Baseball's medical community applies a special designation to pitchers who have undergone two or more Tommy John surgeries. They're called "revisions." When a four-inch scar inside a pitcher's elbow conjures images of red markings in the margins of a college English composition, there's an innocuous, almost casual quality to the term.
In reality, few words can do justice to the emotional toll and commitment necessary to recover from multiple elbow reconstructions. Kansas City Royals right-hander Kris Medlen understands the magnitude of that challenge as a two-time member of the fraternity.
Medlen blew out his ulnar collateral ligament for the first time on Aug. 4, 2010, while throwing back-to-back changeups against Jose Reyes of the New York Mets. Two weeks later, he was on an operating table having his elbow reconstructed by Dr. James Andrews.
The second go-around was more painful -- both physically and emotionally. A year ago March, Medlen felt a stabbing sensation in his elbow while throwing a changeup to Mets outfielder Curtis Granderson in the Grapefruit League. Medlen knew something was wrong, but he bit his lip, dug a thumb into his forearm to keep the pain to himself, and threw two more pitches out of pure exasperation before calling it a day. Before the athletic trainer even reached the mound for a look, he bolted for the dugout with tears in his eyes and his head spinning with doomsday scenarios.
"Everything was good," Medlen said. "Curveball felt good. Changeup felt good. Guys were off-balance, and I was getting them out. Then I throw that changeup, and it's like a knife was stabbing me. I guess I was in denial. So I threw two more pitches and the knife just twisted and twisted again. It was excruciating.
"I'm thinking, 'You've got to be kidding me.' You fight your entire career to establish yourself and get a rotation spot. I was coming off a solid year and everything was coming together. And then it happens again. I'm like, 'I can't believe this is happening to me.'"
Medlen is a little more comfortable recounting the episode 13 months later, as he plugs away in the state of limbo that separates injured athletes from their healthy teammates. He's throwing off a mound again and has a vague eye toward returning to pitch for Kansas City around the All-Star break. But since he's signed to a two-year contract, he can proceed at his own pace without feeling pressure to get back on the mound before he's ready.
Amid the grind of rehab, Medlen finds strength in his self-belief and comfort in the support of an old friend.
While Medlen was rounding into form at Kansas City's spring training camp in Surprise, Arizona, former Atlanta teammate Brandon Beachy was about 20 minutes away at Camelback Ranch, the Cactus League home of the Los Angeles Dodgers. Beachy, also 13 months removed from his second Tommy John surgery, hopes to return to the Dodgers' rotation later this season.
The two pitchers have developed an amusing camaraderie stemming from their shared past. Medlen makes a joking reference to Beachy's good looks when he refers to him as "the Abercrombie & Fitch model." During a recent dinner at Medlen's place at spring training, their wives hung out and Beachy spent time playing with Medlen's 2-year-old son, Max.
"It's a long process, and misery loves company," Beachy said. "We're rooting for each other and following each other. Obviously, it's something you bond over and relate to really well. Not many guys have that experience -- thankfully."
A surge in second-timers Tommy John surgery is generally considered to have a success rate of 80-85 percent, as defined by a return to a prior level of competition for at least one outing. But the procedure has become so routine and is predominantly done by doctors with such extensive track records, there was a period in which it crossed the barrier from successful to foolproof in the public eye. At the height of the lunacy, a narrative developed that every pitcher would inevitably require the procedure, so some high school kids (or their parents) considered having proactive elbow reconstructions just to get it out of the way.
Baseballheatmaps.com, which meticulously tracks Tommy John surgeries, lists Steve Ontiveros as the first big leaguer to have had two confirmed "revisions." Ontiveros had his first Tommy John surgery with Philadelphia in 1989 and his second with Oakland in 1996. Since then, former Reds, Yankees and A's pitcher Jose Rijo attained near-legendary status when he reportedly recovered from three Tommy Johns, two other arm surgeries and a five-year absence from the majors to pitch with Cincinnati in 2002.
Fast forward to today, and Ontiveros and Rijo have lots of company. About 50 pitchers have had multiple elbow reconstructions, and the numbers are increasing too rapidly for everyone's comfort.
Stan Conte, head athletic trainer of the Dodgers, is part of an MLB task force that's keeping tabs on the phenomenon. According to Conte's numbers, the 20 MLB revisions from 2012-14 matched the 20 in baseball during the 12-year stretch from 2000-11.
Conte said revisions generally fall into two categories. The first group, which includes former All-Star closers Brian Wilson and Joakim Soria, had elbow reconstructions in high school or college and eventually blew out the ulnar collateral ligament later down the road in the majors. "You can really blame it on wear and tear," Conte said. "You put a new tire on a car and put 40,000 or 50,000 miles on it and it gets bald again. And then it gives out."
The second group consists of pitchers who needed a second procedure only a few years after the first one failed. It includes the likes of Daniel Hudson, Jarrod Parker, Medlen and Beachy, and is more disconcerting to the medical community because the numbers have surged so much of late.
"You have to ask yourself, 'Why now?'" Conte said. "You develop theories, and that's all we have right now. What we're trying to do is study it to see which theories make sense and which theories don't have any basis."
As baseball mines the data for answers, Medlen and Beachy are among several former Atlanta pitchers in comeback mode. Reliever Jonny Venters, who led the majors with 164 appearances during the 2010 and 2011 seasons, had his third Tommy John surgery in September. He signed a minor-league deal with Tampa Bay in March and is trying to work his way back to the majors. In addition, Cory Gearrin tore his UCL in April 2014 and is currently rehabbing with the San Francisco Giants.
Although Medlen wonders if he might have incurred greater risk bouncing back and forth between the bullpen and the rotation in Atlanta, he absolves the Braves of any blame for his medical issues.
"There are pitchers over there throwing 200 innings and staying healthy, so I don't know what it is," Medlen said. "I never blamed anybody else for anything. It's the same thing when I pitch and someone makes an error: [Stuff] happens. I've never been a person to point fingers, so there's never been a thought in my head that Atlanta did anything wrong. Could I have done something else, like looking at more film to understand my delivery? I don't know."
While Beachy agrees with Medlen that the Braves aren't at fault for his elbow issues, he has followed a different path in his comeback. Medlen went to Dr. Andrews for both of his procedures, while Beachy switched from Andrews to Dr. Neal ElAttrache, a protégée of the late Tommy John pioneer, Dr. Frank Jobe, for his revision. He made the change for peace of mind more than dissatisfaction over Andrews' work.
"For myself to feel good 20 years from now, I needed to do something a little different," Beachy said. "Not that one was right and one was wrong. It just didn't work."
Staying positive The Tommy John surgery recovery protocol is generally consistent regardless of the performing surgeon. Patients are in a splint for a couple of weeks before switching to a brace with hinges. They begin the road back with light range-of-motion exercises, and gradually work their way up to throwing a baseball.
What's the optimal time to pick up a ball? After his first Tommy John surgery, Medlen was throwing in about four months. This time around, he waited until six months and found the timetable was much more beneficial. "It was like night and day better," he said.
The Dodgers take an interesting approach in using a radar gun to monitor pitchers even when they're warming up or throwing in the bullpen. It's meant as a safeguard against pitchers who might get a little frisky and push the envelope.
"We want to keep them in a range," Conte said. "You'll tell a guy, 'Let's throw 65-70 percent today,' and he might start throwing and say, 'I feel great. I'm going to let a couple go.' I don't think anybody blows out with one throw. But if they keep doing it, maybe it could cause a little damage along the way. It's like saying, 'I'm just going to have one candy bar,' and all of a sudden you've had three. That's what we're a little concerned about."
Through experience, Medlen and Beachy have concluded that the old timetable of starters returning from Tommy John surgery to pitch in 12 months is passé and in need of an overhaul. MLB teams seem to agree, and the rule of thumb now falls more in the 16-20 month range. It's easier for teams to exercise restraint when a pitcher gets injured later in the season and has two winters to recover. Such was the case with Mets pitcher Matt Harvey.
"Obviously, the player wants to be on the field," Medlen said. "And the team is paying you, and they want you out there. But I didn't feel normal until a year-and-a-half or two years after I had it, and that's what a lot of other guys say. So why is this 12-month thing even a thing? I honestly have an issue with that."
Can Medlen and Beachy return to the form they displayed when they were healthy in Atlanta? Time, hard work, attentiveness to detail and a little luck will provide the answers. And it helps that they're both a little smarter and discerning about the process than they were the first time around.
When Medlen weighed offers over the winter, he was intent on finding a team with a strong rehab staff and the patience not to rush him. Since signing with Kansas City, he has discovered he has some weaknesses in his left hip that might cause issues in his delivery. If there's even a smidge of a chance that could help him avoid problems, he'll monitor it closely.
Beachy, similarly, has spent a lot of time studying biomechanics and the ins-and-outs of his delivery. But he's taking a pass on the gory details of Tommy John surgery. After his first elbow reconstruction, he received some photos from Andrews of the procedure. This time around, he had no interest.
"I've already become way too in tune with my elbow," Beachy said. "I don't need to see what's going on in there."
Similarly, the pitchers pay no attention to their odds of return, because circumstances vary so much from one pitcher to the next. How does a 28-year-old Beachy compare to, say, a 36-year-old Randy Wolf? And does Medlen, as a command-and-control pitcher, stand a better chance of success than a power pitcher who relies more on velocity?
"People try to generalize the percentages of who comes back," Medlen said. "But I talked to Dr. Andrews, and he told me, 'Guys who have a second Tommy John at 36 or 38 have a lot of other stuff going on.' Bone chips. Bone spurs. I just turned 29 in October and I don't have any of that.
"Percentage-wise, I could give a crap what anybody says. Percentage-wise, what 5-9 right-hander from Norwalk, California, can make it to the big leagues? Tell me those percentages. Every situation is completely different, and that's how I've approached it."
Medlen checks the weekly calendar out of a sense of obligation to see what's next on the horizon. But if he has a bad day, he is experienced enough to know the world hasn't ended and tomorrow will be better. He peppers his conversation with upbeat phraseology, and if he's feeling discouraged, he knows he can go home to his wife, Nicki, little Max and his sister, 4-month-old Penelope, and they'll take his mind off the daily grind.
And when Medlen wants to compare notes on Tommy John surgery, he knows his friend Beachy is always a phone call or a text message away. In the world of Tommy John revisions, it helps to have a lifeline.