Wednesday, May 29, 2024

Pitching injuries seem never-ending, and experts see no easy answer to fix MLB’s biggest on-field problem

Arm injuries to pitchers in Major League Baseball have been an unfortunate part of the fabric of the sport for decades. We’ve seen high-profile stuff like Stephen Strasburg’s Tommy John surgery paving the way for a controversial shutdown the next season. In 2015, the Mets and agent Scott Boras publicly feuded about the best course of action, including innings limits or a potential shutdown, for Matt Harvey in his first season back from Tommy John as the team vied for a playoff berth. Every year, the list of pitchers out for the season seems to double.

The 2019 Cy Young winners, Justin Verlander and Jacob deGrom, both needed Tommy John surgery within the first few subsequent seasons. The 2020 American League Cy Young winner, Shane Bieber, went under the knife this past month. The 2021 AL winner, Robbie Ray is recovering from his own Tommy John. Ditto for the 2022 National League winner, Sandy Alcantara. The 2023 AL Cy Young winner, Gerrit Cole, is looking to return from an elbow injury he suffered in spring training. The NL favorite for the 2024 Cy Young was Spencer Strider of the Braves and, sure enough, he’s now recovering from major elbow surgery (internal brace instead of Tommy John). 

We could keep going. The surgeries sure do. The entire sport, from professionals to teenagers, is feeling it. 

“It’s been a 400% increase in elbow injuries in a 10-year span and there’s no end in sight,” injury expert Marty Jaramillo said recently on CBS Sports HQ.  

“Why the rise?” he questioned. “It depends who you ask and everybody is right.”

Still, seeing so many top names go down this spring was enough to cause the outcry to be louder possibly than it has ever been, if we could measure such a thing. Not being able to measure things will be a theme in this discussion, too. You’ll see. 

The continued surge of major arm injuries to pitchers this season got a little extra juice behind it when the MLB Players Association blamed the pitch clock

Despite unanimous player opposition and significant concerns regarding health and safety, the Commissioner’s Office reduced the length of the pitch clock last December just one season removed from imposing the most significant rule change in decades.

Since then, our concerns about the health impacts of reduced recovery time have only intensified. 

The league’s unwillingness thus far to acknowledge or study the effects of these profound change is an unprecedented threat to our game and its most valuable asset — the players. 

The league turned around and pushed back on the assertion: 

This statement ignores the empirical evidence and much more significant long-term trend, over multiple decades, of velocity and spin increases that are highly correlated with arm injuries. Nobody wants to see pitchers get hurt in this game, which is why MLB is currently undergoing a significant comprehensive research study into the causes of this long-term increase, interviewing prominent medical experts across baseball which to date has been consistent with an independent analysis by Johns Hopkins University that found no evidence to support that the introduction of the pitch clock has increased injuries. In fact, JHU found no evidence that pitchers who worked quickly in 2023 were more likely to sustain an injury than those who worked less quickly on average. JHU also found no evidence that pitchers who sped up their pace were more likely to sustain an injury than those who did not. 

In the ensuing weeks, we’ve continued to see pitchers go down and it’ll keep happening. 

CBS Sports interviewed multiple orthopedic surgeons to get an idea of where the medical community stands on pitcher injuries in general and how certain factors might impact the frequency and severity of injuries. 

Let’s start with the most polarizing potential culprit. 

The pitch clock

There’s some level of disagreement, due directly to the unknown. 

“It’s an interesting theory,” Dr. Rodney Benner, an orthopedic surgeon based in Indianapolis, Ind., told CBS Sports. “I don’t know that we’ve ever had a situation in which there’s been a causal link between the time course over which athletic participation happens and the development of injuries. It’s well-documented that repetitive stress is a bad thing over a long period of time, but I don’t know that we’ve ever necessarily talked about recovery time during participation and whether or not shortening an interval of recovery time like the pitch clock does would lead to injuries. So in my opinion, this is kind of unprecedented. I can’t really think of any other sporting event in which we’ve had conversations around the actual timing during participation.”

Dr. David Geier, an orthopedic surgeon based in South Carolina and author of “That’s Gotta Hurt: The Injuries That Changed Sports Forever,” said the pitch clock could “in theory” be to blame for the rash of injuries.

“The way I look at it, the pitch clock is similar to if you go to the gym to lift weights and you shorten the period of time between sets, you’re probably going to struggle to get the same number of reps in the next set and the set after and the set after that you would if you had a longer period of time, a normal break between sets,” he told CBS Sports.

“So if you continue to do the heavy weights in the same number of reps with shorter rest, you’re not going to be able to work out as long, you’re going to end your workout sooner, or, yes, potentially get hurt.”

Jaramillo, meanwhile, said on CBS Sports HQ that the pitch clock’s role is “hard to prove.”

“Many experts talk about if you were training a long-distance runner, you don’t overnight tell him, ‘you’re gonna be a sprinter now,'” he said. “It’s all about tempo and rhythm. You mess with tempo and rhythm, you increase your potential for injury.” 

Still, it’s possible the recovery time doesn’t have a massive impact and these doctors aren’t sure we could prove it even if it did. At the very least, it’s far too early in the Pitch Clock Era to make such a determination. 

“This question is, does recovery time per individual pitch make a difference?” Dr. Dale Snead, an orthopedic surgeon in Carmel, Ind., told CBS Sports. “Is it one minute and I can throw my fastball two more miles per hour? None of us know that answer. It’s crazy to ignore the science that the arm is not designed to throw a ball. If you create more time between pitches, you’re going to create fewer injuries? That, to me, is a far, far, far stretch.”

All three surgeons repeated the same point: it’s simply too early to know.

“When you think about that, from a research perspective, a relatively small number of pitchers having surgery over such a short period of time, in my opinion is nowhere near enough evidence that we can suggest there’s a causal link between the pitch clock and arm injuries,” Benner said. “It’s such a small sample size that it’s hard to make any real conclusions about this over the short time course. In order to solve this from a research perspective, you would have to track injuries over a long period of time with the pitch clock in place and then compare those rates to another long period of time where the pitch clock was not in place. And all that would show you is an association; that doesn’t necessarily prove that there’s a causal link.”

Geier also pointed out that it’s difficult at this point, during the surge, to tell what’s real and what’s a statistical abnormality.

“You don’t really know until you step back with five or 10 years worth of data and you can really see if there was something. Is this a real increase or was this just sort of a slow uptick, we don’t really know,” he told CBS Sports. “This is not to say that it’s not real, but we don’t know if it’s part of a long-term trend or just a weird statistical thing where it’s all just sort of happened. I feel like sometimes we tend to overreact in the moment. Not that I’m saying we want all these injuries by any means, but it’s just hard to know what to make of it and that’s why assigning blame to a pitch clock or to fastball velocity – you have to be careful about making rules based on something in the moment and we’ve seen that so often.

“I don’t particularly like how both sides are just pointing fingers — Major League Baseball points to a study showing one year of pitch clock with no increase in injuries, well, that’s too short a period of time and the players just absolutely saying it is the pitch clock, I don’t think either of those are helpful. They need to work together and look at all the factors.” 

An unnatural arm motion

We’ve heard it too many times: The human arm is just not made to throw a baseball again and again for years, especially not as hard as you can. 

“That amount of velocity and the torque on the arm, it’s the second fastest thing the human body does after sneeze and that’s just not natural over the course of any game, week, season, career,” Geier said. “It’s going to take its toll.” 

Picture the hardest sneeze you’ve ever experienced. Annoying, right? Maybe even painful. Potentially dangerous if you’re driving. Now picture having that happen to you 100+ times in a day and then repeating that every five days, plus some practice sneezes on the days in between. That’s almost torturous, no? 

Kids are putting their arms through that from a young age. There isn’t really a comparison in any other major North American sport, either. Even a quarterback uses a different ball and motion.

“If you think about a rubber band, essentially, and pull it as fast and hard as you can, every time you pulled it until it snapped, that is a baseball pitch,” Snead explained. “Every single throw is thrown as if it’s a snap of the rubber band. It’s just an incredible amount of force across the elbow.”

Perhaps the rubber band analogy isn’t as painful as imagining the sneezing one, but it’s certainly as effective. 

Arms just aren’t made for this. 

“Adding more time between you doing that,” Snead said, “absolutely will not change the injury rate.” 

Velocity and maxing out at all costs

Justin Verlander is a future Hall of Famer, an MVP and a three-time Cy Young winner. He’s always been thoughtful about his craft. He’s also had Tommy John surgery and returned to win one of those aforementioned Cy Young awards. Earlier this season, he said one of the biggest problems was that all the pitchers are maxing out: “I think the biggest thing is that the style of pitching has changed so much. Everyone is throwing the ball as hard as they possibly can and spinning the ball as hard as they possibly can.”

Teams cycle through relievers at an alarming pace. We’ve all seen it. Nondescript relievers throwing high-90s with a sick breaking ball seem to roll off an assembly line. From a front-office perspective, if one gets hurt, just grab another and plug him in — look at how many injuries to stud pitchers the Rays, for example, have seemed to go through and they just keep finding ways to have top-shelf performing arms, for the most part (though it seems to be starting to take its toll this year). 

“We heard Justin Verlander talk about that, suggesting that it was a real issue — that guys are throwing so many more max-effort pitches than they used to and I think that also would warrant more study in order to be able to prove it,” Benner said. “I don’t know if we’d be able to show that this is correct, either, but there’s no doubt velocities across the league seem like they are up and number of pitches thrown 98-100+ miles per hour is definitely up, so all of these things are coming to the forefront of people’s minds just from a research perspective.”

Geier similarly acknowledged that teams clearly value fastball velocity above almost anything else.

“We always thought that, at least at the youth level, that it was the offspeed pitches and maybe it is, but you start to wonder at the major-league level if it’s throwing 98, 99, 100 for X number of pitches per game, game after game after game,” he said. “I think that’s one of the areas if we’re going to stick with a pitch clock — and I’m not necessarily opposed to it, because the game is too long — then you run into the issue of teams pulling their starters earlier and now there are more pitching changes throughout the game. There’s gotta be a little bit of give and take there. I don’t know necessarily how you balance that.” 

Some of that top-shelf stuff seems necessary as the hitters get more and more powerful, but part of that approach loses an artistry to pitching. It isn’t even a recent thing. It’s been a discussion, apparently, going back to the Dead Ball Era. 

“Some pitchers will put all that they have on each ball,” Hall of Fame pitcher Christy Mathewson wrote in his 1912 book,”Pitching in a Pinch: Baseball from the Inside.” “This is foolish for two reasons. In the first place, it exhausts the man physically, and when the pinch comes, he has not the strength to last it out. But second and most important, it shows the batter everything he has which is senseless. A man should always hold something in reserve, a surprise to spring when things get tight.”  

And yet teams still prioritize high-risk pitchers because they are the ones with the high-velocity, high-spin stuff. That’s what is most reliable to get outs. 

“The issue with velocity is a little tricky,” Geier said “Because you can blame the [front offices] on what the teams prioritize by paying all the money to the pitchers who throw 98-102. A pitcher can still be successful with dominant offspeed pitches and good location.” 

Greg Maddux was a master at holding something in reserve. Instead of trying to blow hitters away, he set them up. He was a surgeon instead of just trying to overpower everyone. He’s one of the greatest ever and it does a disservice to any pitcher to be compared to Maddux, but he also had a smooth throwing motion with excellent mechanics and we can’t dismiss that part of it.

Technique matters, the surgeons agreed. So does luck. But velocity may just be king.

“If no one could throw above 85 mph,” Snead said, “the injuries would be nothing.”

The ‘sticky stuff’ crackdown

Tyler Glasnow famously mentioned the crackdown against illegal “gripping agents,” or “sticky stuff,” after he tore his UCL in 2021. 

“I just threw 80 something innings and you just told me I can’t use anything. I have to change everything,” he said at the time. “I truly believe 100% that’s why I got hurt. I’m frustrated MLB doesn’t understand. You can’t just tell us to use nothing. It’s crazy.” 

Glasnow has since clarified that his biggest issue was changing course mid-season, but it’s a worthy discussion to be had, since everything is on the table here. 

Pitchers have gotten accustomed over the course of years in professional baseball to coating their fingers with illegal substances in order to more easily hold the ball. Now, remove the substance and those same pitchers are looking to maintain as much of their spin as possible, which means they are figuratively choking the life out of the baseball. That puts extra strain on the forearm muscles, which feed into, yes, the elbow ligaments, specifically the UCL.

Logically, it lines up, right? Alas, it’s incredibly difficult to research such a thing, because of the myriad variables, such as who was using what substance and when and with what frequency. 

“We’ve removed the tacky substance,” Jaramillo said. “Now every pitcher has changed the way he grips the ball to maximize spin rate. But guess what? How the new grip is involved, it is maximizing the load on the inside part of the elbow.” 

Perhaps there’s a discussion to be had on allowing pitchers to use a little bit tackier substances without allowing them to go all the way to stuff that seems like a cheat code, such as Spider Tack

Youth leagues and misinformation

Dr. James Andrews has been discussing for years the issue with so many people believing Tommy John surgery makes you stronger — not necessarily a super power a la “Rookie of the Year,” but not really too far off. The mindset in far too many parents of a youth pitcher seems to go: He’s already great, but if he gets Tommy John surgery, he’ll get stronger and throw harder. 

Andrews has noted that he dealt with many parents over the years insisting that he perform the procedure on non-injured players. He always declined. Instead, he spent his time trying to find other methods to curb the injuries, such as an elbow brace that prevented full extension.

A 2012 study conducted by Christopher S. Ahmad found that the following percentage of respondents felt that Tommy John surgery should be performed on healthy players to improve performance: 

  • 30% of youth, high school and college coaches
  • 37% of youth, high school and college parents
  • 51% of high school players
  • 26% of college players

It is jaw-dropping that such a large percentage of these people truly believe that having a doctor carve into an otherwise healthy arm is better for the player. It’s that type of misinformation that must be dealt with and it’s going to take years. 

Perhaps we’ve made headway since then that poll was taken 12 years ago. I still feel it is pertinent, though, because the youth and high school athletes from 12 years ago are now major-league age and we’re seeing the arm-injury problem continue to worsen. Basically, that poll speaks to the mindset that has helped create this problem. Anecdotally, anyone who has spent significant time around youth sports these days would say not much has changed. 

For anyone curious as to how a pitcher would seem stronger after the surgery, there’s an easy path to follow here. Let’s say a 15-year-old pitcher tears his UCL and has Tommy John surgery. He had been throwing 78 mph at the time. When he comes back, all of a sudden he feels better and is throwing low-80s. Well, by the time he comes all the way back, he’s 17 now, so he’s bigger and stronger. Plus, the 78 mph heater was coming via a damaged arm ligament and now the ligament is (at least mostly) healthy. Not only that, the wear and tear of throwing so much went away post-surgery as the arm was rested and then rehabbed. During the rehab process, the muscles and ligaments in the area were continually strengthened without the damaging process of throwing something like 75 max-effort pitches multiple times a week. 

If you go through that entire process, the result of the pitcher throwing harder once he’s finally back to full health is one of the easiest conclusions on the board. Of course the kid feels significantly stronger now. 

Not only that, you have to account for the opportunity cost of 18 months of athletic competition lost from a childhood. There’s immeasurable value in those years, I firmly believe. Think about how much fun youth sports can be and then go back and picture losing multiple seasons to injury. You don’t get those back. 

Finally, this above scenario totally ignores any possible setbacks. Even with an otherwise strong and healthy adult like Walker Buehler, it took him nearly two years to return from the time of his injury. Others never recover. Josh Johnson‘s career was ruined after a second Tommy John surgery. Jarrod Parker never pitched in the majors again after his age-24 season. Countless pitchers never reached the majors or even professional ball before arm injuries ruined their careers. 

Still, it’s hard to find a deterrent for parents living vicariously through their children — or simply believing they have a special child who will end up making millions of dollars in the majors. 

I’ll choose Lucas Giolito as an example. He was a prodigy in high school who was expected to be drafted first overall or head to UCLA on a full ride. Instead, elbow concerns dropped him to 16th overall, when the Nationals selected him. He was injured and underwent Tommy John surgery almost immediately. That was in 2012. This past spring, he needed another procedure (internal brace; not Tommy John) and will miss the 2024 season. That part sucks. Again. 

Of course, Giolito also got a signing bonus of nearly $3 million after he was drafted. In between the surgeries, he became an All-Star, was the ace of a playoff team and will have made over $40 million by the end of 2024. For nearly every family pushing a child in youth sports, that’s a success story, not a warning shot.

This isn’t ruining lives down the road like CTE. It’s an elbow and as long as you aren’t throwing a ton once your baseball career is over, whenever that might be, it doesn’t affect your quality of life. 

If the parents are willing to take that risk, why wouldn’t the coaches? And the kids? Get outta here. 

Workload, pitch mix, ball weight in youth leagues

The biggest concerns with young players would be the velocity kids are throwing at such a young age in addition to the heavy workload these children take on. 

Even in terms of individual youth teams being strict with pitch limits on their own players, there’s still plenty of unknown out there, including if breaking balls at an early age are actually a problem. 

“I’ve tried to research this, but as doctors we’ve done a very bad job,” Snead said. “We’re not able to tell these Little League baseball players how many pitches [are detrimental]. When we started off, it was breaking balls that were bad, so you just throw a fastball and changeup. Then we realized that might not be the case, maybe it’s the pitch count. Well, guess what? We don’t include the number of throws you make in between innings. So there’s no way that’s the right answer.”

Even so, Snead said, it’s clear that the wear and tear at that age isn’t helping.

“The kids are bigger, stronger, faster!” he said before transitioning back to his rubber band analogy. “They are throwing faster, harder and the arm is not something that’s designed to [throw a baseball]. It’s cumulative. If you keep pulling that rubber band, pulling that rubber band, pulling that rubber band, eventually it’s going to break.” 

Baseball diamonds are scaled down for the smallest children when they start playing. The bats are smaller. They start hitting off of a tee instead of off pitching. Yet the baseball is basically the same size as a major-league ball from the youngest age. 

“I’ve looked at the weight of the ball,” Snead told CBS Sports. “You try to throw a baseball, a golf ball, a volleyball, a basketball and the forces across your elbow are all going to be different. But yet, in the younger group, they’re throwing the same size ball as a major-league pitcher with a hand that can’t do it. Even in basketball the youth ball is smaller…We should use a smaller, lighter ball for the younger kids to try and help save their elbows. If we can protect our Little League players, maybe it would help.” 

The problem, of course, is that the parents and kids just can’t be policed properly. There are rules in place for pitcher usage pretty uniformly across youth baseball at this point, but Andrews spoke about the problem of year-round baseball and kids playing on multiple teams at once more than a decade ago

“These kids that are playing 85-90 games a season at the youth level are doing a disservice,” said Snead.

For decades, medical and sports communities have tried to hammer home the importance of variety. No one sport should be year-round for kids, especially not for pitchers in baseball. So many other sports are available to be played in the fall and winter, and unless your pitcher is also the star quarterback, they won’t be stressing their throwing arm in any of those sports. 

And yet, the problem persists. Too many parents just aren’t listening. 

Snead told me there will be times a parent brings a young child into his office with an ailing arm. He first asks them, “how many games did [the child] have last weekend?” and the answer will routinely be in the 6-8 range. In one weekend.

But, again, what’s the deterrent in the eyes of these parents? So many of them will agree with the general point, but then will let their actions say something else, which is: Well, sure, but my kid is special.

“At the end of the day, all the professionals that I hold in such high regard, they all said the same thing: Every young man, every young woman, who pitches, they get so many innings on their arms and if a parent thinks that their kid might be a Ferrari, why would you put so much mileage on that Ferrari so early?” Jaramillo said on CBS Sports HQ. 

It’s a great question that doesn’t have a good answer. 

An unfortunate reality with no end in sight

The most significant takeaways right now? Well, we know that pitching hurts arms with high frequency. That’s probably the only thing we know for sure. 

“There’s just not a right answer to this,” said Geier. “We just don’t have the data as to what any one factor is and I suspect it’s a group of factors that have led to this surge in injuries, not just the pitch clock, not just the ridiculously hard throwing that we’re seeing over the last couple of years even though it’s probably the biggest culprit, but we can’t even prove that. It’s just really tricky.” 

We think we know that certain things increase the risk for injury within the realm of pitching: 

  • High velocity
  • High workloads over long periods of time
  • Poor mechanics
  • Maybe the pitch clock, but maybe not
  • Maybe breaking pitches at an early age
  • Far too many games, year round, at the youth level

Still, there’s just so much unknown and it all varies on a player-by-player basis. It’s difficult to know a path forward. 

“If we don’t have the answer, we need to be better about just saying ‘I don’t know,'” Snead told CBS Sports. 

I don’t know. 

I don’t know what the answer is moving forward. I am pretty confident in saying I know injuries are going to continue to be a major part of our game, though, and that it feels like it’s going to take years decades to fix, if it can ever be fixed without morphing the game into something entirely different.

Other than that, I don’t know. No one does.

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