Spring notes: Three relievers hit the shelf

The season hasn't even started, and two closers are already sidelined for the season. Over the weekend, the Cincinnati Reds announced that Ryan Madson, who was signed just this January, suffered a torn ulnar collateral ligament (UCL) and is headed for Tommy John surgery. This news came one day after the Royals announced Joakim Soria would undergo Tommy John surgery (by Dr. Lewis Yocum) on April 3.

While Madson becomes yet another pitcher to fall victim to the almost-commonplace procedure, recent statistics suggest the prospect of a successful return is quite high for him. In perhaps the largest collection of data of pitchers post-TJ surgery, Dr. James Andrews and his colleagues at the American Sports Medicine Institute in Birmingham, Ala., have found that approximately 75 percent of major league baseball pitchers are able to return to what was perceived as their prior level of performance following this surgery.

In Soria's case, however, the sample size is much smaller. This will be Soria's second TJ surgery, and fewer pitchers exist who have undergone more than one Tommy John procedure, much less returned to the major league level afterward. In a study published in the American Journal of Sports Medicine in 2008, the authors reviewed the cases of 15 patients -- 12 professional and three collegiate baseball players -- who had undergone revision surgery for a retear of a reconstructed UCL. According to the study, only one-third (5/15) were able to return to their previous level of play for at least one season.

Even that number might not tell the whole story. While a major league pitcher returning to the major league level following surgery sounds like a success story, what matters most to teams is whether that pitcher can truly perform at the same level as he did pre-surgery. There is certainly plenty of evidence that suggests pitchers can return to top form following an initial Tommy John surgery, but what about after a second procedure? Stan Conte, senior director of medical services for the Los Angeles Dodgers, tried to answer that question as the team evaluated whether to sign pitcher Chris Capuano, a member of the two-Tommy John procedure club. Conte attempted to evaluate the workload of pitchers returning from a second procedure as a measure of their success. Starting with the somewhat arbitrary premise that a team would want a pitcher to return to the mound for at least 40 percent of his previous workload in order to be willing to carry him on its roster, Conte reviewed the numbers. Under these criteria, a 30-game starter prior to injury would need to deliver at least 12 major league starts to meet 40 percent of his prior workload. For a reliever, since game starts would be irrelevant, the 40 percent of prior workload would be tied to number of appearances.

Conte found that only 14 percent of starters were able to return at a level that met these criteria, but 60 percent of relievers were able to meet the mark. Also worth noting: Two of the starters who failed to meet the criteria for return as starters were still able to return successfully as relievers.

While that data might not be perfect or absolute, it does suggest hope for Soria, who, as a reliever, appears to have better odds of a successful return than he would as a starting pitcher. Soria is only 27 years old and still could have plenty of baseball left in him, as long as his arm cooperates. There is no doubt Soria faces another lengthy road to recovery, but his ability to successfully return from his initial procedure, combined with this positive outlook for relievers, should help.

It's worth noting that Capuano was among that 14 percent of successful returning starters -- he made 31 starts for the Mets in 2011 -- thus making the Dodgers' decision to sign him an easier one. In Saturday's exhibition game, Capuano looked strong as he struck out five and allowed two runs in five innings while making his fourth start of the Cactus League exhibition season. The Dodgers are hoping he'll remain part of that 14 percent.

Joba hurt again

A player suffering two serious injuries within the span of a year just doesn't seem fair. Fair or otherwise, Yankees pitcher Joba Chamberlain, who recently suffered a significant ankle injury while still recovering from Tommy John surgery, will now be rehabilitating his right leg along with his right arm. Chamberlain suffered the injury Thursday and underwent surgery the same night. He suffered an "open" dislocation, meaning the skin was broken in the process, which required immediate treatment to help guard against infection along with the corrective surgery. Chamberlain was able to leave the hospital Sunday.

Chamberlain will be in a non-weight-bearing cast for six weeks, followed by a walking boot, according to Yankees general manager Brian Cashman. The keys for the rehab process and his ability to progress are pretty straightforward: Monitor against infection, hope that the tissue heals uneventfully, progress to normal walking as weight bearing is permitted, then gradually resume functional activities with an eye on returning to baseball. Even if every detail of the injury and subsequent surgery were made available, the timetable for recovery would still not be set in stone. How his body heals and whether any unexpected issues crop up (such as infection) will go a long way in determining how swiftly Chamberlain is able to progress. But if there was no significant nerve, vascular (circulatory) or cartilage damage as a result of the injury, if healing progresses at a normal rate, and if there are no major setbacks along the way, the potential exists that Chamberlain could make a 2012 return.

Assuming Chamberlain gets through the initial phase without incident, the other primary challenge will be getting full range of motion back in his ankle. These injuries can be associated with chronic stiffness and scarring in and around the joint and require aggressive work directed at restoring normal movement. There is also the issue of strengthening the muscles in the entire lower extremity, which will naturally atrophy as a result of the extended immobilization. Then there is the matter of regaining balance and proprioception (essentially awareness of where the body is in space), a critical component of a pitcher's balance while in a single-leg stance on the mound. While there is much to overcome, Chamberlain will be focused on little else other than his recovery and can dedicate himself to doing just that. On the positive side, he does not have the demands of a position player, who must routinely field the ball or turn corners while running the bases. While he does have certain fielding responsibilities as a pitcher, those requirements are not as strenuous as they might be for another position.

There is that small matter of Chamberlain simultaneously returning from Tommy John surgery, however. Fortunately for him, he was quite far along in that recovery process when the ankle injury occurred. Chamberlain was already throwing in the bullpen and had even begun mixing in some breaking pitches, indicating that the bulk of his remaining recovery centered on increasing his workload. While the throwing sessions are obviously going to be interrupted for some time, there is plenty of upper-body and core work that Chamberlain will be able to maintain. The primary measure of protecting his arm will be ensuring that he has sufficient leg strength before returning to throw.

Naturally, there is no way to definitively determine whether Chamberlain will be able to pitch this season or even whether he will pitch again. That said, it is also too soon to rule out the possibility that he not only returns, but he does so in this calendar year. "He was saying he could be back on the mound in July, that's what the doctors are telling him," Cashman told the New York Post, adding, "That's the optimistic side." Chamberlain, who is still just 26 years old, was already demonstrating a steady progression in his return from Tommy John surgery and, in the eyes of many, was ahead of schedule. Optimism could be just what he needs to get through this latest obstacle.

Age is but a number ...

Rarely do we hear about pitchers in the twilight of their career opting for Tommy John surgery. Even less frequently do we hear about their comeback afterward. Between the time necessary to progress through the various stages of rehabilitation and the energy required -- both mentally and physically -- to commit to the recovery effort, the hill is often too steep to climb for those who know the end of their playing career is drawing near anyway. So why did Jamie Moyer elect to undergo surgery and attempt a comeback? After all, while the overall success rate of a pitcher's first Tommy John surgery is quite high (see above), Moyer's age (49) makes him an outlier, not only in regard to those who undergo the procedure, but among all baseball players.

But Moyer has always been an outlier. Never known for his velocity, Moyer's results have depended more on finesse and mechanics, location over heat. And he's still getting it done; from 2008 to 2010, he posted a respectable 37-26 record with a 1.29 WHIP.

Moyer, a southpaw, suffered the injury to his left elbow in 2010, then sat out the entire 2011 season while rehabilitating. During that time he worked as an analyst for ESPN, even providing firsthand insight into the recovery process during the baseball season. In January 2012, Moyer signed a minor league deal with the Colorado Rockies, and at the age of 49 he's competing for a spot in the starting rotation. Moyer has had several starts this spring, the results of which have been mixed, but Thursday's outing, which I attended, was particularly solid. Moyer pitched four perfect innings, throwing 30 of his 45 pitches for strikes, and netted four strikeouts. While the radar gun readings registered variants in the 70s, Moyer has never been known for his velocity (even he acknowledged his lifetime ceiling was probably 83 mph). And that, says Moyer, may be one of the traits that has allowed him to stay in the game so long. "I don't have to throw as hard as some guys do to come back, because I have never been that guy," said Moyer.

Last year Moyer acknowledged that the rehab process was far more extensive than simply the elbow. In fact, beyond regaining range of motion and strength about the elbow, the bulk of rehabilitation focuses on things away from the elbow, such as upper back, shoulder, core and leg strength, conditioning, flexibility, neuromuscular training and, as one begins to pick up the baseball again, proper throwing mechanics. These are all things most pitchers never have the chance to fully address while healthy because they don't have enough downtime to do so. But once injured, they are forced to reassess and rebuild.

Moyer has taken full advantage of that opportunity. Beyond the formal rehabilitation work he did immediately following surgery, along with additional training he did at the Phillies' facility in Clearwater, Fla., Moyer worked closely with a physical therapist in Southern California. "His name is Yousef, and he is an amazing man," said Moyer, adding, "I don't know if I've ever met someone who cares so much about each and every patient." Moyer was well-versed in the specifics of his particular program, explaining the attention to detail with which he conducted each exercise, even as he continues them independently. Moyer pointed out to me that the majority of the exercises are for his scapula (shoulder blade) and shoulder, noting that he has been working on strength deficits that have been present for years. And he's seeing progress. He also spent time working on conditioning in the dunes near Torrey Pines. "No running downhill, only uphill climbing," said Moyer who has a fractured patella (kneecap) in his injury history as well. Moyer knew he needed to be in superior cardiovascular shape to be able to compete, and he appears to be.

Moyer says the workout combination had him feeling "just right" before he headed to spring training. It certainly looks like it's paying off as Moyer appears calm and confident, yet intensely competitive, as he awaits his fate with the Rockies.