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Surgically Impaired Farm System – Part 1

Posted by Jason A. Churchill on August 16, 2005

If you are under the age of 30 and hear the name “Tommy John,” it may or may not mean anything to you – baseball fan or not. But to those who have heard the name before it likely means something entirely different then the few who actually watched the man, Tommy John, pitch in the big leagues for 27 seasons.

The left-hander is best known for being the first recipient of a surgically repaired ulnar collateral ligament in his pitching elbow, a procedure performed by innovative surgeon, Dr. Frank Jobe.

John entered Jobe’s care when he learned that his left elbow ligament was trashed and that he’d likely never throw a competitive pitch ever again. Left with no other options, the then 31-year-old John told his doctor to simply “make something up.”

The rest is history and specialists today estimate that at least 85 percent of the “Tommy John” procedures that are completed are successful, including the overwhelming number of baseball players, specifically pitchers, that are operated on each year.

Star hurlers such as John Smoltz, Mariano Rivera, Eric Gagne, Kerry Wood and Matt Morris have all successfully recovered from Tommy John surgery – and have experienced similar success post-operation as they had before going under the knife.

But the success of Jobe’s invention and the fruit of John’s perseverance and determination cannot provide a blanket solution for the injury to the pitcher. The elbow seems to grow safer and safer from career-ending injuries every year that orthopedic surgeons study and improve the ligament replacement surgery. But that is only half the problem.

It is said that the elbow provides the pitcher with his breaking ball while his ever-so-critical velocity is supplied by his throwing shoulder – and this is where the more serious problem arises.

Two separate injuries occur to the shoulder area – a torn labrum and a torn rotator cuff. Tears in the labrum are much more serious than rotator cuff tears, due to the nature of the anatomical parts themselves.

The rotator cuff is made up of four small muscles that, in essence, hold the shoulder in place and aid in the lifting and rotating of the joint. The muscles and their tendons form a cuff at the top of the shoulder. The four muscles (supraspinatus, infraspinatus, subscapularis, and teres minor) originate from the scapula, or wing bone, and form a tendon unit.

When the muscles tear in the rotator cuff, typically in the supraspinatus, the area needs to be surgically repaired. The same is true in the case of a torn labrum, but two crucial factors make the labrum injury a career-threatening endeavor, while those who have undergone rotator cuff surgery have a much greater track record of recovery and post-operative success.

Unlike the rotator cuff, the labrum is not made up of muscles. Instead it is made up of a thin template of collagen that rests between two bones – the head of the humerus and the glenoid fossa, which is the light curvature where the humerus naturally sits.

Also unlike the rotator cuff procedures, labrum surgery is much more difficult to diagnose. Many experts and specialists claim that the best thing to do when a possible labrum tear presents itself, is to do nothing. Allow the labrum to rest, and hope that the tears repair themselves. The only way to properly diagnose a labrum tear is to perform exploratory surgery – which many doctors in baseball prefer to avoid, at least as a first option.

Why is the rotator cuff much more likely to heal properly than the labrum?

Muscles can be strengthened, even beyond their original levels, both surgically and naturally with proper rehabilitation and rest. The labrum is not made up of muscles, and the collagens that make up the labrum are unable to be strengthened, surgically, nor naturally. The only hope is that the natural healing process is effective enough and fast enough for the pitcher to return to action within two or three calendar years. The surgery cleans the labrum and reattaches the torn areas to their opposing connection.

The labrum provides the shoulder with shock absorption and is an important part of its overall connective structure. When it tears, the strength in the shoulder is reduced greatly, which is why pitchers often complain of a lack of stamina as well as discomfort in their shoulders.

Dr. James Andrews, Dr. Lewis Yocum, and Dr. Anthony Tropiano are all well-versed and experienced in the field of repairing elbow ligaments and repairing rotator cuffs and labrum tears. All three have yet to be presented with a preventative method or training regimen that is reliable to any extent. Translation: There is no means for an active pitcher to stave off the injury.

At this point in time, a labrum cannot be rebuilt or replaced and the experts and specialists that study the labrum injury suggest that the cause of the majority of labrum tears occurs when pitchers throw too often when they are grossly fatigued. Sounds like an easy fix until all of the facts are given.

It is nearly impossible for the club to quantify when a pitcher has reached a high fatigue level. It’s also extremely difficult for the pitcher himself to determine when his shoulder is tired. A pitcher’s overall fatigue factor is not an accurate indication of whether his shoulder has reached its limit. Those who claim that one simply has to “baby” the young pitcher have to realize that each arm is different and no matter how much the pitcher in question is treated with kid gloves, tearing a labrum is virtually unavoidable. If the labrum is going to tear, the only way to avoid it is to stop pitching – which defeats the purpose altogether.

Tommy John surgery is blamed mainly on two issues; the radar gun and the high rate of sliders and curveballs that are being thrown at such intermediate ages – when arms are immature and still developing physically.

But the list of successful returns of major league stars to the mound grows every season. Since the middle of 2004, A.J. Burnett, and quite possibly Seattle’s Rafael Soriano, can be added to the aforementioned list of flame-throwing superstars. Burnett has returned to form and is one of the league’s top free agent commodities heading into this winter’s open market.

The rotator cuff injury tried to claim the career of perhaps the greatest pitcher to ever throw a fastball in America’s pastime. In 1985, Andrews performed an hour-long procedure on Roger Clemens, using an arthroscope that was typically used in repairing knee injuries.

Twenty years, six Cy Young’s and 323 wins later, the Hall of Fame awaits the former shoulder surgery patient.

But the labrum surgery has yet to become a part of the medical marvels as its fellow surgeries have done. The labrum cannot be rebuilt, is terribly complex to diagnose and just as difficult to avoid.


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