Atlanta Braves pitcher Kris Medlen is headed for Tommy John surgery, according to MLB.com. The same is true for the A's ace, Jarrod Parker. It's also true for Brandon Beachy, who follow Corey Luebke and Daniel Hudson.
While this is all too common among pitchers at all levels, all of them are headed through the process for a second time.
He previously had the surgery after rupturing his ulnar collateral ligament in 2010. Medlen made it back and excelled both in the rotation and the bullpen. His ascension to dominant starter was surprising and occasionally attributed to his Tommy John surgery, though there is absolutely no evidence that he or any other pitcher has seen a performance gain from the procedure.
Facing a second procedure, Medlen faces the same year away from the game and grueling yearlong rehab. Many Braves fans are asking whether or not he faces the same sort of potential when he returned. Second replacements are called revisions by surgeons and are rare in terms of surgery. Only a handful of specialists like James Andrews, Neal ElAttrache, and Tim Kremchek will do more than a few of these.
Medlen is hardly alone. Brandon Beachy is also headed for a second Tommy John surgery, adding to the long list of Braves trekking from Atlanta to Dr. James Andrews' office. Add in Patrick Corbin from the Arizona Diamondbacks and Jarrod Parker, who would also be having a second surgery and had his first while with the Diamondbacks, to the list of recently injured pitchers.
There's not much in the way of evidence or even anecdote, but what we know gives us a good look at Medlen's future. He should be able to return sometime in early 2015 and there's no physical reason why he couldn't return to the Braves rotation and even return to his previous level of performance.
While Tommy John surgery allows a player to come back, it doesn't make them invulnerable. In fact, it's the coming back that is likely the problem. Pitchers, especially mature and successful pitchers, aren't likely to make significant mechanical changes. Do the same thing and you'll get the same result, which, for these pitchers, was a ruptured ligament.
It's important to note that this is not a failure of the surgery, the rehab or even the pitcher. This is like blaming the car for a tire going bald. It's a recurrence of a problem with a known etiology. Calling this a failure demonstrates a fundamental misunderstanding of the procedure.
It's easy to suggest biomechanics should be changed, that hip and shoulder strength and flexibility could be augmented, but it's much harder to tell a multi-million dollar pitcher to change what has made him successful.
On top of that, the use of biomechanics is spotty at best in the major leagues. Even with the use, teams don't have a perfect prediction system.
One of the teams that uses biomechanics extensively is the Baltimore Orioles. In spite of this and several other factors, the Orioles lost prize pitching prospect Dylan Bundy for a year after he injured his elbow last season. He had Tommy John surgery and should be back this summer. Most teams ignore biomechanics altogether, including the Braves.
So even if we don't know the force that Medlen, Bundy or many individual pitchers are exerting on their elbows on each and every pitch, we do know that there's clear evidence that the ligament broke down, either insidiously or traumatically. Given the same tasks, similar force and any other significant changes, a transplanted ligament is likely to break down again after a period of time.
One thing we do not know for any pitcher is how much their ulnar collateral ligament can handle. There's simply no way to know this, though we know that it will be significantly different for every pitcher, just as they exert different forces in their pitching motion. Some pitchers are likely to have "weak" ligaments and some have strong, making the same force give different results.
There is a "Tommy John honeymoon," a period after the surgery where it appears there is a significantly lower risk of damaging the replaced ligament. Studies have shown that over a period of four to five years, the transplanted tendon becomes a ligament. However, remember that there's at least a chance that the pitcher's ligament was structurally unable to handle the load of pitching. A strong harvested tendon helps, but at a cellular level, will change.
Medlen was inside the normal "honeymoon" period, so it would be interesting to know what Dr. Andrews will find inside his elbow. Was the transplanted tendon fully ligamentized? Was his natural ligament weaker? No pitcher is going to let a surgeon open up the non-dominant side to check.
The surgery for a revision is different as well. It's not substantially different in technique, but requires some changes. The bone has already been drilled for the previous ligament replacement, but new holes are required. There's less space for that, as well as further damage and "mileage" on the elbow.
The upside is that the player has been through the process before. He's not likely to be surprised by anything in the rehab and understands the effort and patience necessary. As long as the player is not struggling on a performance level and is not advanced in age, there's little to show currently that a revision is less successful than an original.
A recent study published in the American Journal of Sports Medicine and conducted by the Kerlan-Jobe Orthopaedic Clinic focused on the rate of return from Tommy John surgery. Previous studies peg the number anywhere from about 75 percent up to 87 percent. This recent study shows that only five players out of 179 did not return to play.
Dr. Neal ElAttrache, a Kerlan-Jobe surgeon and team physician for the Los Angeles Dodgers, told me in a phone conversation that the return rate doesn't surprise him. "The surgery itself isn't the problem any more. It fixes something that was previous career ending and gives the player a chance to come back and play at the same level."
The study is clear that there is no performance boost and there may be a bigger cost. Currently, there are no pitchers in the Hall of Fame that have had Tommy John surgery. John Smoltz is likely to be the first in the next couple years, but behind him, there's not much coming.
Adam Wainwright is the most likely, with almost no one else "on pace." Pitchers like Chris Carpenter, AJ Burnett and Joe Nathan simply don't have Hall of Fame numbers and little time to accumulate them.
I spoke with Jay Jaffe from SI.com, who has done extensive work on quantifying Hall of Famers. Jaffe believes that there are three factors holding back Tommy John pitchers (including Tommy John himself!) from being inducted. The first is that the BBWAA has been stingy in electing pitchers, putting in only 15 since 1981.
The second is that durability is key to getting to huge numbers, like 300 wins. Of the pitchers that have hit major milestones, few have had major surgeries, with only Roger Clemens having a major surgery, though he missed almost no time after it.
Finally, Jaffe believes that because the operation was done so seldom into the mid-1990s, there were fewer opportunities. I agree, but I'm focused on the second with the dearth of likely Hall of Famers coming.
There are a number of players that have had two Tommy John surgeries, or even more. The "record" is five, but Jose Rijo is a special case and several of the failures were caused by external forces rather than being an actual redo. Nine current players, including Brian Wilson, Joakim Soria, Chris Capuano, Jason Frasor and Kyle Drabek have had two.
While it may appear that there are few starters that have returned after a repeat Tommy John, it's still a small sample size. Since relievers tend to be max effort pitchers, one theory is that they are more likely to do a traumatic sprain of the repaired ligament. There simply haven't been any studies done, though anecdotally this matches up with surgical findings.
As more pitchers have the surgery when they are younger, the two will collide and could open up the possibility that we see an explosion of second and third revisions. How baseball as a whole deals with this could be one of the most important sports medicine decisions they make in the next decade.
Medlen's revision will not make him invulnerable any more than the first surgery did. If he continues to put too much force on the elbow, it will break down again. However, there's no reason to believe that he will not be able to return. The last decade of sports medicine research shows us that.
As a symbol, Medlen and the other pitchers headed to operating tables remind us that as a whole, baseball doesn't know how to prevent arm injuries. A decade plus of pitch counts, cautious progressions and long toss have not reduced pitching injuries one iota. It's time to step back and maybe even start over, or else get used to seeing the best pitchers heading to surgery time and again.
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