Commentary

Nothing 'minor' about shoulder surgery

Fully recovering from shoulder operation usually far less likely than elbow procedure

Originally Published: September 14, 2010
By Jerry Crasnick | ESPN.com

A pennant contender can always use reinforcements, so Chris Young keeps plugging away in the minors in hopes of making a contribution with the San Diego Padres. One night he's pitching relief for the San Antonio Missions in the Texas League, then it's off to the Pacific Northwest for a start with the Triple-A Portland Beavers, followed by a cameo with the Lake Elsinore Storm in the California League playoffs. Young doesn't stick around long, but he makes sure to pay for the food spread at every stop.

[+] EnlargeChris Young
Mark J. Rebilas/US PresswireChris Young has pitched in one game this season after undergoing surgery on his right shoulder in August, 2009.

It's been 15 months since Young shut it down with discomfort in his right shoulder, 13 months since Dr. Heinz Hoenecke performed arthroscopic surgery to repair an impingement, and five months since Young threw six innings and 86 pitches against the Arizona Diamondbacks in his only major league appearance of 2010.

The initial news accounts of Young's surgical procedure in August 2009 described it as a "minor cleanup.'' In reality, shoulder cleanups are "minor'' only if it's somebody else's shoulder.

After Young threw a bullpen session in February, Padres manager Bud Black said he was in a "very good spot.'' In April, Young went on the disabled list with shoulder tightness and told reporters, "I'm not too worried about it.'' That was followed by an aborted minor league rehab start in May, an MRI and months of strengthening exercises, long toss and simulated games before Young finally received clearance to begin his whirlwind tour of San Diego's farm clubs. He's starting to feel like a kid who's forced to unwrap his big birthday present in installments.

"I want to pitch in a big league game,'' Young told reporters last week. "That's my goal and that's what I'm working for.''

Young's intentions are admirable and his commitment is beyond question. But if he wanted certitude, he picked the wrong body part.

Elbows vs. shoulders

If 2010 is the "Year of the Pitcher," it's also the year of the pitching injury. The Minnesota Twins lost Joe Nathan to a torn elbow ligament in spring training, and made do with Jon Rauch and then Matt Capps in the closer role. Jake Peavy, the Chicago White Sox's presumptive ace, suffered a detached latissimus dorsi muscle in July and hopes to be ready by spring training. And now the New York Mets, whose capacity for generating bad news knows no bounds, just lost ace Johan Santana to shoulder surgery.

The most high-profile blowout of the season came in August, when Washington Nationals phenom Stephen Strasburg threw a 90-mph changeup to Philadelphia Phillies outfielder Domonic Brown and reacted as if he'd just touched a piping-hot stove burner. After two medical consultations, an MRI, lots of internal hand-wringing and some ill-conceived remarks by Nationals broadcaster Rob Dibble, Strasburg underwent reconstructive elbow surgery earlier this month.

The injury was an emotional crusher for Strasburg -- not to mention Nationals fans and the team's season ticket department. But if Strasburg needs a boost, he should check out the 2010 All-Star Game rosters, which featured 11 former Tommy John surgery patients. The list includes Josh Johnson, Brian Wilson, Billy Wagner, Tim Hudson and 2009 AL Rookie of the Year Andrew Bailey.

Hudson, 35, tore his ulnar collateral ligament in 2008, and Dr. James Andrews replaced it with a tendon from his hamstring. Hudson returned a year later looking sharp enough to warrant a multiyear contract extension, and now he's a contender for the National League Cy Young and Comeback Player of the Year awards. As Braves catcher Brian McCann recently told the Atlanta Journal-Constitution, "His sinker's sinking harder. His cutter is cutting harder. Everything has that extra gear to it.''

Hudson stops short of calling his elbow reconstruction a fortuitous event, but he concedes that his time away from the field might have done him some good.

"If you're in your 30s and you have a major surgery, you're obviously concerned,'' Hudson said. "But for an older guy going through Tommy John, you have a year to let your body kind of recharge and get stronger. It's almost like you take a pit stop for a year. You can get your elbow redone and get everything else good to go.''

Hudson's professional peers with shoulder problems don't have such uplifting stories to tell. Mark Mulder, Hudson's former Oakland A's teammate, retired after several failed comeback attempts and is now playing competitive golf. Erik Bedard has undergone two shoulder operations and pitched a total of 164 innings in three seasons with the Seattle Mariners. Chien-Ming Wang won't pitch this season in Washington. Kris Benson's recent comeback attempts with Texas and Arizona fizzled, and Mark Prior is giving it one more shot with the Rangers after an audition in the independent Golden Baseball League.

Young is one of three prominent NL West starters trying to overcome shoulder problems. Colorado lefty Jeff Francis posted a 4-4 record in 16 starts, spent a month on the DL and returned to the rotation Monday against San Diego. And Arizona's Brandon Webb, who has yet to pitch in the majors this season, is hoping to squeeze out a few relief innings this month in advance of becoming a free agent in the offseason.

St. Louis righty Chris Carpenter, pitching's patron saint of perseverance, has seen both sides. In 2002, doctors repaired Carpenter's right labrum and inserted three tacks to keep it in place. His body rejected the tacks and scar tissue formed around it, and he had to undergo another surgery in 2003. The experience made Carpenter's 2007 elbow reconstruction seem like a joyride.

"With your elbow, you go through the program, get the range of motion back and do some wrist [exercises], and the pain goes away, everything feels good and off you go,'' Carpenter said. "When you get into the shoulder, it's a flip of the coin.

"For me, the two big things were getting the strength back and not being scared to let the ball go. I consider myself lucky that I was one of the positive outcomes. But my shoulder is still sore off and on, and I have to continue to work hard at it. You'll never have the same shoulder once you have that issue.''

Thank you, Dr. Jobe

Several years ago, the American Journal of Sports Medicine studied 68 pitchers over a five-year span and found that 82 percent of Tommy John patients were able to return to their pre-surgery form in a span of 18½ months. That's particularly impressive considering that the procedure pioneered by Dr. Frank Jobe -- replacing a damaged elbow ligament with a tendon from another part of the body -- remains almost unchanged from the first surgery performed on John in 1974.

In 1995, the Texas Rangers began charting the progress of pitchers in the system who had undergone arm surgery. The Rangers found that about 85 percent of pitchers with elbow injuries made complete comebacks, while fewer than 50 percent came back from shoulder problems to regain their previous levels of health and performance.

Dr. Keith Meister, the Rangers' team physician and a James Andrews disciple, has operated on many of those Texas pitchers, along with several prominent pitchers from other organizations. He repaired Webb's shoulder injury in August 2009, and recently operated on Oakland pitcher Ben Sheets' torn flexor tendon.

Although Meister has seen the positive results from Tommy John surgery, he cautions that it's a serious procedure, with risks involved, and said a lot of athletes don't rebound as hoped. Elbow reconstructions are not, as some news accounts suggest, as simple as a trip to the local Jiffy Lube.

"There are a lot of misconceptions out there,'' Meister said. "Everybody believes, 'I'll get my Tommy John done and it's almost a rite of passage, and I'll be back throwing harder and I'll be stronger.' But there are absolutely no guarantees. In my practice, I see a tremendous amount of kids with elbow problems. A lot of them are second opinions, and more often than not I'm telling them they don't need an operation.''

If Tommy John surgery is considered a new lease on life for a pitcher, shoulder problems are often viewed as a death sentence. That's a major oversimplification. But if a pitcher is going to incur one or the other, the track record is better and the road map for recovery more defined for elbow patients.

"The stresses and loads that the shoulder sees are far more complex than what the elbow sees, and the patterns of movement are more complex, so the problem becomes much more complex,'' Meister said. "If we have to rank them in order of problematic, it's rotator cuff, labrum, then elbow ligament. The rotator cuff is the 'tire tread' of the shoulder, so to speak, so when you wear the tire tread out, more often than not the shoulder goes.''

The shoulder is a shallow, ball-and-socket joint -- often compared to a "a golf ball sitting on a tee'' -- held together by the labrum and rotator cuff, and it's subject to extreme forces. The elbow is a "hinge'' joint, subject to less movement and protected by bone. While ulnar collateral ligaments can go in a flash, they're less susceptible to erosion over time.

"Superficially, 90 percent of scopes or rotator cuff surgeries are just a cleanup,'' said Jamie Reed, the Rangers' medical director and head athletic trainer. "You're not repairing or fixing anything. It's like when you take a rope and go over the corner of a table, back and forth, and get all that fraying. It's the same when you get inside a shoulder. It starts to clog up and get inflamed, and that's where a lot of guys have shoulder pain and discomfort. You're basically getting that tissue that needs to be debrided out of the way.''

[+] EnlargeBrandon Webb
San Gabriel Valley News/Icon SMIBrandon Webb underwent right shoulder surgery in August, 2009, and has made one start in the last two seasons.

Pitchers recovering from Tommy John surgery are generally able to pick up a ball in three months, begin throwing off a mound after six, and move closer to pitching in games after nine months. Reed said the Rangers typically prefer to take things a little slower -- with a 4-7-11 timetable.

Cincinnati Reds pitcher Edinson Volquez returned to the rotation in August, 13 months after Tommy John surgery. He earned a trip back to Class A ball for a refresher course because of his inability to throw strikes, but looked impressive in striking out 10 Pittsburgh Pirates upon his return. The consensus is that Volquez will be better next spring, when his elbow reconstruction is five or six months further in the rearview mirror.

What's the rule of thumb for pitchers recovering from shoulder surgery? Meister tells his patients to expect at least a year of recovery even if all he does is go in and clean up a "little bit'' of labral tissue. But former All-Star Jason Schmidt thinks two years might be a more reasonable target for some pitchers.

Schmidt speaks from experience. After signing a three-year, $47 million contract with the Los Angeles Dodgers before the 2007 season, Schmidt had difficulty throwing strikes and was consistently registering between 82 and 85 mph with his fastball.

"I thought the radar gun was broken,'' he said.

When doctors went in for a look, they were stunned that Schmidt could even reach home plate with his pitches. The damage included a torn labrum, frayed biceps tendon and inflammation of the bursa, a fluid-filled sac that reduces friction in the shoulder. After two surgeries, three victories and 43⅓ innings as a Dodger, Schmidt called it quits in 2009.

Schmidt, now 37 and living in the Phoenix area, follows the game closely enough to relate to the emotional travails of Webb, Young & Co. He remembers how his shoulder would feel fine one day, and inexplicably throb or feel weak the next. He alternated between resting the shoulder and pushing even harder, but neither approach provided more than a temporary respite.

"It's like you're on top of the world … end of your career … on top of the world … end of your career,''' Schmidt said. "That's the hard part -- you just don't know what you're going to get day-to-day.

"After you get your shoulder fixed, you try to throw from your normal arm angle and feel a little pinch there. So you drop down a little bit and don't have that pinch, but you can't locate. And then, since you've dropped down, you start putting pressure somewhere else and your elbow feels sore or you feel soreness in another spot in your shoulder. It's a never-ending battle.''

Schmidt stays busy in his retirement coaching his kids' teams and helping out with a friend's venture capital business. He spoke by phone last week while waiting for his 3-year-old to finish a swim lesson.

Along with the sense of frustration and uncertainty that he felt because of his shoulder injury, he had to deal with the disappointment and guilt of giving the Dodgers almost nothing in return for their $47 million investment.

"That was the hardest part -- signing the contract and getting hurt right at the beginning,'' Schmidt said. "I would love to have those three years back and be that guy to win the big game and help take the team to the playoffs or the World Series.

"If I were still 24 or 25 or even 30, I would still be rehabbing. I wouldn't give up. But I knew going into L.A. that it was probably going to be my last contract. I was ready to spend more time with my family, and that made it easier to walk away from the game. I just didn't get to go out on my own terms.''

Proactive measures

From 1995 through 2003, the Rangers performed 48 shoulder surgeries on pitchers in their organization -- an average of about six a year. Then the team made some changes to foster better coordination among the medical staff, trainers, coaches, front office and talent evaluators in the field. When Texas scouts follow players in the draft now, they're more inclined to be on the lookout for warning signs that might spell trouble down the road. Maybe the team will pass on a prospect with questionable mechanics, or the coaching staff will be more vigilant in correcting flaws in a delivery.

Coincidentally, the Rangers aren't doing nearly as many surgical procedures. From 2004 through 2010, the Rangers performed only 11 shoulder surgeries on pitchers in the organization.

Chris Carpenter With your elbow, you go through the program, get the range of motion back and do some wrist [exercises], and the pain goes away, everything feels good and off you go. When you get into the shoulder, it's a flip of the coin.

-- Cardinals pitcher Chris Carpenter

"That's 37 more pitchers who have a chance to develop,'' Meister said. "That's two full drafts worth of pitchers.''

Milwaukee Brewers pitching coach Rick Peterson is on a personal crusade against pitching injuries. In 2009, Peterson helped found a company called 3P Sports that incorporates his philosophies on biomechanics, conditioning and pitching drills to help enhance performance and reduce injuries for pitchers at all amateur levels. Dr. James Andrews and former big leaguers Tom Glavine and Al Leiter are among the pitching experts involved with Peterson's program.

"What's the best practice to optimize the prevention of injury? First, you need to have a great physical conditioning program so that pitchers can handle the torque and the movement in their deliveries,'' Peterson said. "And second, you need a biomechanical analysis to make sure the delivery is clean. There are certain red flags in a pitching delivery where the prediction of injury is off-the-charts high.''

When injuries do occur -- and they're going to happen regardless of how painstakingly pitch counts and deliveries are monitored -- an athlete's competitive drive and resourcefulness come into play. The best pitchers find a way to adapt, whether it's changing an arm slot, adding a pitch or making do with less velocity on the fastball.

"As surgeons, we all think we know what we're doing and that we can fix you,'' Meister said. "But at the end of the day, the great athletes are going to make you look best.

"I like to say that 'one man's soreness is another man's pain.' Every Major League Baseball pitcher has to throw with a certain amount of discomfort. You either accept that and realize that you need to be able to throw at 100 percent when you only feel 80 percent, or you don't survive in this game. And you need to continually make adjustments. I think that helps explain the greatness of pitchers like Greg Maddux, Tom Glavine and John Smoltz. And to think -- they were all on one pitching staff.''

By that definition, it's no wonder that Carpenter is so highly regarded within the baseball fraternity. His pitching counterparts who have seen his work regimen and maintenance program have a better understanding why he's been able to endure all the pain, discomfort and setbacks in his career.

Pitcher Joe Nelson, who survived major elbow and shoulder problems to play six years in the big leagues, has seen Carpenter's workout routine first-hand, and he was astonished by the commitment involved.

"I know how hard his rehab is,'' Nelson said. "I've watched him do it. You're talking five or six hours a day on whole-body stuff, and two hours working the most mundane, tiny muscles where nobody else in the world sees the results unless you're throwing a baseball.

"It's a very difficult, monotonous process, and it's not for everyone. Some guys just can't fight through it. It doesn't feel good when you pick up a ball and throw and it hurts every time. You're like, 'Is this really worth it?' But some guys keep banging their head against that wall, and they wind up saying, 'Yeah, it's worth it, because I've made it back again.' ''

Is it worth it? That's a question Chris Young, Brandon Webb and countless others have probably asked themselves during long, solitary hours of rehab. Elbows might be more forgiving than shoulders, but the sense of accomplishment is the same for every pitcher who makes it back. And the search for answers is always the hardest part.

Jerry Crasnick is a senior writer for ESPN.com. Click here to purchase a copy of his book, "License to Deal," published by Rodale. Crasnick can be reached via e-mail.

Jerry Crasnick | email

ESPN.com MLB Sr. Writer