Roy Halladay struggled throughout the 2013 season. His arm slot has changed, likely because he was trying to find a comfortable way to get the ball to the plate. That change is common and signals damage inside the shoulder, which is exactly what was found upon imaging.
Halladay will now have arthroscopic surgery to correct a frayed labrum and rotator cuff, as well as clean up bone spurs or debris inside the shoulder.
While damage to the labrum and cuff can be devastating, Halladay and his doctor, Neal ElAttrache of the Kerlan-Jobe Clinic, feel confident that the damage is minor. The biceps, labrum and rotator cuff often work in concert, leading Dr. Stephen O'Brien to call the area the "biceps-labrum complex."
Minor fraying is an indication that the area has been stressed over time, but has not given out completely. The location of the fraying would be instructive, but as of now, there's been no comment on this. The likely areas are in the back of the shoulder, where pain from both types of injuries tends to be felt.
There is a bit of a chicken-and-egg issue here since the damage is thought to be minor. Did Halladay change his arm slot because of the BLC damage, or did the BLC get damaged because new muscle areas and patterns were created by the arm slot? With fraying, there is less indication of a traumatic event and more one of wear and tear.
Halladay has been well-used, but seldom has shown any sign of overwork. Comparing Halladay's workload to other pitchers of this era makes it look that way, but comparing him to players of even the last generation doesn't appear to indicate any real abuse.
Halladay's workload in comparison to Roger Clemens is light. Neither was a max-effort pitcher and had great success over the course of a decade. Notably, Clemens came back from shoulder surgery on almost precisely this issue, though his came at the dawn of his career rather than the twilight.
Halladay's delivery is unusual, largely the result of Queen dropping his arm slot to a sidearm and increasing the lateral motion created naturally by the mechanics rather than additional spin.
Yes, Halladay is a sidearmer; look at the picture to the right and note that without the tilt of his shoulders, the acromial line—an imaginary line from elbow to elbow, through the shoulders—is almost perfectly flat, while the pitching forearm also stays relatively flat at the point of release. This is not uncommon, though few are as pronounced as Halladay.
During the 2013 season, Halladay often dropped his pitching elbow further. The technique takes pressure off the shoulder.
Try this at home: Put your arm out to a pitcher's "90-90", where the pitching arm is extended into the shape of an L. The upper arm is parallel to the floor and extended at a 90-degree angle. The forearm is bent at 90 degrees, putting the forearm parallel to the body.
If you pull the arm back slightly, you will feel some tension at the back of your shoulder. Drop the elbow towards the floor slightly and you will feel that pressure release. However, the shoulder joint itself is now in a much less advantageous position and throwing from this position can cause some issues.
As Halladay heads to surgery next week, what are the best-case and worst-case scenarios for what happens? Let's take a look:
The best-case is also the expected case. Dr. ElAttrache expects to go into the shoulder arthroscopically and be able to clean up the damage without performing any significant repairs. With the scope, the surgeon can shave down the fraying, remove the bone spurs and other assorted debris and leave Halladay with smooth, healing surfaces.
Halladay will almost immediately begin to rehab and could be throwing as soon as six to eight weeks afterward. His rehab should move quickly as the shoulder strengthens and is freed up by the repairs. The strength and stamina will have to be built up through a throwing program. Halladay will be able to move quickly if things inside the shoulder aren't causing pressure or discomfort.
Once Halladay begins to throw, watch for his elbow location in his delivery. If the surgery works, it should be assumed that the elbow will come back up to the normal slot and that the Phillies will see increased control and velocity from Halladay.
In the best case, Halladay will have no physical setbacks in the rehab process, will show quick comfort in his throwing program and will have to rebuild stamina in order to return, a relatively simple process that Halladay has done many times before.
The worst-case scenario is that once Dr. ElAttrache gets inside the shoulder, he finds more significant damage. While MRI and other advanced imaging techniques give a good view inside the joint, it is not perfect. There is a reasonable chance that there is more advanced tearing of one or both damaged structures that would necessitate a more significant repair.
Rather than just cleaning things up, the surgeon may have to repair the structures using some combination of fixation (anchors) and repair (stitches), as well as debridement. If there is significant impingement or osseous changes, a simple removal of bone spurs may need to be changed into a resection, where a portion of the bone is shaved or cut off.
Even if things go well, Halladay may not be able to return this season. While the three-month return will be difficult, seeing Halladay back on a mound this season is quite possible. It would also be normal to see this extend well past the three-month period. Dr. Keith Meister tells his patients that even with a minor repair, the shoulder will need a year or more to return to normal.