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A Pitcher’s View On The Tommy John “Epidemic”

Los Angeles Angels Shohei Ohtani (17) in action, pitching vs San Francisco Giants.
Kohjiro Kinno/Sports Illustrated via Getty Images

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This story was originally published at Baseball Prospectus on Feb. 14.

Every time a notable pitcher needs to undergo baseball’s most well-known surgery, there seems to be an influx of ill-informed opinions that come with it: some from people who should know better, and some who shouldn’t. But what seems to rarely make its way into the public eye is the opinion of the players who actually have to have this surgery. I’m here to rectify that situation, and explain how a pitcher, who has had Tommy John surgery, views the perilous relationship that all pitchers share with the surgeon’s scalpel, whether they have to go under it or not. 

Last year in particular was a rough one for Tommy John surgeries, or perhaps a bountiful one, if you happen to be a well-renowned orthopedic surgeon. It seemed nearly every week we were greeted with a new high-profile victim of baseball’s most notable and feared surgery. The rate of TJ surgeries last year was the highest in recent memory, outpaced only by 2021, when everyone was coming off of the significantly shorter 2020 season. With the much lower workloads of the 60-game season, and a full sabbatical for much of the minor leagues, it’s not too much of a shock that 2021 saw so many injuries. The 2022 season wasn’t without its hiccups as well, with a bit of a delayed start and an abbreviated spring training that also likely contributed to a higher rate of injuries, at least during the early part of the season. But 2023 was relatively normal by comparison, so what’s pushing the rate so high? Well, believe it or not, it’s not as simple as some would have you believe!

There’s an almost incalculable number of factors that determine whether a pitcher will get injured or stay healthy. If it were something simple, major-league teams would be much better at preventing injury, or at least not giving out massive contracts to pitchers who would spend much of them rehabbing at their spring training complex. And don’t be fooled by the snake oil salesmen on Twitter who will confidently announce when they predicted a pitcher would get hurt, because they make such predictions for nearly every pitcher they see. Much like putting bets on almost every number at the roulette table, this method guarantees a hit every now and then, but it’s going to give most of your money to the house sooner rather than later. But tweets don’t cost anything (yet) so there’s no risk in simply saying you dislike the mechanics of every pitcher you see and predicting they’ll get hurt at some point, then peacocking the correct drop in the ocean of predictions when the proverbial broken clock is correct. And don’t worry, the few pitchers that they deem to have “sustainable” mechanics? As soon as they find themselves on the injured list, or under the knife, the so-called experts will claim they changed their beautiful, perfect mechanics to something worse, conveniently right before they got hurt. No way they could have predicted it, simply out of their hands.

For all the medicine-man charlatan routine worthy of Signor Pirelli, the simple truth is this: The act of pitching is insanely stressful on the body, and anyone who performs it for any significant amount of time is bound to get hurt in some way. In cadaver testing, the Ulnar Collateral Ligament (the one replaced in Tommy John Surgery) will snap well before the equivalent stress of a 90 mph fastball is put on it. This explains why there aren’t many dead guys in the league these days, though Rich Hill is getting up there a bit. So, the ligament in your elbow that needs to be replaced in all of these victims of Mr. Tommy John can’t even handle a fastball at 90, it’s no wonder that this happens so often, right? Shohei Ohtani’s UCL handled 10 mph harder than that for years, and his first replacement UCL did as well! How come everyone’s elbow doesn’t immediately disintegrate the first time they throw a ball over 90?

There are 16 muscles that cross the elbow, and most of them help mitigate the insane amount of stress that goes into throwing a baseball even 90 miles per hour. Your UCL doesn’t take the full amount of the force that’s required to pass through your elbow joint on the way to releasing the ball, or pitching would have stuck with underhand lobs and calling high or low. However, as anyone who has ever gone up a very long flight of stairs or generally done anything is aware, muscles get tired and less effective when they work a lot. And naturally some of the stress *is* being taken by the UCL. One of the core principles that goes into rehab throwing programs is that you can’t get a new ligament ready for the stress of pitching without putting stress on it. 

Many an armchair expert will tell you that they’ve actually solved the problem, so let me take a moment to dispel you of these notions, if you happen to be one of these intellectual standouts. 

”Pitchers need to use their legs more, these guys are getting hurt because they’re throwing with all arm!”

If you have access to a radar gun, I implore you to try to throw a baseball at it as hard as you can from your knees. If you cracked 70 mph I would be impressed. That is, almost by definition, throwing the ball with all arm, and maybe some torso rotation. Counter to what the “conventional” wisdom about pitching says, the more efficiently that you use your legs, and the rest of your body for that matter, the more stress you’re going to be putting on your elbow. And I hear your cries, “no, that’s not what John Smoltz says!” But I ask you to take a moment and think, really think about this. If you use your legs to generate as much force as possible in a pitching delivery, and then efficiently transfer that energy through all of the other parts of your body on their way up to releasing the ball, all of that energy *has* to pass through your elbow on its way to your hand. The thought that you can produce the same or even better velocity and reduce stress on the elbow by “using your legs” more efficiently is, in a word, asinine. Legs don’t make you throw harder, they let you throw harder. The force that causes the ball to leave your hand at whatever speed it did literally had to have been transferred through your elbow joint in order to reach your hand and therefore the baseball. 

“Pitchers are trying to throw too hard! They should stop trying to throw max effort and then maybe they’ll stay healthy!” 

Everyone is definitely trying to throw hard, I’ll give you that, but there’s a reason for this. Baseball is a complicated game and many factors that go into what makes some guys good and other guys not; by and large they aren’t totally understood, even to this day. One of the few things that does have a definite positive correlation with success at the major-league level, however, is velocity. So naturally, pitchers are training to improve the thing that is most strongly correlated with success at the highest level of the game. In the same vein, major-league hitters are very good, and so taking some off in the name of trying to stay healthy probably isn’t actually going to be a winning proposition for all but the most physically gifted of pitchers. 

“But, but Greg Maddux! He didn’t throw hard and was a Hall of Famer because he could locate and make the ball move!”

Greg Maddux’s fastball velocity was graded as a 70 or 80 (as high as the scale goes) when he came up, has said several times that he was trying to throw the ball as hard as he could because that’s how you make it move more, was playing in an era where pitchers got 3-6 inches off the corners of the plate, and had arguably the best command of all time. If more pitchers could emulate what Maddux did and have success, there would probably be more of them in the big leagues. However, there’s really just Kyle Hendricks.

Throwing harder makes all of your stuff better, so it’s the obvious strategic choice for most pitchers to go for. That said, nobody actually understands how command works—or to put it another way,  there is a generally much better understanding within the game of how to improve a pitcher’s velocity than there is on how to improve his command. Even if you aren’t a top-end velo guy, throwing 92 still gives the hitter less time to make a decision than throwing 89 does, and therefore makes the rest of your pitches better. I think I speak for the dominant portion of pitchers when I say that most of us will take the higher injury risk associated with throwing harder in exchange for a better chance of getting hitters out.

And why do we take that trade-off? Because, to put it simply, nobody who has entered the professional ranks as a pitcher did so because they wanted to make sure they never hurt their arm. It’s part of the unspoken agreement that we all have with this game, whether you’re aware of it or not, and these agreements exist for other positions on the field, and other sports as well. Catchers know it’s neither healthy nor sustainable to sit in a squat for several hours, but if you want to play the game, that’s what you have to do. Baseball contains several of the most violent motions in any sport, and requires repeated aggressive rotation in only one direction, which creates massive imbalances in your body after thousands of repetitions performed over years and years of training, practice, and competition. On some level, every football player to have reached a certain level is aware of how seriously they can be injured in the course of any given play in a sport that’s so violent. If your main concern is making sure you never sustain any kind of traumatic injury, you should simply never step foot on the gridiron. Football is more than a contact sport: It’s a collision sport.

The violence in football is obvious. It is apparent in every single play, mountains of men trying to force their way past each other and going airborne to tackle each other to the ground. Meanwhile, the violence inherent in baseball is sometimes so subtle you wouldn’t even know that it’s there. It isn’t interpersonal violence like football; it’s an intrapersonal violence inside every player. Every pitch, every diving catch, every 2-0 daddy hack is putting an unbelievable amount of force on the body of the player performing it. The challenge of staying healthy in football is to not get hurt by the other players, the challenge of doing so in baseball is to not hurt yourself in pursuit of high performance. However, people seem to have significantly less sympathy for injuries when the violence that caused it isn’t as obvious as “300-pound man tackled him a little bit wrong this time.” Baseball injuries are rarely caused by these sorts of physical interactions, much to Super 70’s Sports’ chagrin. Instead baseball injuries are almost mundane, which leads to the assumption that they were easily avoidable if not for the hubris of the player. Oh, you got hurt because you threw too hard? Have you considered maybe not throwing so hard? Consider if football fans reacted to injuries this way. Excuse me Mr. NFL running back out for the year with a torn ACL, did you consider maybe not getting hit so hard, or possibly getting out of the way of the large man coming to tackle you? If I were you I would probably have just not landed on my leg in a way that tore a crucial ligament in my knee, but perhaps I’m just built different. 

The reason that pitchers get hurt so often is simple: The human body is not meant to do what pitchers do. I present this with a caveat, though, which is that I would argue that the human body is literally built to throw things. There’s evidence that thrown object hunting is actually a crucial point in human evolutionary history, and the human shoulder joint is capable of ranges of external rotation not seen in any of our nearest primate relatives. There’s a very common adaptation that occurs in the human shoulder joint that only occurs if you throw things a lot from a young age, called humeral retroversion, that actually changes the joint to allow for more external rotation at the shoulder, which generally allows you to throw things harder. This is why you can almost always tell which celebrities throwing out the first pitch at the ballpark played when they were younger and which ones didn’t. If you didn’t, your arm doesn’t have the room to “lay back” and the resulting throw looks awkward and pushy. So, if the body is meant to throw things, then what do I mean when I say that it’s not meant to do what pitchers do? I mean that the body is not built to withstand the forces associated with going out on a foot-tall hill and throwing a five-ounce ball as hard as you can 100 times. So, the base job description of a pitcher comes with a pretty heavy injury risk as is. Great, you’ve solved the mystery. Unfortunately, there’s just one more thing. 

As I mentioned earlier, there are 16 muscles that cross the elbow and make a valiant effort to try to relieve the UCL of the massive amounts of stress that each pitch puts on it. I also mentioned the relatively indisputable fact that muscles don’t work as well when they’re overworked. Now, if I were in charge of making decisions at Major League Baseball, and I were aware of the fact that pitching is very stressful and that muscles don’t work quite so well when they don’t have enough time to recover, I would most certainly put a pitch clock in place. That is, of course, if I were being bribed heavily by Big Orthopedic Surgery. It isn’t yet clear how much this particular piece of the puzzle is contributing to the higher injury rate this year, but it is certainly contributing, whether MLB wants to acknowledge that or not (spoiler: they don’t). Trust me, I agree with the clock on principle—no one wants to watch Pedro Báez take 90 seconds between pitches—but to deny that the clock is a contributing factor to the high rate of elbow and shoulder injuries this year is to ignore the fact that the Commissioner’s New Clothes aren’t real and he’s actually just naked. 

The Baseball Prospectus logo, horizontally presented.

I can hear you, screaming into your various-sized screens, “But Mr. Wholestaff, shouldn’t the pitch clock incentivize pitchers to try to throw at a more sustainable effort level in order to avoid injury?” And the answer, if you haven’t figured it out yet, is obviously no, because again, the goal of pitching isn’t to avoid injury, but to avoid losing. Every pitcher will by and large be doing the same thing they were doing before, trying to throw the best stuff they can in order to get hitters out and hoping that they don’t get injured in the process. 

By now you’re probably wondering how anyone stays healthy at all, or why some pitchers play their whole career mostly intact. The answers to why are well beyond me (or anyone else who tells you that they have them), but I do have a bit of a theory based on something a fellow pitcher that I was rehabbing with once told me. The pitcher in question was there for a lat strain: nothing too big, but enough to keep him sidelined for a few weeks. Offhandedly, he mentioned that one time he was having an MRI done on his elbow, and they discovered that his UCL was around a millimeter thicker than average. That doesn’t sound like much, but the UCL is only about two millimeters thick to begin with. The conclusion that he and the doctor reading the MRI came to was that he was probably significantly less likely to tear that ligament because of its unusual thickness, and so he probably never hasto worry about it. From that anecdote I’ve extrapolated a weird little theory that it’s unlikely will ever be proven true or false, which is that some guys literally are just built different, and their UCL is just a little bit thicker than average, and that allows their ligament to survive the stress of pitching. Of course, this isn’t actually a solution, and you can’t sell it to people to guarantee that they never get hurt, so it’s not currently a particularly popular theory. 

I imagine at this point you’re asking yourself what the point of writing all of this was if I’m not even going to offer my thoughts on what the solution to this “epidemic” might be. And the answer is simple, there isn’t one, and no one will be doing anything to cure the epidemic, because it isn’t in anyone’s best interest to do so. Pitchers aren’t going to stop trying to throw hard because it would be actively detrimental to their goals of getting hitters out and getting to or remaining in the major leagues. The league doesn’t care because the pitch clock is doing its job and making games faster, and there’s a seemingly endless supply of hard-throwing pitchers ready to step up as quickly as the injured ones fall. Sure, some of the injured ones won’t ever be the same—Tommy John has a good success rate but is by no means perfect—but hey, it’s fine, there’s always a new guy coming up to fill the void left by the ones broken beyond repair. So until the cycle breaks somehow, which I certainly don’t see happening any time soon, the beatings will continue until morale improves. 

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