PORT ST. LUCIE, Fla. -- New York Mets pitching coach Dan Warthen spotted Johan Santana flinching in discomfort while striking out Omar Infante to end the fifth inning at Turner Field in Atlanta on Sept. 2, 2010. Yet as he rested on a table in the visitors' clubhouse, while trainer Ray Ramirez stretched his left arm, Santana didn't want to leave the game.
"You all right?" Warthen asked.
"I'm going back out there. I'm going back out there," Santana replied.
"Are you all right?" the pitching coach repeated.
"I'm going back out."
"You're not going back out."
Bravado aside, even Santana ultimately recognized the left shoulder that had landed him a six-year, $137.5 million contract with the Mets had deteriorated to the point that he was incapable of pitching.
Twelve days later, after an ill-fated -- and probably ill-advised -- attempt at Wrigley Field to throw a baseball off a mound, during which he lacked any control and "didn't feel like me," Santana underwent surgery to repair a torn anterior capsule.
The procedure had been performed previously on only a handful of pitchers, beginning with Bret Saberhagen on May 28, 1996, says Mets medical director Dr. David Altchek, who operated on Saberhagen at the Hospital for Special Surgery in Manhattan and who also did Santana's repair.
The sparse list of pitchers now also includes Santana's teammate Chris Young, as well as Mark Prior, Chien-Ming Wang, Rich Harden and Dallas Braden. It left a two-inch scar at the front of Santana's prized shoulder, by the armpit -- roughly half the size of Young's scar, incidentally.
"Yeah, there was a little bit of a fight," Warthen recalls about the conversation regarding Santana's shoulder health in Atlanta, "but I think we all realized it wasn't a good thing."
Says Santana: "I walked in after that inning and I knew something was wrong. I went back into the training room and asked Ray to stretch my arm because I didn't feel comfortable. He stretched it, and I was thinking if I was going to go back out or not. Dan came over. I was like, 'Something's just different.' I wanted to go back out, but we decided no más. I took my shirt off and that was the end of it."
Now, after a spring training in which he reliably made five Grapefruit League starts and produced a 3.44 ERA while working every fifth day without interruption, the 33-year-old Santana is on the verge of delivering his first major league pitch in 570 days. Manager Terry Collins affirmed Sunday that Santana will start on Opening Day on Thursday afternoon against the Atlanta Braves, the same opponent he faced in his last regular-season game, this time at Citi Field opposite right-hander Tommy Hanson.
Because anterior capsule surgery has been performed so infrequently on pitchers, how Santana's recovery unfolds will contribute to determining the procedure's effectiveness in extending careers. Altchek believes the southpaw will remain a success story.
"I think we're out of the woods. I really do," Altchek says. "It's just restoring effectiveness as a pitcher. He hasn't pitched in a long time."
Santana is more cautious.
"Let me tell you something," he says. "I've got to do this over and over and over I don't know how many times. When I go every five games and pitch and get to 90 to 100-plus pitches per game, after that I'm pretty sure there will be a good idea on how close I am. But I've done this three times where I've gone over 60 pitches. And I still have a ways to go.
"It's tough. You go one game at a time, or one day at a time. There are times you feel really good. And then you come back and the next day you don't feel so good. That's where you have to look for that balance. As of right now, I feel OK. I feel fine."
The surgery, encapsulated
At medical conferences involving orthopedic surgeons, doctors in the audience often insist during Altchek's presentations that anterior capsule tears must be a new phenomenon. After all, they reason, they have never seen it.
"And then those of us who have seen it will chuckle and think, 'Well, it's probably seen you,'" Altchek says.
The front of the rotator cuff often obstructs viewing the anterior capsule on standard MRIs, leading to misdiagnoses.
The term capsule actually is a misnomer, Altchek says. The capsule is the set of ligaments that run between the ball and socket, holding them in place. The ligaments nearly completely encircle the shoulder. They span the front, bottom and back of the shoulder, but not the top.
Tearing the anterior capsule can result in the ball slipping forward in the shoulder socket during the delivery. Young actually felt discomfort in the back of his right shoulder before his May 16, 2011, surgery, even though the tear was in the front of the capsule, because the rear ligaments that remained intact were stretching as the ball slipped forward in his socket.
If the tear occurs on the socket side, the repair can be done through a less invasive arthroscopic procedure, as was the case with Braden as well as former New York Yankees catcher Jorge Posada. If the tear is on the ball side, the surgeon is required to make an incision and go in through the front. That was the case with both Santana and Young.
Torn anterior capsules very likely are not new injuries among pitchers. Standard MRIs often are not conducive to revealing the tears. A more sophisticated MRI usually is required, or some other sleuth work.
"It's often something that you make an indirect diagnosis of," Altchek says. "In other words, you see fluid in that location, where you're not supposed to see fluid. Then you kind of work backward from there. And then you realize you can see the tear. But it's hard to see."
Says Santana: "I knew that I didn't feel right, that something was wrong in there. And then when Dr. Altchek came out, he told me it didn't look too good, that I hurt my anterior capsule. You could see it on the MRI. It was white stuff. But, at the same time, he was optimistic, because he said he could see it. He knew exactly what they were going to do. They had a plan. So it was good news. He could read it right away. He said there were cases where they couldn't read it."
The small number of pitchers who have undergone the procedure thus far leaves recovery timetable estimates imprecise.
"It's too small a number to really be confident about when they're going to come back, and how to exactly manage their recovery," Altchek says. "We're still feeling our way through, quite honestly. It obviously takes a minimum of a year. That's the absolute minimum. And probably the average is going to net out to be closer to two."
Wang made his major league return on the two-year anniversary of his anterior capsule surgery, on July 29 of last season against the Mets. The former two-time 19-game winner as a Yankee went 4-3 with a 4.04 ERA in 11 starts with the Washington Nationals during the remainder of the season. Braden, Young and Harden's procedures all have been performed in the past 10 months.
Shoulder surgeries generally are more difficult to overcome than elbow surgeries. The Mets witnessed that reality with John Maine, who initially underwent what seemed like a routine shoulder cleanout and never regained the zip on his fastball. Yet Altchek believes the gravity of surgery to repair a torn anterior capsule may be less severe than other notable baseball procedures performed on the shoulder. Altchek believes close to 70 percent of pitchers who undergo the anterior capsule surgery ultimately will return to an effective level in the major leagues, with half of those pitchers meeting their previous level of performance.
"There aren't enough numbers to say, but I'd say based on anatomy and biology -- just theoretically -- this should be more predictable than rotator cuff," Altchek says. "Rotator cuff has less good blood supply, more difficulty healing, and undergoes technically more force. So I think when we get larger numbers, you're going to see that rotator cuff is a worse injury, per se, than this, and has a worse prognosis."
"Tommy John surgery wasn't Tommy John surgery until he came back and won how many games in the big leagues? Then it was deemed a success," says Young, who hopes Santana and he can be comparable early success stories with anterior capsule surgery.
Older pitchers seem to be more susceptible to the tear.
"There's definitely a trend toward the older pitchers to get them, which we're trying to figure out why," Altchek says. "We see it much less commonly in young pitchers -- almost never. And we think it's due to changing mechanics. You're trying to reach back and get more velocity. We think it's because of the inelasticity effects of aging of the capsular tissue."
Santana gutted through the latter part of the 2008 season with torn meniscus cartilage in his left knee. Scouts believe compensating for that injury may have prompted him to alter his mechanics, although Warthen thinks the root of the shoulder injury simply was "a lot of mileage."
The Mets are being vigilant in trying to ensure Santana's current mechanics are consistent with before his injuries. Warthen has sent video to experts. He commissioned a biometric analysis. The pitching coach last week handed Santana the results, and adjustments to his hip positions were recommended.
The road back
If any Met has the tenacity and competitiveness to rebound from anterior capsule surgery, it figures to be Santana. The year he joined the Mets, in 2008, Santana pitched effectively late in the season with the torn meniscus. Despite the injury, he saved the Mets from elimination in Game No. 161 that year. Working on short rest and coming off a career-high 125-pitch outing, Santana tossed a three-hit shutout against the Marlins to delay what turned out to be unavoidable.
Unlike the knee, though, the shoulder would not allow the ultracompetitive Santana to pitch through the trouble. The issue was not pain, but a lack of control caused by the shoulder slipping in its socket. During the bullpen session in Chicago to test the shoulder three days after being pulled from the game in Atlanta, the harder Santana threw, the less he was able to control his offerings.
"Let me tell you something: I didn't feel any pain in my shoulder," Santana says. "I just felt discomfort and I felt a pulling sensation in front of my arm and my pec. And it was manageable. My pain in my shoulder came after my surgery. That's when I felt big pain. That's when I saw that scar -- a couple of inches, whatever that was.
"With my knee, I could feel it was swollen and pain. Bone chips in my arm, you could feel them. But in my shoulder, no."
The return from the surgery has not been perfectly smooth, which is to be expected.
Last spring training, general manager Sandy Alderson forecast a return near the 2011 All-Star break. After Santana pitched in a Florida State League game on July 28, however, he needed another five weeks to get back into a game with Class-A St. Lucie. After those two appearances, he did not reappear until the fall instructional league in Fort Myers, Fla., where he lives.
"My first game, I felt really, really good," Santana recalls about the summer start for the St. Lucie Mets. "The recovery time wasn't there. When I talk about recovery time, I wasn't ready for my next outing after that one. It took over two weeks to really feel good again and be able to throw in a game. That was part of the process. At the time, when that happened, I was like maybe 10 months after surgery. That's what they told me: There's going to be a lot of ups and downs. There are going to be good days. There are going to be bad days. That's something where you have to listen to your body."
Santana shut things down for the winter in early October to allow his body to recuperate from a full season of rehab. During the offseason his activities included being part of a group that bought the Venezuelan soccer club Estudiantes de Merida, for which he cheered as a child. Santana is trying to help restore the soccer club to respectability. It currently is tied for 16th in the 18-team first division in his native country. The bottom two clubs are subject to relegation to the second division.
Santana has demonstrated an ability to pitch every five days this spring training, albeit at lower pitch counts than the regular season will demand. However, in his final Grapefruit League start, last Monday against the St. Louis Cardinals, Santana's velocity -- which had been sitting at 88-89 mph in previous exhibition outings -- sagged to 86 mph in the first inning. He regained zip in the middle innings, before it again dipped to 87 mph in the fifth and final frame of his 88-pitch outing.
The Mets ascribed the velocity dip to nothing more than normal spring-training achiness, enhanced by a significant layoff from major league competition in Santana's case, and not anything worrisome regarding the shoulder. (Still, Santana received an injection of the anti-inflammatory medication Toradol.)
Even working at diminished velocity, Santana has been able to fool batters this spring training.
In a March 21 game, also against the Cardinals, David Freese's bat twice went flying into foul territory as the 2011 World Series MVP swung at third strikes -- once on a changeup, once on a slider. Former teammate Carlos Beltran struck out on a changeup from Santana in the most recent game against St. Louis.
"He's going to continue to progress," Beltran says. "I bet he feels happy. He feels like probably the first year in the big leagues. You know what? He knows how to pitch, so he will find out the way to compete out there. His fastball right now is not there, but it's not that it's not going to be there. I believe it's going to get better, once he goes out there and continues to gain confidence and feels loose. He's a guy that's going to compete."
Says Warthen: "There are very few still around here that remember his last game in 2008, where he never broke 88 mph and threw a shutout against Florida. He can pitch with whatever velocity he has."
The Mets will be conservative with Santana early in the season. Collins acknowledged Santana's April pitch counts will be in the 80- to 95-pitch range. The way the schedule is structured with team off-days, at least six of Santana's first seven starts will come with an extra day of rest.
"I think it's the right way to do it," Altchek says. "Absolutely the right way to do it."
The Mets need Santana to anchor their staff, and not just because of his Cy Young pedigree. He is owed $24 million this season, roughly 26 percent of the team's payroll. Next season, in the final guaranteed year of his deal, he is owed $25.5 million.
There is a vesting option for 2014 at $25 million that likely would require Santana to pitch 215 innings the previous season. Otherwise, he will get another $5.5 million in the form of a buyout.
The Mets desperately need that capital working rather than on the disabled list.
"We're happy with his recovery. Super happy," Altchek says.
Nineteen months after their intense conversation at Turner Field after the pitching coach spotted Santana flinching on the strikeout that ended the fifth inning, Warthen and the southpaw had a far more jovial exchange Saturday. Inside the Port St. Lucie main stadium, with the major league team on the road, Santana was facing imaginary Braves batters, with Warthen calling out the name of the invisible player at bat.
"Brian McCann," Warthen announced. Santana then worked through his approach to Atlanta's six-time All-Star catcher.
After the session, the lefty walked by Collins.
"You've got your pitcher for Thursday," he said.