In a packed Chicago operating room on July 14, Dr. Anthony Romeo prepared for one of the most important surgeries of his career. Fellow surgeons, orthopedic residents, nurses, a videographer and a photographer gathered at the Rush University Medical Center, eager to watch their colleague perform a surgery he had never attempted.
On any patient, the procedure would carry enormous responsibility. But that day, Romeo's patient was former Cy Young winner and Chicago White Sox pitcher Jake Peavy. He had entrusted his $52 million throwing arm to Romeo after he tore his right latissimus dorsi tendon completely off the bone.
It was a rare injury. No major leaguer had been known to fully tear the tendon, which connects the latissimus dorsi muscle to the humerus bone and helps transfer the force of pitching from the legs to the arm.
"I'm honored that he trusted me that way," Romeo said. "Some of my peers may think I'm a little crazy for making that leap of faith -- that I would do that, and that I would be confident that it would work out well for him."
Romeo, an orthopedic surgeon and one of the White Sox's team doctors, had vast experience operating around the lat muscle and its tendon, but his surgeries usually involved removing the tendon and using it for other shoulder surgeries, most often the rotator cuff. Peavy's surgery required Romeo to reattach the tendon to the bone.
If successful, Peavy's career might be resurrected. If not, the 29-year-old right-hander would likely be done with baseball.
His doctor watched him 'break'
The injury occurred on July 6, in the second inning in a game against the Angels. Peavy's 22nd and final pitch was a fastball to Mike Napoli.
"I just felt like somebody shot me," Peavy said. "It was just an excruciating pain."
Flustered and having trouble breathing, Peavy didn't immediately walk off the field. He circled back to the mound, clearly hurt. Romeo was watching the game on television from his home and saw Peavy's arm hit his side after throwing the pitch. Romeo knew one of Peavy's muscles had failed to bounce his arm back; instead it swung like an open gate.
"When somebody literally breaks right in front of you, it's not a good thing," White Sox pitching coach Don Cooper said.
Peavy walked into the training room and said he felt as though the muscle on the right side of his back was flapping at his side, just under his armpit. His stomach was queasy.
Other major league pitchers have experienced tears of their lat muscles before, Kerry Wood, Brad Penny and Tom Gordon among them. But most such tears were torn 30 to 40 percent of the way through, and all were rehabbed without surgery.
"We don't have a scientific basis for why certain individuals may get it or not get it," Romeo said. "We hear rumors and speculation of poor pitching mechanics, but honestly, the truth is we don't really know the answer as to why a pitcher would go on to rupture his latissimus tendon."
Peavy was told his career could be over. Romeo said he thought the only way to salvage it was surgery. Peavy asked Romeo if he had ever performed the surgery.
"I have not," Romeo told him.
Peavy then asked if Romeo could safely do the operation without injuring any other parts of his arm.
"I believe I can," Romeo said.
Peavy knew surgery would be the only realistic chance of returning to baseball. But the decision was fraught with uncertainty because there would be no medical or rehabilitation roadmap. Peavy was potentially going to be a modern-day Tommy John.
The ups and downs of rehabbing at home
The Peavy family ranch in Semmes, Ala., provided a sanctuary for Peavy. It was in a small Southern town of 15,000, where Peavy grew up hunting, fishing and surrounded by close family. His grandfather, Blanche, taught him baseball and was his idol. When Blanche died in a workshop accident when Peavy was in eighth grade, it was devastating.
"We lost him at 58 years old," Peavy said. "It's life changing."
Peavy, raised as a country boy proud of his upbringing, is old school. He doesn't believe in icing after games and prefers no pain medication. He first entered the league with the San Diego Padres when he was 20 years old and became a face of the franchise. Armed with a violent pitching motion that whipped a mid-90s fastball, a cut fastball and a slider, Peavy dominated the National League, culminating the 2007 season with a Cy Young award.
Emotional and passionate, he also became known for yelling at himself on the mound and as a fierce competitor. Peavy was raised to be accountable and responsible. He often would pitch hurt. When Peavy was traded to the White Sox in July 2009, he rushed back from a severe ankle injury out of respect and deference to the organization and its fans.
"I think anybody will tell you I'm a competitor," he said. "You wanna get out there, especially when you're a guy who's been traded for. I wanted so badly to be out there."
Just over a week after coming out of a boot, Peavy was on a rehab assignment and eventually went 3-0 with a 1.35 ERA and a 0.85 WHIP for the White Sox at the end of the 2009 season.
He said that marked the beginning of a "perfect storm" of injuries. Because of the ankle injury, he wasn't using his lower body as much, which threw the rest of his mechanics out of whack. The strong finish in 2009 provided false hope, and Romeo said he thinks that by last year Peavy's mechanics were harming his arm. He pitched through pain, including a stretch in June during which he even threw a shutout.
But it all blew up that night against the Angels.
"We had some tendinitis in the arm area," Peavy said. "But we never knew anything like what was about to happen."
Returning to Semmes was the only logical place for Peavy to heal after the surgery. Semmes is where he, his three children and his wife, Katie, return every year to ride horses, fish and hunt.
One of Peavy's hobbies is perusing flea markets and estate sales. An old medical chair he bought during one of the ventures provided a two-week home for him at his parents' house after the surgery. Immobilized, with his right arm in a sling, two painful incisions healing on his side and resisting most pain medication, Peavy spent most of his time in that chair, contemplating his career.
He said he had endless thoughts of retirement, of what his life would be like without baseball. Then, he came to a realization.
"I was just at peace with what was happening," Peavy said. "I've been very blessed in the game of baseball and to have what I have and to have done what I've done. If it was meant to be the last pitch, I think I would eventually come to terms with that and be OK."
Slowly, he started to heal.
Following the Brees model
Soon after his injury, Peavy received a call from New Orleans Saints quarterback Drew Brees. The two had been friendly when Peavy was with the Padres and Brees played for the Chargers. Brees had suffered a career-threatening injury in his last game with the Chargers and underwent major shoulder and rotator cuff surgery.
"People were counting Drew out a few years ago," Peavy said. "And this guy goes to New Orleans, after countless days of rehab and strength conditioning, he goes on to be a world champion -- better than he's ever been. That's the mold you wanna follow."
One of Brees' trainers, Todd Durkin, owns Fitness Quest 10, a training center in San Diego. Durkin developed a specific program for Brees to strengthen his shoulder after he was hurt. Peavy connected with Durkin and Dr. Kahl Goldfarb of Water Sports Physical Therapy to work on a concentrated rehab and conditioning program.
Peavy still had a home in San Diego, and his children attended school in the area, so it was a perfect fit. But when he arrived in San Diego in early October, he had serious concerns about impingement in his shoulder. The White Sox had gotten him to the point he was able to stretch his arms over his head, but Peavy felt a pinching pain at the end of his motion. It was a scary, unsure time.
Goldfarb said he analyzed Peavy's whole body and treated him from his feet to his shoulders. Goldfarb said one challenge with athletes is they don't have full range of motion throughout their bodies and in their joints. That can place stress on joints and can lead to conditions such as arthritis. Hands-on orthopedic muscle therapy is meant to help stimulate all of the joints and loosen them up, he said. It provided Peavy's body, especially his back, shoulder and arm, a range of motion they had never had.
"Jake was really motivated," Goldfarb said. "He was interested in understanding the underlying cause of what was going on. He felt that if we can work on all the surrounding muscles and joints that his mechanics will be correct and he could avoid those other issues. After that, I think his confidence level soared."
Peavy came into Goldfarb's therapy center three times a week, working anywhere from 90 minutes to three hours a day. The first month of rehab was the most critical, Goldfarb said, because he needed to stabilize the muscles, making sure motion, strength, timing and balance were emphasized.
"We had to look deeper into his shoulder and we looked at the joint capsule, which is like Saran Wrap and wraps around the bones and holds the joint together," Goldfarb said. "He had a lot of trauma to the back of the joint capsule, and our job was to allow that joint capsule to move properly, so you loosen it up, and it allows [the muscle] to move properly without pinching."
Goldfarb and Durkin gave Peavy exercises he had never done before, which still remain critical to his health and progress. One of them was working through his entire throwing motion, but in slow motion, balancing at each step, using pulleys and bands to create speed and resistance, so when Peavy throws in real time, the muscles are already strengthened and trained to move efficiently.
Another exercise was a twist on the traditional plank move; Peavy would get into pushup plank position and rotate his body to either side and lift one arm up to the sky. That move would not only strengthen his core, but engage an entire set of muscles he would need when he started throwing again.
"He was very curious about the process," Durkin said. "You could tell he wanted to learn what he was doing."
But the rehab was not all smooth. It became much more difficult when Peavy's 52-year-old father, Danny, was diagnosed with liver cirrhosis in December 2010. A disease that runs in the family, Peavy went home to Alabama for stretches of time this winter, interrupting his work with Durkin and Goldfarb. At one point in December, his father was admitted to the hospital for an infection, and Peavy went to a sporting goods store, purchased dumbbells, a medicine ball and a stability ball and did exercises in the hospital waiting room. He studied exercises off Goldfarb's website and worked from a video Goldfarb had made on Peavy's phone of him working out.
"I had to improvise," he said.
Watching his father battle a life-threatening disease while trying to return from a career-threatening injury made this winter one of the most challenging times in Peavy's life.
"You always see your father as this massive guy who's never gonna die," Peavy said. "He's immortal, almost. And when you get some humbling news that my dad gets, it's a tough few days. Most people say, 'Why me?' But you know my dad, he said, 'Why not me?' It's true, it can happen to anybody."
Spring training game a milestone
As the months progressed, so did Peavy's rehab. He picked up a ball in December and threw for first time since his surgery. By January, he was throwing off a mound, and just before spring training he was up to 40 pitches.
One of the biggest milestones Peavy made happened Friday, when he stepped on a mound and pitched in a game for the first time. It was almost eight months to the day, and in his first spring training game, against the Angels, Peavy threw 26 pitches in two hitless innings -- his fastball reached 92 mph. He credited Romeo, Goldfarb and Durkin for how well he feels.
"They are awesome, and [because of them] we are quite ahead of schedule and feeling this good," he said.
Peavy said after the game he had normal soreness, but he knows because of his competitiveness he has to be careful about pushing his body too much and not letting the emotion and adrenaline override any pain. He's scheduled to pitch again on Wednesday, and he said he has vowed to be better about being smarter.
"I can't make any promises," he said. "I've just gotta find a happy medium. You have to be smart about it. You understand what your body is telling you, and you certainly try to be a better judge."
Durkin and Goldfarb think he can come back from the injury just as strong, if not stronger, than he was before. Romeo said there is no way to predict how Peavy will fully heal. It's unclear if Peavy will be able to make what would be his first start on April 6, but already he has exceeded expectations.
"I believe I've got a lot left," Peavy said. "At times, I feel like [people] talk about me like I'm an old man. I'm 29 years old; I'm going to do everything to come back to be the guy I was before the injury and I expect to be that guy.
"I wanna pitch until someone tears my uniform off me."
Amy K. Nelson is a staff writer for ESPN.com. She can be reached at Amy.K.Nelson@espn.com.