What it Means When a Pitcher Has to See Dr. James Andrews for Elbow Soreness: A Stephen Strasburg Update

Have you ever been watching ESPN and heard the name Dr. James Andrews?  Dr. Andrews is a board certified orthopedic surgeon, who is best known for performing orthopedic surgeries on professional athletes. Due to his skill as an orthopedic surgeon, his name is now somewhat of a alarm for sports fans, as it means one of their favorite players may be heading to the disabled list.  For the purposes of this post, we will be discussing ulnar collateral ligament (UCL) injuries in overhead throwing athletes, using Washington Nationals pitcher Stephen Strasburg as our example.


On August 17, 2009, the Washington Nationals signed Strasburg to a record breaking 4-year, $15.1 million dollar contract out of San Diego State University.  One year later, Strasburg hit the disabled list with elbow pain, only to later find out he had torn his UCL.  

First off, let's discuss how/why this injury happens.  The overhead throwing motion is extremely stressful on the elbow and over the course of a pitcher's career, the amount of pitches thrown adds up.  This amount of stress may eventually lead to stretching/fraying/tearing of the UCL.  In 2002,  Lyman, S., et al., examined the effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers, finding that the greatest determinant of injury likelihood is that of pitch count.  We will later discuss the implications in development/training of both young and mature athletes.  

At this time, let's review the surgery to repair this torn ligament.  Named after former Los Angeles Dodger's pitcher Tommy John (who was the first professional athlete to successfully undergo the operation), this surgery was invented by Dr. Frank Jobe, and involves the reconstruction of the UCL via graft (cadaver or homograft).  Dr. Michael M. Reinold, PT, DPT, SCS, ATC, CSCS, rehab coordinator for the Boston Red Sox notes that "Although our success rates are close to 85-92% in elite pitchers, other studies have shown only 74% of high school pitchers return to play."  

What does this mean for Stephen Strasburg?  Estimated return to play is roughly 8-12 months, therefore Strasburg will miss the 2011-2012 season, as there is no need to rush him back early and risk further injury. What will be interesting is to see how his performance is affected following his rehabilitation phase.  Many pitchers who have undergone this surgery have reported being able to throw harder than before their initial injury.  Does this mean Strasburg will end up like the kid from that movie Rookie of the Year?  Are people justified in thinking to have this surgery electively in order to throw faster?

According to Dr. Jobe, this is somewhat of a misconception.  He explains this scenario as more of a return to previous function, rather than hyperimprovement.  Job states that, "When a pitcher comes in with elbow problems, you often see that their ligaments were already wearing out well before. Maybe four or five years ago they could throw a 95 mile an hour fastball, but they've had that ability diminished as the ligament's been stretched. What the surgery does is restore the ligament's stability to where it was four or five years ago. A pitcher might say the operation did it, but it's just more stability in the arm contributing to better mechanics." Following the surgery, the patient will typically begin their rehabilitation program which can last up to 12 months.  Early on the focus is on regaining range of motion, eventually moving towards strengthening and participating in a throwing program.

Ok now that we have discussed the injury, surgery, and prognosis/rehabilitation, let us now look at the implications in amateur/professional sports.  As noted earlier, pitch count is the primary determinant for likelihood of injury in the overhead throwing athlete.  Combined with the increase risk of injury following fatigue, a pitcher throwing excessive innings is a high risk candidate.   Limitations on pitches thrown or consecutive games thrown, such as those employed by the Little League World Series are key is decreasing the risk for young athletes.  Parents also may be wondering if their child is at risk by attempting to throw breaking pitches.  Dr. Jobe's answer to this question is the following: "I don't think throwing the curve puts that much more stress on the arm. I think learning how to throw it does. That's why Little League kids get in trouble. They want to throw a curve so they spend every afternoon throwing to their dads, trying as hard as they can to get it. Then if they're good, the coach wants to win. If it's the playoffs, the same kid might pitch three days in a row."  Again, we see that pitch count should be of primary concern.

Alright, that's enough for now. That was an extremely long post.  Hope it was educational.  If you have any comments or suggestions, feel free to email me at jcachodpt@gmail.com, or contact me via facebook.  Hope everyone had a good Wednesday.  Until next time!