Pain before gain: MLB scrambling to find solutions to pitching-related injuries

With a high level of concern, Spin Williams hit send. During a 12-day span in May 2014, six starters in the Washington Nationals organization had been injured. Williams, the Nationals’ senior advisor for player development, had been studying pitching injuries and solutions in 2013 more than he had in the past. Then the batch of injuries hit. Williams’ worry prompted him to release the mass email through the organization. He wanted ideas.

Injured pitchers are not new. They are not specific to the Nationals, an organization known for its tautly structured Tommy John surgery recovery program and its shutdown of Stephen Strasburg in 2012. What has changed is a group effort across the game to reduce the number of injured pitchers. It’s a vexing process of trying to manage multiple levels, with varying motivations, which oversee an unnatural physical effort: Throwing a baseball.

Last season, Major League Baseball launched Pitch Smart, taking the first step toward outlining age-appropriate throwing programs for youth levels. USA Baseball and MLB were the drivers behind its creation. They hope word of best practices spread to stem a rise of pitcher injuries.

When MLB contacted research and medical doctors who had been watching the problem, a correlation was discovered. There were more injuries in younger pitchers as the players evolved from from three-sport athletes to bigger and stronger year-round pitchers. First documentation of overuse and injury at the youth level began in the 1990s. Those kids recently became the professional players embroiled in a surge in surgeries. Baseball is searching for a solution.

“To play baseball, you have to throw the ball,” Williams, a former pitcher, said. “That’s the only way you’re going to learn your craft and trade. We have to allow them to continue to throw, but we have to be smart as an organization and we want to try to be aggressive with trying to keep the injuries down. Because it is getting to epidemic proportion right now and I think it’s important that we continue to research, continue to find ways to cut the injuries down. We’re never not going to have injuries. But, if we can cut them down somewhat and protect our kids more, we’ve got to do it.”

A detrimental disconnect

There is a disconnect between beliefs at higher levels and what is happening with developing players. Williams, Virginia coach Brian O’Connor and Dr. Glenn Fleisig, the research director for the American Sports Medicine Institute, stand united. Pitchers should throw less. Yet, teenagers are throwing more.

After Williams sent his email, the Nationals began to alter their approach. They changed their offseason weightlifting and throwing programs to provide more recovery time. The Nationals also added a full month to their pitchers’ offseason shutdown, escalating the rest period from two months to three.

Williams is 59 years old. The specialization of youth athletics is strange to him. He also thinks it’s detrimental to pitching arms, joining O’Connor and Fleisig in that thought. Bigger, stronger kids are throwing more often. At showcases, speed is the thing. One travel team is often not enough, particularly if the neighbor’s child is on two.

“I think the thing we’re seeing is they’re playing baseball in the summer, then they’re playing fall ball, then they’re taking lessons in the winter and throwing with people giving lessons, then they start up in the spring again,” Williams said. “So, at a young age, they’re tearing down their body and they’re not giving their body time to recover.

“The other thing I see is stronger bodies at a younger age. There again, that’s another reason they need time to recover. I think, if I had to put my finger on one thing, it would be that throwing continuously year round and not giving their body time to recover. As an organization, we’ve addressed that. Hopefully we see the results down the road, but only time will tell.”

Virginia just won the College World Series. If a pitcher wants to play for O’Connor in Charlottesville, he should plan on putting down the baseball. O’Connor and his pitching coach, Karl Kuhn, have extensive philosophies about when players should be pitching. Incoming freshmen are often told to not throw in the summer. The Cavaliers use a 120-pitch count limit for starting pitchers. O’Connor said they exceeded the limit twice in the last seven years by three or four pitches. Once, the pitcher had a perfect game. The other time was during an NCAA tournament game.

The core ideas of Pitch Smart have O’Connor’s backing. It helps that he can relate on several levels. O’Connor was a high-end college pitcher who stalled in the minors. He said he threw all the time. Now, he is managing first-round draft picks and striking a balance between Virginia’s success and the futures of his pitchers. O’Connor grapples with thoughts about how to best protect developing pitchers.

“I think a lot of it, quite frankly, falls on us as parents, and I’m one of them,” O’Connor said. “That you want so much for your children to be successful and we think that them focusing and concentrating everything in one area, will help them … that makes sense, that would make them the best that they can be, right? And, I actually think we’re hindering them.”

Like Williams, O’Connor wonders about two major things: Where has the three-sport athlete gone, and if people at the upper levels of the game are recommending rest, how come those involved in youth baseball do not appear to be listening?

“[Kuhn] said it best, so I want to give him the credit for saying this,” O’Connor said. “The guy that all of us pay to put our pitchers back together, [Dr.] Jim Andrews — that’s who 80 percent of the people are sending men and kids to to put them back together — he is saying that every pitcher should take a minimum of three months off. So, think about this: The guy that everybody’s paying to put them back together, says you should take three months off, but people aren’t following it. How does that make any sense?”

Evolutions in research

Soreness coaxed O’Connor into an appointment with Dr. Frank Jobe, who first performed Tommy John surgery. Jobe told O’Connor in 1992 he needed the surgery, which reconstructs the ulnar collateral ligament in the elbow. O’Connor chose not to have it. He went the pitcher’s equivalent of the tough-guy route — something that can cause its own damage — and chose to pitch when sore. At the time, the surgery was also seen as much riskier than today.

In 2015, viewing Tommy John surgery with such trepidation is as antiquated as the era in which John played. Big-name pitchers, such as Strasburg and Matt Harvey, have had the surgery and returned to throw 97 mph. Teams are drafting players, like the Nationals did with Lucas Giolito, knowing they will need UCL surgery.

The operation and recovery process have evolved like other surgeries. Time with the surgeon is less. Rehabilitation timetables are more succinct. In 12 months, a pitcher can be back on the mound, though it usually takes longer. In the past, a doctor may as well have been telling a pitcher they were going to sever his throwing arm.

That, in part, explains the uptick in Tommy John surgeries. An ESPN study in 2013 showed that one-third of active major league pitchers had undergone the procedure. Numbers for youth pitchers are harder to come by. But, Fleisig said research at ASMI — which was founded by Andrews, who is also atop the listings on the Pitch Smart advisory committee — showed an increase in youth baseball players having the surgery in the 1990s before the increase among professionals.

“It was like deja vu,” Fleisig said. “We put one-and-one together as a committee and said, ’These are connected.’ Whatever these kids were doing as high school kids 12 years ago, they are now today’s 27 year olds. These things were connected.”

Fleisig believes there are false beliefs attached to the surgery. According to his research, a pitcher who has Tommy John surgery returns to their normal level four out of five times — not 100 percent. He also warns against the thought that pitchers can return and be better than before the surgery.

“One thing I’ve heard is it’s going to happen anyway, let’s do it and get it over with at the beginning,” Fleisig said. “Another thing I’ve heard is after the Tommy John, he will be as good as he would have been, no harm except for losing time. And, another thing I’ve heard, that after Tommy John surgery, they’ll be even better than they were before. So, I’ve heard all those things. None of that’s true.”

Assessing the damage

Before Nathan Kirby showed up to be a starting pitcher at Virginia, his elbow would feel sore because he was trying to be cool. Kirby would throw sidearm when he was 10 or 11, which left him temporarily tender.

He said his travel team coach was an advocate of multiple sports and taking time off. Kirby didn’t throw a curveball until he was 18 years old. Despite how he was handled, O’Connor and Kuhn told him not to throw the summer before his freshman year. A summer without touching a baseball was odd for Kirby, but, unlike some stubborn pitchers, he acquiesced.

“He’s a lot smarter than I am,” Kirby said, referring to O’Connor.

After his freshman season, O’Connor and Kuhn developed a program specific to Kirby. Other pitchers received their instructions. During the season, Kirby will lift weights to sustain strength during the year. He has a strong belief in leg strength in order to sustain velocity. In the offseason, he lifts more.

In 2014, he threw a no-hitter against Pittsburgh. Kirby was later named the co-ACC pitcher of the year after his sophomore season. In June, Kirby was drafted 40th overall by the Milwaukee Brewers. When deciding the right time to leave college, Kirby says worrying about injury was never part of the consideration. But, he’s aware of the perceived and real Tommy John surge.

“I think it’s hard not to think about it,” Kirby said. “I don’t know what to think of it. But, I certainly do notice it. It seems like every year the first couple weeks, a lot of people go down. Who knows? It could be from the cold weather. Getting back into it, you may not have your delivery and you throw a pitch wrong. I don’t know.

“I’m certainly keeping my fingers crossed it doesn’t happen to me. It definitely seems to be pretty prevalent. It could have always been that way and we just may not have made as much of a deal about it or know as much as we do about it today. I have no idea.”

Kirby missed time this season because of a sore latissimus dorsi muscle, not arm problems. He has had an operation on his non-throwing shoulder. When he was in Pensacola, Florida, to see Andrews, he ran into another former Virginia pitcher, Danny Hultzen.

Hultzen has not had Tommy John surgery. But, he has had major shoulder surgery that took him from being a No. 2 overall pick to desperate to leave the Seattle Mariners’ spring training home in Peoria, Arizona, for anywhere in the organization.

When Hultzen was young, he said he threw all the time. His youth coaches didn’t think much about the consequences, nor did he. Hultzen threw long toss as often as he wanted to, which was a lot. At St. Albans School, Hultzen was one of two starting pitchers. He said there were pitch-count guidelines, but he did not have “a coach tell me how much was too much or too little.” He said he made it a point to take time off in the late fall and early winter before resuming baseball in January.

When he arrived in Charlottesville, Hultzen and his roommates went out to play catch. Kuhn heard of this and stopped it. Hultzen took the summer off. He was under Virginia’s pitching approach now.

Hultzen was a left-hander who threw four-seam and two-seam fastballs in the low-90s. A “Vulcan” changeup and a slider were also in the quiver. He dominated in college. The Mariners selected him No. 2 overall in 2011.

At spring training in 2012, he walked off the mound after seven pitches. All were strikes. He was done because that was the only inning he was slated to pitch that day. Anticipation for an early and long-term impact was high.

Gone was Hultzen’s time as a first baseman during his non-pitching days in college. He began to throw much more in the pros, in part because of the team’s program, in part because he was filling time after catch and pitcher’s fielding practice. More long toss. More bullpens. More throwing.

“I kind of thought, ’Oh, because I’m not hitting anymore, I can work more on pitching,’” Hultzen said. “But that ended up hurting me, I think.”

His arm hurt. The pain only produced silence and persistence. Hultzen said he tried to push through no matter how his arm ached. Every day after he pitched, he would play catch from 150 feet. “No matter what, every single time.” Long toss every third day. Stay on schedule. This will help.

Hultzen was pitching for the Tacoma Rainiers, the Mariners’ Triple-A affiliate, by this time. The major leagues were about 40 miles north in Seattle. In a twist, he was like his former coach, O’Connor, pitching through pain, except Hultzen was doing it out of stubbornness, not out of surgical fear.

“As an athlete, from a pure competitive point, you never want to come out of the game, you never want to say, ’Oh, this hurts’ because that’s viewed as weakness,” Hultzen said in April. “You don’t want to be viewed as [meek]. You don’t be viewed as that, so you’ll do anything and you’ll keep pushing through, having a kind of blind mindset it will get better or go away.

“That’s when people … I think that’s what happened with me. I didn’t want to say anything because I didn’t want to be viewed as soft and I didn’t want to be viewed as, ’Oh everybody’s always hurt and he’s not tough enough to stick through it.’ I think that obviously ended up hurting me. There was some stuff I kept throwing through and that made my shoulder even worse.”

Hultzen missed the 2013 and 2014 seasons after he had surgery to repair a torn labrum and rotator cuff in his left shoulder. He spent solitary, grinding months in Peoria at the Mariners’ spring training complex, the same place he flipped a dominant single inning during his rise, rehabilitating his arm. This spring he was able to throw again for the Mariners in spring training. They sent him to Double-A Jackson. Hultzen threw eight innings in three starts before going on the disabled list on May 26 with shoulder fatigue. He has not pitched since.

Much of the randomness in trying to protect pitchers from injury are summarized in Hultzen’s travails. When he was young, how much he threw was not a concern, which may have eventually hurt him. In college, he was on a protective schedule, yet his shoulder later failed him anyway. In the meantime, Hultzen’s determination to keep going became something he feels damaged him. No pitch-count guideline is going to stifle that mentality. Only lost years will.

“I’m not trying to be a tough guy anymore,” Hultzen said. “Though it’s really hard to say you’re hurting, that’s the smart thing to do. It’s dumb to try to throw through it. It’s dumb to try to tough it out because you could ruin your career doing that. You could ruin your arm doing that. So, it’s obviously the right decision to speak up if you’re not feeling right.”

Shifting the mentality

Before baseball’s amateur draft began on June 8, Fleisig’s phone was ringing. The questions stirred him.

Teams began asking if they should draft more players who take part in baseball year-round or those playing multiple sports? Should they pick players with high-ball velocity now? Should they draft more pitchers from the north instead of the south, since players in the south are more likely to play more and have more wear and tear on their arms?

“These are questions that teams are raising that they never did before,” Fleisig said.

Fleisig thinks Pitch Smart’s three-pronged approach will work. The first step is using Major League Baseball as the vehicle to spread the word to kids and parents. Having guidelines allows coaches to point to something when a parent is upset or kids want to continue to compete. It can also work in the reverse for a parent concerned about how much throwing their child is doing.

Second, continue to have organizations, like Little League has, latch onto Pitch Smart guidelines. This year, Pitch Smart announced a compliance program. USA Baseball and MLB have no enforcement mechanism for the approach they outline, so they are hoping a virtual stamp of approval for leagues, teams or organizations — even travel teams — can influence business models and allow the market to put value on such accreditation.

Last is a more ethereal hope. Fleisig refers to this as “the prize.”

“You and me could tell all the kids, ’Don’t do this, don’t do that,’ but they think the prize is still out there,” Fleisig said. “[If] they think the kid who pitches the most innings is the one who gets drafted, then our message can’t be as strong. If the prize is actually changing, if the pro teams are going to draft less guys who are playing year-round and less guys who have had some injury problems, then the reward or the prize won’t be there to abuse the pitch count.”

Pitch Smart is in its infancy. Rick Riccobono, the senior director for development at USA Baseball and its lead on Pitch Smart, said he’s hoping for the site’s information to continue to spread. The guidelines on the site now could change as more information comes available. At this time, it’s charted out by age for players up to 18 years old. After that, throwing programs are at the discretion of a college or a professional organization, groups often with different short- and long-term demands for their pitchers.

“I think the consensus certainly is there’s no silver bullet with this right now,” Riccobono said. “There is no single cause. So, to suggest simply by moving to pitch counts we solve 100 percent of the ailments or problems related to Tommy John surgery, nobody’s claiming that on our end.

“This is a step in the right direction. We feel that the site and the resources are a great first step. Nobody is saying it’s perfect. But we feel like this is a really important element of the problems we’re seeing across the board, and I think we can universally agree that when we see reports over the course of a year of a kid throwing 180 pitches in a game or sometimes even more, or throwing 100 one day and coming back and throwing another 100 the next, I don’t think anyone has any question that those kind of areas are detrimental to the athlete. Those are the scenarios we are trying to get away from first and foremost.”

Waiting for a solution

In the last month, Tommy John surgery has ripped through baseball headlines. Cody Morris of Reservoir High School in Fulton, Maryland had Andrews repair his torn UCL on May 28. Morris said he threw just 90 innings the prior season when he was the Maryland Gatorade Player of the Year, then took last fall off. Duke star and Great Falls, Virginia native Michael Matuella had Tommy John surgery just before the draft. He went from a possible No. 1 overall pick to a third-round selection. Young big league stars Jose Fernandez and Matt Moore are expected to return from Tommy John rehab this week. The Tommy John vortex continues to swirl.

Spin Williams is still working toward a best-case solution. He wonders about the influence of weightlifting. Perhaps the extra torque is an influence on the spate of surgeries. Maybe kids will return to multiple sports, and the parent or coaches will back off. He’s convinced recovery is a key and hopes over time the club benefits from the changes in rest. Williams does know one thing, he’d be happy to leave mass emails to someone else.