Youth Pitchers Feeling the Pinch of Tommy John Surgery Epidemic
Youth pitchers feeling the pinch of Tommy John surgery epidemic By Laken Litman
Kellen Sillanpaa remembers the big games.
There was a no-hitter in the championship game of a travel tournament when he was 12; the “120-pitch epoch,” where nobody came close to hitting it out of the infield; and the high school playoff game in which he struck out the side in relief as a freshman.
Sillanpaa was competitive, talented and threw hard. College recruiters were watching. But there was a problem. Sillanpaa kept throwing through elbow pain and eventually needed Tommy John elbow surgery, from which he would never fully recover.
The procedure, in which a pitcher’s ulnar collateral ligament in his throwing elbow is reconstructed, has become a topic of national conversation with 28 major leaguers having the surgery or expecting to have it this year. But the injury is also shutting down players years before they even reach the big leagues, with the number of procedures at the youth level rising at an alarming rate. James Andrews, the famed orthopedic surgeon, has called it an epidemic.
Gavin Floyd, who recently returned from Tommy John surgery, left a game with a broken bone in his elbow (Credit: AP)
In 2000, Andrews and his colleague, Glenn Fleisig, reported performing Tommy John surgery on 17 youth and high school players, making up 18% of all elbow reconstructions they did that year. In 2010, the last time Andrews and Flesig collected the data in a similar fashion, there were 41 surgeries on kids making up 31% of the procedures. And Andrews says the stats have gotten worse.
“The largest number of all those different groups, believe it or not, is high school kids,” Andrews told USA TODAY Sports. “They outnumber the professionals. There was a tenfold increase in Tommy John at the high school/youth level in my practice since 2000. I’m doing way more of these procedures than I want to.”
Furthermore kids are less likely to return to their previous form after the surgery, dispelling the notion that pitchers should get Tommy John surgery as soon as possible because it will help them throw harder.
Andrews said the success rate of the surgery on children is lower than it is for adults.
“When we say ‘success,’ that means they go onto play baseball. There’s a higher failure rate than older pitchers because they’re so young and just don’t know how to get through the surgery.”
Andrews said 25% to 30% of kids who have Tommy John surgery aren’t playing baseball two years later.
That doesn’t mean the surgery failed. It could mean a player lost his scholarship or his position on the team or just never got back to playing.
Count Sillanpaa among those out of the game as he prepares to head to college.
“It’s just hard,” said Sillanpaa, who lives in the San Francisco suburb of Fairfield, Calif. “You grow up spending so much time thinking about playing in college and how awesome it’s going to be.”
‘Is it worth it?’
Sillnpaa, 18, said he plans to study political science at Southern California in the fall. Once upon a time he thought he would be also be playing baseball at Stanford, Washington or Cal Poly, the schools who expressed interest in the 6-1, 180-pounder when the speed in mph of his pitches was in the mid-80s.
“We had an all-state pitcher on our varsity that had just left and went to Arizona, and I thought that Kellen could have been that kind of player and maybe something more,” said Jason Chatham, Sillanpaa’s coach at Rodriguez High School in Fairfield. “He was a really talented kid.”
But Sillanpaa had Tommy John surgery when he was 16 and ulnar transposition surgery, which repairs the nerve near the funny bone, two years later, and that was the end of baseball.
“I can honestly tell you that I worked harder than anybody else,” Sillanpaa said. “I can’t hit 80 (mph), I play like crap and have a second surgery on my arm. It’s like, ‘Is it worth it?’”
Sillanpaa first noticed soreness in his left arm when he was 9, but it didn’t affect him, he said. By the time he was 13, it became an issue. He went to see Arthur J. Ting, an orthopedist who has treated prominent Bay Area athletes, including former San Francisco Giants outfielder Barry Bonds. Ting said Sillanpaa‘s elbow was structurally sound, although he put Sillanpaa in a brace for six weeks.
Sillanpaa gave up football and basketball and devoted himself to travel baseball. By the time he was a high school freshman, Sillanpaa starred for the junior varisty and varsity teams. But Sillanpaa struggled in a tournament the following summer and went back to Ting, who said his UCL was not torn.
“He said if I were a big leaguer and was having as much trouble as I was, he probably would have just done the surgery even if the MRI didn’t show it was torn,” Sillanpaa said. But because of Sillanpaa’s age the fact he was still growing, Ting advised against the surgery.
After taking another break and lifting weights in preparation for his sophomore season, Sillanpaa took the mound for a scrimmage and felt a twinge in his elbow. He lost velocity on each subsequent pitch, from 85 to 80 to 77. He had an MRI exam and continued to throw while waiting for the results. The verdict was in: Sillanpaa had torn the UCL and needed Tommy John surgery.
“All that falls on me as his dad,” said his father, Ted Sillanpaa. “Looking back, hindsight, if I had known when he was 11 or 12 that he was going to be a Division I prospect or somebody that scouts thought could get drafted when he was 14, I’d have given him a (pitch count). My experience was that at that really young age it’s just about playing and having fun and making memories.”
Dr. James Andrews (Credit: USA TODAY Sports Images)
Sillanpaa rehabbed for a year after the surgery but still didn’t feel right as he entered his junior season.
“Everybody would always tell me, ‘Kellen, you have the surgery and it’ll be like you have a brand new arm,’” he said.
It’s much harder for young pitchers to come back from Tommy John surgery than professional athletes because major league teams are financially invested in their players.
“They’ve got them for the long haul,” Andrews said. “They’ve got the best of care, a full-time trainer and therapist with them every day. They continue to get paid so they can survive while they’re getting well, and the team sees them fitting in 10 years down the road for longevity.
“In high school, everything is a hurry-up. Same thing in college. ‘I’ve gotta be well by senior year so I can get a scholarship.’ ‘I’ve gotta be well by junior year in college so I push, push, push so I can enter the draft.’ If they finish college and haven’t gotten well from the surgery, what do they do then? They’re in limbo. They gotta go play independent ball or something. It’s a problem with these younger age groups.”
Sillanpaa’s discomfort eventually turned into nerve pain, though he kept pitching. Finally Ting said he needed ulnar nerve transposition surgery.
“I’ve never had in my career a harder-working kid. And that’s not hyperbole,” Chatham said. “Kellen was the hardest worker, so I know that everything that could have been done in order to get his body back into shape was done. He followed the directions of the doctor, and he worked out every part of his body in order to alleviate stress on his arm and on his elbow.”
In 2007, the Little League International Board of Directors unanimously approved pitch count limits based on research conducted by Andrews and Fleisig. Andrews said that injuries at that level have dropped by 30%. His next project is to get similar rules adopted by each high school athletic association.
“You can’t go through the federal government and say change the rules in all 50 states,” he said.
This is how the game gets changed. Kids think if they can throw an 85-mph fastball they’ll get recruited, and they’re right because Division I coaches and big-league scouts look at velocity. Therein lies the problem.
“The coaches are looking for that, unfortunately,” Andrews said. “We need to de-emphasize that at all levels. That’s what’s happening in the pros, too. We’ve got guys that two years ago were throwing 85 and now are throwing 95. How does that happen in two years? And they’re throwing their ligament out right and left.”
After all of the pain and two surgeries, Sillanpaa doesn’t like to watch or talk about baseball anymore.
“I’m not one of those guys where sports is everything and if I get hurt and can’t play anymore then the whole rest of my life is going to be ruined because I can’t do anything else,” he said. “But on an emotional level, I’ve spent so much time thinking about this, it feels like there’s something missing.”
Too Hard, Too Fast, Too Much, Too Soon
Baseball’s Pitching Dilemma: ‘Too Hard, Too Fast, Too Much, Too Soon’
By Danny Knobler
He played high school baseball. He played fall ball. He played summer ball.
But during those three months of the summer, Josh Beckett almost never pitched. His father wouldn't allow it. His coach wouldn't allow it. For those three months a year, Beckett played the outfield instead.
"I definitely don't think I was abused," Beckett said one day in late May. "My dad would never have let that happen. [Summer league coach] Clay Hill wouldn't let it happen. My high school coach, too."
A few days after we spoke, Beckett would make the 321st start of his 14-year big-league career, and it would be a memorable one. He threw the first no-hitter in the major leagues this year, against the Philadelphia Phillies.
One other thing about Beckett: He's never had Tommy John surgery.
He's 34 years old. He's closing in on 2,000 major league innings. He's been on the disabled list with blisters and with mild strains, and he needed surgery last year for thoracic outlet syndrome. But at a time when it seems every pitcher has had Tommy John surgery once, more and more have had it twice and others are on the way to get an MRI to see if they need it, Beckett has so far avoided it.
There's no real way to know if not pitching for those three summer months in high school has helped in keeping his elbow relatively healthy for the 15 years since then. Not every pitcher whose arm is abused gets hurt, and not every pitcher who was protected stays healthy.
But at a time when doctors and trainers describe what we're seeing as an "epidemic," with another baseball draft fast approaching (it begins on Thursday), and more and more of the available pitchers having already had Tommy John surgery or likelier than ever to need it in the years to come, it's probably worth paying attention to some guys who didn't need to get cut.
The numbers really are staggering.
In just April and May of this year, 28 professional pitchers underwent Tommy John surgery, according to an online database maintained by writer Jon Roegele. Only two of those pitchers (Josh Johnson and Peter Moylan) were past their 30th birthday. Five were 21 or younger.
Roegele's list doesn't even count pitchers who aren't yet in pro baseball. Studies by the American Sports Medicine Institute in Birmingham, Alabama, reveal that anywhere from one-quarter to one-third of Tommy John surgeries performed in recent years have been on pitchers in high school or even younger, a huge increase from 10 years ago.
East Carolina University pitcher Jeff Hoffman, who likely would have been one of the first players drafted this year, was one of this spring's victims, going under the knife on May 14. Nevada-Las Vegas pitcher Erick Fedde, another likely first-rounder, according to Jim Callis of MLB.com, also had Tommy John surgery in May.
Doctors and trainers increasingly believe that overuse of teenage pitchers is behind the rise. They also believe that overuse and overthrowing as a teenager leads to a far greater risk of serious arm trouble as a professional. And they have studies to prove it.
"I don't think there's any question it starts in youth baseball," said Kevin Rand, who has spent 33 years in professional baseball, the last 12 as the head athletic trainer for the Detroit Tigers. "You read medicals of kids in the draft, and you'll see one where this kid could have been a good pitcher, but it ended at 15.
"They're throwing too hard, too fast, too much, too soon."
Ask around the baseball world, and you'll hear the same thing from everyone—from current major league pitchers to trainers, doctors, scouting directors, college coaches and even coaches involved in youth baseball.
You'll hear of kids pitching 12 months a year. You'll hear of kids playing for multiple teams during the summer so that they can pitch multiple times per week. You'll hear of kids throwing in a high school game one day and then visiting a private pitching coach and throwing more just two days later. You'll hear of kids visiting private strength trainers, lifting weights and then pitching in a game the very next day.
You'll even hear of 12-year-olds trying to throw split-finger fastballs.
"It's nothing short of child abuse is what it is," Rand said.
But it's not illegal.
"Many [youth baseball programs] have good regulations," said Dr. Glenn Fleisig, the research director at ASMI. "But there's a lot of baseball that is unregulated. Little League Baseball brought [overall limits] up in court, but the kids and the parents won.
"The courts said it's their free right to pitch as much as they want."
Fleisig, who serves on USA Baseball's medical and safety committee and also as the pitching safety consultant for Little League Baseball, can only work to spread the word and get his recommendations out to parents.
The Tommy John epidemic has helped his cause in a way, leading to this story and many others, and leading to Fleisig being swamped with interview requests.
"Someone should do a study on my overuse," he joked.
But really, he and the other medical people want this story to get out. They want it talked about, because they understand that their only chance to combat this epidemic is to convince parents that they need to protect their kids.
"I think a lot of people are looking at it—and that's a great thing," said Stan Conte, the veteran athletic trainer of the Los Angeles Dodgers and a member of a Major League Baseball committee studying the issue.
"Hopefully we can get youth leagues to protect the kids from themselves," Conte said. "It has to be the adults in the room making the decisions. But parents all think it's someone else's kid who is going to get hurt."
More and more kids are getting hurt, and more and more are getting fixed.
Tommy John surgery, originated in 1974 when Dr. Frank Jobe had the revolutionary idea of using a tendon from elsewhere in the body to replace the torn ulnar collateral ligament in Tommy John's 31-year-old left elbow, has indisputably saved the careers of hundreds of pitchers over the 40 years since then. It's been perfected to the point that 80 to 90 percent of pitchers who have the surgery are able to return to the same or higher level of competition in a year.
You'll hear that pitchers come back from Tommy John surgery stronger than before, throwing harder than before. You'll hear that you might as well just give all pitchers Tommy John surgery, just to get it out of the way.
Don't believe it.
First off, there is a risk. As much as Tommy John surgery has been mastered, there are a significant number of cases in which it doesn't work.
Second, nobody comes back throwing harder because he had Tommy John surgery. The doctors say the best they can hope to do is make the replacement ligament as good as the original. If there's any increase in velocity, it's due to other factors (such as getting stronger or normal development).
Finally, Tommy John surgery often isn't the final word. The best guess now is that the replacement ligament has a shelf life of about seven years, or at the most two or three years longer. Thus, a pitcher who needs Tommy John surgery at age 17 could be looking at another one by the time he's 24, or just when his major league career would get going.
And the success rate of a second Tommy John surgery is significantly lower.
Professional teams are well aware of that risk. At least 10 of the 30 major league organizations won't even consider drafting a pitcher if he has already had Tommy John surgery.
Other organizations are willing to take the risk, if they believe the reward is high enough. The Washington Nationals drafted Lucas Giolito in the first round in 2012, even though they knew he would likely need Tommy John (he did), and some team will likely use its first-round pick this June on Hoffman.
Nobody knows for sure why more kids are getting hurt. Nobody knows for sure how to keep kids from getting hurt.
But plenty of very smart people are trying to figure it out.
Fleisig's group believes it has identified risk factors and has published and publicized the risks and their recommendations. The ASMI group includes on its website a list of recommendations for helping young pitchers lower the risk of injury. Soon, ASMI's Dr. James Andrews and Dr. Kevin Wilk plan to release a smartphone app that will help parents and young pitchers set up their own throwing programs.
"Research has shown that the amount of competitive pitching and pitching while fatigued are strongly linked to injury," the ASMI doctors stated. "Other risk factors may include pitching on multiple teams, pitching year-round, playing catcher while not pitching, poor pitching mechanics, and poor physical conditioning."
Coaches and others involved in youth baseball say they see far too many cases in which young pitchers are subject to many or all of those risk factors.
One coach of a travel team in New Jersey said that when his team finishes with its final showcase event on November 1, he recommends that his pitchers shut down from all throwing until at least January 1.
"But I know some of them don’t," the coach said.
The same coach said that he knows some of his pitchers will pitch on American Legion teams during the week, and then come to pitch for him on weekends.
And that's in New Jersey.
There was a time when professional teams saw it as an advantage to draft pitchers from cold-weather states, because the simple change of seasons made it less likely that they had been overpitched. But with the increase in the number of indoor mounds, the explosion in the number of independent pitching instructors and the growth of travel teams and showcase events, even pitchers in the Northeast and Midwest aren't immune from abuse.
"There are so many pitching instructors that they might actually outnumber the pitchers," said Jerry Ford, who runs Perfect Game USA, one of the best-known and most successful of the groups that run showcases and tournaments for amateur players. "There's a pitching instructor on every corner."
Many parents who believe their sons may have the ability to get a professional contract or a college scholarship are willing to pay whatever it takes for what they hope is the best instruction and the best chance. And if one pitching instructor can't help little Johnny throw harder, then maybe the next one can.
And that's the other thing about young pitchers today. They definitely do throw hard.
The research studies all indicate that increased velocity brings with it an increased risk of injury. But the studies haven't been able to keep up with the increases. One 2006 paper discussed risks for pitchers throwing at 85 mph or faster.
Not even a decade later, that line of demarcation seems laughably low.
One major league team saw 103 draft-eligible pitchers this spring alone who touched 95 mph or higher on the radar gun. That same team saw 251 pitchers who touched 92 mph.
Another scouting director said he saw at least two high school pitchers this spring who he clocked at 98 mph or better.
"That's unheard of," he said.
The doctors believe that the risk of injury rises with the velocity, and ASMI's recommendations for young pitchers include a line that says bluntly, "Avoid using radar guns."
The problem with that is that radar guns have become such a big part of scouting—and velocities have increased so rapidly—that pitchers who don't throw hard enough have little shot at getting drafted or getting a chance at a major college scholarship.
"They may not have Tommy John surgery if they threw 85," Perfect Game's Ford said. "But we wouldn't know who they were."
Conte, the Dodgers trainer, makes the opposite case.
"What people have to understand is if you're good enough, it's going to work out—if you stay healthy," he said.
Dr. James Andrews also recommends that the youngest pitchers stay away from breaking balls, even though numerous research papers have actually said that throwing curves at a young age is a minimal risk factor for Tommy John surgery.
For all the talk of velocity and instructors and pitch counts, the thing most doctors, trainers and coaches seem to come back to is that young pitchers are pitching too much.
One high school pitcher in Washington state proudly reported that he had thrown 194 pitches in a single tournament game this month.
"I quite honestly didn't know it was that number," Rochester High baseball coach Jerry Striegel told The Chronicle, after finally taking Dylan Fosnacht out of the game in the 15th inning, "but I'm surprised at the number of people who have really gotten concerned."
Two months earlier, a high school pitcher in Japan reportedly threw 232 pitches in one game.
But stories like those have been around for years. Baseball people in New Jersey still talk about the high school game where future major leaguer Al Leiter struck out 32 batters in 13 innings, throwing more than 200 pitches in the process.
The difference now is it's not just about one game or one weekend. Pitchers now are throwing more pitches, more often.
"There's one thing that's important that's been totally abused," said Tom Holliday, who coaches pitchers at North Carolina State. "And that's the thing called rest."
Holliday said he is constantly shocked when he talks to high school pitchers he is recruiting. One will tell him of pitching in a high school game on a Friday and then going through a full pitching lesson with an instructor two days later. Another will tell him of pitching on multiple summer teams.
"Kids are throwing all year round," he said. "Oh my God, have things changed. A high school guy shouldn't throw all year. Go swimming. Go do what people do in the summer."
But most kids don't do that, and most parents see pitching more as a way to push their kid toward fame and fortune.
Most, but not all.
Mets pitcher Zack Wheeler.
Zack Wheeler was one of the fortunate ones. His older brother Adam had his own pitching career ended by shoulder trouble, and their father was determined to try to keep young Zack healthy.
"I was 11 years old when my brother was drafted, and 14 when he started having arm trouble," Zack Wheeler said. "He'd sort of had arm trouble in high school. My dad was smart enough to know that his son—me—had a good arm. So he went to my coaches and said, 'I'd appreciate it if you don't overpitch my son.'
"One time in high school he went to the coach in the middle of a game. I was at 100-some pitches, and he just went to him and said, 'Hey, that's enough.'"
Wheeler was a two-sport athlete in high school, so he never played winter baseball. His father taught him to throw a curveball at age 12, but he wouldn't allow him to throw it in a game until two years later. He never saw a radar gun until he was 16.
"And I didn't really even care," Wheeler said. "Now, a kid is 12, and instead of trying to get outs, he's trying to throw hard. I never tried to throw hard. That's just what came out."
It still does. Wheeler turned 24 on May 30. He's in the New York Mets starting rotation, one of the more promising (and harder-throwing) young pitchers in the game. And, at least so far, still one of the healthy ones.
There's no way to know for certain if he's healthy now because his father didn't allow him to overthrow when he was a kid. There's no way to know if he'll stay healthy, because any pitcher is at risk.
But if it's your kid, don't you think it's worth trying to lower that risk?
Danny Knobler has been covering baseball for more than 30 years, including 18 seasons on the Detroit Tigers beat for Booth Newspapers and six seasons as a senior MLB writer for CBSSports.com. He has also written for Baseball America, ESPNNewYork.com and MLB.com.
Coaches corner - Pitching Vol. 1
Youth Baseball Pitching Injuries
Baseball is one of the safest sports available for today's youth. However, many of the serious injuries suffered by adult baseball pitchers may have begun to develop at the youth level. One of the missions of the USA Baseball Medical & Safety Advisory Committee is to provide scientifically based information to its youth baseball members to reduce the risk of injury and maximize the younger player's ability to perform and advance to higher levels.
Coaches Corner - Hitting Vol. 1
As pitchers get better and throw harder, the reaction time a hitter has to make his decision and swing gets shorter and shorter. One of the building blocks we teach here at All Star helps eliminate extra movement in the swing. The secret is to separate the "trigger" from the swing.
In every athletic motion there are two parts. First, there is a small action getting the body in position. This preparation phase, or trigger, is typically small, slow, and in the opposite direction of the main action. The second part is the main action.
Coaches Corner - Pitching Vol.2
The main job for a pitcher is simple: to deliver pitches that are hard to hit. The art of pitching gets infinitely more complicated from there. Pitchers and coaches can easily over-complicate young pitchers by adding breaking balls and two or three different types of change-ups. While every different type of pitch has their advantages that make them essential to polished pitchers, it is easy to overlook the value of changing speeds. Change-ups and slow curves are the obvious pitches that come to mind, but you can also change speeds with your fastball by changing the location.
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