasons).

The first group is being studied, but it's that second group that has raised so much concern. Studies are underway, asking: Is it a result of pitchers who push a little too hard, too fast while rehabbing? Does the rehab program, or schedule, need to be re-examined?

Is this about pitchers with flawed mechanics who come back and go right back to the same flawed mechanics? Or is it possible Tommy John surgery itself isn't the surefire cure-all it's made out to be?

"There are a lot of urban myths out there," Ciccotti said. "There's [the theory that] we'll fix it and you'll be better than you were before. That's an urban myth. There's also [the belief that] everyone comes back in 12 months ? so, there's that pressure to get back -- and if it takes you 18 months, 'What's wrong?'"

But there's also one big-picture dose of reality to keep in mind: This is a surgery with an incredible success rate -- but it's not 100 percent.

"If 90 to 95 percent get back, that means 5 to 10 percent don't get back," Ciccotti said. "So the more of these you do, the 5-to-10 percent may stay the same, but there's a larger number [of total surgeries] because more are being done. And if we're talking about professional athletes, they're more discussed."

So, what are these repeat Tommy John surgeries telling us about the nature of that surgery itself? The sports-medicine community isn't prepared to say yet. But an incredible amount of research is being aimed at that very question as we speak.

Is there a 'cure' for the 'epidemic'?

The old baseball joke goes like this: How do you keep a pitcher from getting hurt? Easy. Don't let him pitch in the first place.

When the topic turns to how to prevent this stampede to the Tommy John surgery O.R., you hear that one a lot. But let's pose this question: Are we sure that's true?

"I know this is a bold statement, but I do not believe throwing is an unnatural act," Conte said. "The shoulder, I think, was designed to throw. ? When the cave men threw a rock [at whatever prey they were hunting], if they threw it underhand, they'd have starved to death. So they threw overhand. The shoulder is designed to do that. What it's not designed to do is throw repeatedly for two hours as hard as you can. It's just like the tires on your car. Tires are designed to run for 40,000 miles -- unless you drag-race. They're not designed for that. So they wear out a lot sooner."

In other words, the research on these injuries begins with the premise that all these sore arms are wearing out. The question is why. And everyone has a theory:

  • It's youth baseball: Studies conducted by Andrews and America's most prominent biomechanics expert, Glenn Fleisig, have focused increasingly on year-round youth baseball as a prime culprit in causing arm injuries later in life -- and sometimes not so much later. We reported on Fleisig's research in a 2012 piece on Stephen Strasburg's shutdown by the Nationals. It's pitching past the point of fatigue, Fleisig has found, that is the prime cause of injury. So, it's rest that alleviates that fatigue. But year-round pitching, at a young age, simply isn't allowing younger pitchers to rest and recover. And the results often don't show up until after they've turned pro. But is that something big league teams can prevent? "I'm not sure how you stop that," Conte said, "other than to stop it at the youth level."

  • It's "bad" mechanics: The more people in baseball study biomechanics, the more aware they're becoming that some pitcher deliveries carry more danger signs than others. Yet the trend line increasingly leads pitchers down the road to "bad" deliveries, not "good" deliveries. "I think, as a sport, we've actually done a good job of limiting pitches and counting pitches," said Jeff Bittiger, a former big league pitcher, independent league manager and pitching coach, and now a scout for the A's. "But I think this is more a matter of style, the way the game is played now and the type of deliveries that are being taught." By that, he means, the trend is toward pitching "downhill," at the bottom of the strike zone. Which means the "only way to finish those pitches is straight down," he said. "And to get there, you have to be a 'short-strider.'" Remember that old, long-striding "Tom Seaver drop-and-drive delivery" that pitchers used in the 1960s, '70s and early '80s -- while [theoretically] staying a lot healthier and pitching many more innings? "No one would ever teach that now," Bittiger said. But even when biomechanical studies -- and prior injuries -- give clear signs that a pitcher's delivery is leading him toward a serious injury, "when they're professional ballplayers, it's hard to change them," Ciccotti said. "And sometimes their coaches don't want to change them -- because that's what got them here."

  • It's velocity: Never, at any time in history, have we seen more pitchers who can throw a baseball at 95 mph or higher. And never have we seen more pitchers who can approach, or even burst through, the 100 mph barrier. So it seems like simple biology that more velocity equals more elbows exploding. Right? "That higher velocity," Ciccotti said, "means higher force going through the ligament." So, although the entire body's ability to have legs, hips, core and shoulder work together to allow a pitcher to throw that hard is "amazing," Ciccotti says, it's still "Russian roulette. At high velocity, any pitch can cause a rupture. ? So the faster you throw the ball, the more chance you'll be an elite pitcher -- but there's a price to be paid." That, too, is a logical and scientific conclusion. But earlier this year at FanGraphs, Jeff Zimmerman unveiled the results of a fascinating study of the 56 big league pitchers since 2007 who have been clocked at 100 mph by Pitch f/x. He found that 25 percent of them eventually had Tommy John surgery. Which seems like a lot -- until you remember that one of every four men who pitched in the big leagues in 2012-13 was a guy who had had TJ surgery at some point. So there appears to be little difference in the Tommy John rate between pitchers who breathe that 100 mph fire and those who don't. But one problem, Zimmerman told ESPN.com, "is that there just are not enough 100 mph throwers to give us a large enough sample size."

  • It's pitch counts: We live in an age when pitch counts appear on a corner of our TV screens, updated after every pitch. So clearly, they must be a big deal. But are they as big a deal as we make them out to be? "I've never been able to find a study, or do a study, that shows the relationship between pitch counts and injuries," Conte said. Now once upon a time, back in 2001, there was a study on this -- by Keith Woolner and Rany Jazayerli in Baseball Prospectus -- that did establish a link. But it was based on the much higher pitch counts of that era, which could range to 130-140 pitches, or even higher. Since then, Jazayerli told ESPN.com, "No one that I'm aware of has studied the issue in as much detail in the 12 years since, which might seem strange except that pitch counts dropped so dramatically from 1998 to 2005 -- give or take -- that the issue essentially evaporated in the analytical community." So, now that 120 pitches or so has become pretty much the absolute max, does it still make sense to blame high pitch counts for an uptick in Tommy John surgery? "Who would say it's OK for a pitcher to throw 140 pitches?" Conte said. "I wouldn't say that. And if I wouldn't, that would suggest I think pitch counts have something to do with injuries. But where's the science that says that?" Aside from Fleisig's studies of younger pitchers, the fact is, that data doesn't exist.

  • It's the love affair with Tommy John surgery: Finally, one odd trend Conte has discovered in his research is an increase in time spent on the disabled list by pitchers with elbow issues but a decrease in the time logged because of shoulder trouble. The percentage of pitchers who land on the disabled list hasn't changed. And the percentage of time on the DL because of arm problems hasn't changed. What has changed over the past five years, Conte says, is that shoulder injuries used to be the No. 1 reason for lost time -- and accounted for more than twice as many DL days per year (about 9,000) as elbow issues (about 4,000). Now, strangely, elbow time has zoomed up to No. 1 and shoulder time is down. And one possible reason, Conte theorizes, is that pitchers are opting for Tommy John surgery at any sign of ligament trouble -- but gravitating away from shoulder surgery "because the rate of return is so dismal." When a pitcher with a partial ligament tear has Tommy John, he knows, with reasonable assurance, that he'll be back in a year or so. If he opts for rest and rehab, on the other hand, his future is shrouded in mystery. So, think of the pressure that weighs on everyone -- pitchers, doctors and everyone around them -- to choose surgery, not the old-fashioned route. "It's really hard sometimes," Ciccotti said, "to get athletes and their advocates -- if they're younger, their parents, and if they're older, their agents -- to accept non-operative treatment." So, is it way too fashionable to have Tommy John surgery these days? It just might be.

So those are the big theories. But do any of them -- valid as they all are -- fully explain what we're seeing? It doesn't seem like it.

"The truth is, it's not pitch counts," Conte said. "It's not fatigue. It's not velocity. It's not youth baseball. It's all of those. The question is which has the most impact on the result. And that takes more scientific study."

So, what can baseball do about it?

Thanks to the work of people such as Drs. Glenn Fleisig and James Andrews, there is clear evidence of arm abuse in youth and amateur baseball -- and, as a direct result, there are mandatory Little League pitch counts that are designed to control that workload. But how does that help Major League Baseball? Sadly, it doesn't.

So, in 2011, Ciccotti's elbow study group started on a job that should have begun years ago -- studying all elbow injuries, including a look at every possible cause, effect and result of Tommy John surgery, in the major leagues and minor leagues.

That study is charting the progress, or lack thereof, of every TJ patient in professional baseball. It tracks the specific diagnosis, the length and schedule of the rehab process, and when (or whether) the pitcher made it back to the mound. It includes personal interviews with every player. And it now includes, as of this spring, a biomechanical profile of each one of those pitchers.

"This research," Ciccotti said, "is so much more focused than in years past. ? And we're sifting through this data right now."

The hope, he says, is that, "toward the end of the season, we'll have something that will help us to give recommendations to the athletic trainers and doctors, that can help us improve in this area in the near future."

And once the biomechanics data is analyzed by mid-to-late autumn, he says, it could provide enough insights that "we may be able to redefine, or at least refocus, some key areas to improve treatment but also to provide us with preventive measures, as well."

Once that ball begins to roll, only then will we start to have a true idea of what's causing this Tommy John surgery "epidemic," and what can be done about it. But in the meantime, pitchers will fire away. Surgeons will reconstruct more ligaments. And the sports-medicine community will keep exploring the mysteries of the human elbow. And that exploration figures to last, well, forever.

"The problem," Michael Ciccotti said, "is that this is not a three-piece puzzle. It's a 10,000-piece puzzle."

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