Pitchers, arm injuries and comebacks

No pitcher wants to hear he needs surgery on his throwing arm, but if the damage is severe enough, it may be unavoidable. Most throwers who reach the point of surgery are hopeful that going under the knife will allow them to return to their chosen occupation. But as anyone in the baseball medicine field will tell you, a pitcher's return from surgery is never guaranteed.

The commonplace occurrence of arm surgery amongst professional pitchers reflects the cumulative wear and tear caused by repeatedly throwing a small white ball at high speeds. The terms "Tommy John" (now more often associated in the minds of this generation of fans with an elbow surgery than with the individual after whom the procedure is named), "rotator cuff repair" and "torn labrum" have all made their way into the baseball vernacular, perhaps desensitizing us to just how serious these procedures are. While much progress has been made both in terms of surgical technique and in the rehabilitation parameters following surgery, we have not yet arrived at a place in medicine where a return to play is assured.

That said, the outcomes for elite pitchers following ulnar collateral ligament (UCL) reconstruction (more commonly referred to as Tommy John surgery) are quite good. In a study published in the American Journal of Sports Medicine in 2007 that looked specifically at return to play for major league pitchers following UCL reconstruction, 82 percent successfully returned at an average of 18.5 months after surgery. The term "successfully returned" is key since no pitcher wants to come back a lesser version of his former self. In the AJSM study, reconstructed pitchers were followed for seven consecutive seasons and demonstrated no significant change in mean ERA or WHIP when compared to their pre-injury numbers. While good outcomes following Tommy John surgery have been widely reported, this study was unique in that it focused specifically on major league baseball pitchers.

For a pitcher facing elbow reconstruction, this data is certainly encouraging. While there's no getting around the length of time it requires to return and the diligence necessary to adhere to the rehabilitation process, the general takeaway for professional players is that they have a very good chance of returning to their prior form. As Washington Nationals rookie ace Stephen Strasburg headed for his Tommy John surgery this September he could take heart in seeing teammate Jordan Zimmermann returning to baseball one year after his own such procedure.

For pitchers facing shoulder surgery however, what waits on the other side is far less certain. Only 35 percent to 50 percent of throwing athletes return to their previous level of performance following shoulder surgery. One study presented at the 2008 American Orthopaedic Society for Sports Medicine Specialty Day Meeting indicated that of 12 players at the high professional level (major league baseball, Triple-A and Double-A) who underwent shoulder surgery, only one made it back to that high level of play. These numbers may help explain why Mark Prior has been unable to recapture the glory years, why Jason Schmidt now works in business, not baseball, and why Brandon Webb, who last pitched in a game in April 2009, has yet to return to the mound.

Why the difference?

One factor has to do with the basic anatomy and biomechanics of the two joints. The elbow is a hinge joint with primary movement in one direction that allows for bending and straightening. The shoulder, however, is a more complex joint that allows for significant movement in three planes.

In fact, the human shoulder is so mobile, we can practically make a 360-degree circle with the arm. Pitchers, as a function of their position, have even more mobility in their throwing shoulder. Just look at any still image of a pitcher when his arm is in the late-cocking position (just before he begins the forward motion of his delivery) and it seems as if his arm is on backward.

But that mobility comes at a price. Increased range of motion translates to less stability in the joint, which is why shoulders are one of the most easily dislocated joints in the body. Although technically a ball and socket joint, the shoulder is somewhat unusual. The "ball" portion of the shoulder formed by the humerus or arm bone rests on a very shallow "socket" formed by the outer facing aspect of the shoulder blade. Were it not for the labrum (a ring of cartilage that lines the shoulder) -- ligaments in the joint, a fibrous capsule around the joint and finally all of the surrounding shoulder musculature -- the ball portion would fall off the socket with only minimal movement.

Consequently, any disruption of those surrounding tissues can not only cause pain, it can also spell trouble for shoulder stability. And when it comes to pitchers' shoulders, a torn labrum, ligament damage, capsular tears and rotator cuff strains can all be part of the picture. With the combination of power and finesse demanded of the shoulder in an elite thrower, compromising any of these structures can certainly alter his performance. Surgical repair may help provide stability, but the challenge is doing so while allowing the pitcher to retain enough mobility to resume pitching.

The interrelationship of all these structures makes deciding how much to do once operating inside the shoulder "an experienced guess" according to Dr. Jeff Guy, team physician and medical director at the University of South Carolina. Guy, who trained under and now teaches with the renowned Dr. James Andrews, says that whereas Tommy John surgery primarily involves replacing a single ligament, most shoulder problems are complex and involve multiple structures. For a surgeon, the goal is to do enough to address the damage without overdoing it.

"It really comes down to clinical judgment at the time," Guy said. He describes shoulders that exhibit signs of severe wear and tear with fronds of tissue hanging inside the joint. "When the tissue is frayed you try to clean it up as best you can and hope that you've addressed what's causing the [athlete's] pain."

One of the challenges when it comes to pitchers and shoulder surgeries, according to Los Angeles Dodgers medical director Stan Conte, is while there are numerous outcome studies related to Tommy John surgery, good shoulder outcome studies are lacking in professional baseball.

As Conte put it, "We often just talk about cases."

"We talk about Mark Prior, we talk about Chris Carpenter, we look at how individuals have done," Conte said, "but we don't have very many good studies with large sample sizes. We really need a study with not 20, not 40, but 100 to 200 pitchers to find out what the outcomes truly are in professional baseball players.

Conte emphasized that a solid study needs to focus on professional baseball players, not other overhead athletes like volleyball players or even collegiate pitchers, because the requirements of an elite pitcher's profession are unique.

Major League Baseball is working on putting together just such a study and is issuing grants to promote research. Currently, a database of player injuries does not exist in MLB as it does in the NFL and the NCAA. MLB's research committee (of which Conte is a member) is trying to change this. Gathering data would allow for retrospective studies, which could provide insight into the complex questions surrounding these pitching injuries, including how to better prevent them from occurring.

Until there are more definitive answers, baseball medical and coaching staffs will continue to tweak all the potential variables that influence the shoulder as best they can, maintaining shoulder range of motion, strengthening the shoulder, trunk and legs and examining pitching mechanics.

And pitchers will continue to push the envelope of what the human body can withstand.