- The Washington Times - Monday, September 5, 2011

The pitch was a changeup, no different than 178 other changeups Stephen Strasburg had thrown for the Washington Nationals. But as the baseball left his hand Aug. 21, 2010, something inside his $15.1 million right elbow popped. Strasburg shook his arm. This wasn’t right.

A thick, stubby link in his elbow called the ulnar collateral ligament had ripped apart. The ligament, better known for the procedure to replace it - Tommy John surgery - holds the joint together.

Fourteen years before Strasburg’s birth, Dr. Frank Jobe first replaced the ligament in a sore-armed Los Angeles Dodgers left-hander named Tommy John. With a few tweaks, this is the same procedure the Nationals are counting on to save the career of their 23-year-old ace as he returns to Nationals Park 382 days after his fateful changeup.


The injury used to rip apart careers. Now the once-revolutionary Tommy John surgery is as remarkable as a trip to the dentist. Four other Nationals pitchers wear the surgery’s four-inch scar: Sean Burnett, Todd Coffey, Ryan Mattheus and Jordan Zimmermann. Other pitchers from Chris Carpenter to Tim Hudson to Josh Johnson have undergone the procedure since 2007 and returned to their All-Star ways.

“Years ago, it was a lot of tears and crying and upset,” said David Altchek, the medical director for the New York Mets who has performed more than 1,000 of the surgeries. “Now it’s almost relief.”

Sudden as the pop in Strasburg’s elbow seemed - general manger Mike Rizzo labeled it a freak occurrence - it wasn’t. Talk to any doctor who performs the surgery or biomechanics expert analyzing the minutiae of pitching mechanics and you’ll hear the ligament never tears cleanly in pitchers. Those come when someone lands awkwardly on, say, a knee and ruptures an otherwise heal-thy ligament. Instead, the aftermath of a pitcher’s damaged elbow resembles a rope where the strands have frayed until they finally snapped.

Before the injury in 2010, Strasburg threw only 123 1/3 innings in between the majors and minors and 1,073 pitches for the Nationals. Overuse is the primary culprit, as the problem builds over time. One study of pitchers between 14 and 20 years old in the American Journal of Sports Medicine discovered the risk of injury was 36 times greater among those who threw after their arm felt fatigued. Off-kilter mechanics and poor conditioning contribute, too. While no one can pinpoint the reason for Strasburg’s injury, the 6-foot-4 hurler is noticeably trimmer and spoke about his improved fitness after his first rehabilitation start.

But each doctor brings the conversation back to overuse - the cumulative effect of too many pitches, too many innings when one’s arm is tired, too much use of core muscles.

In 2009, Zimmermann tried to pitch through the discomfort in his right elbow. After a stint on the 15-day disabled list and a minor league rehabilitation start, his velocity and control were normal. But after each pitch, Zimmermann’s elbow stiffened badly. A magnetic resonance imaging test revealed 80 percent of the ligament was torn.

“All the Tommy John injuries are from overuse,” said Glenn Fleisig, director of research at the nonprofit American Sports Medicine Institute in Birmingham, Ala. “They say, ‘It was cold’ or say, ‘I threw a curveball’ or, ‘It was the 100th pitch and I felt something snap or pop.’ It’s not reality. … The injury did not happen on that pitch. That was the last straw.”

Added Dave Attenbaugh, a biomechanist at ASMI: “You saw what was happening for however many months and years culminating in that one pitch.”

When a pitcher’s arm is cocked back as far as it can go and about to move forward, the most stress is on the elbow. The UCL resists the force created by the arm moving back, essentially keeping it from doing loops around the body. You’re applying a varus torque to the valgus load. Like rubber bands, the ligaments and tendons are stretched to their limit.

Normally, proper mechanics should protect the elbow. But when pitching while fatigued, the usual microscopic tears in the ligaments don’t have time to heal. Those tears accumulate and could, eventually, end with the dramatic pop. Even perfect mechanics, pitching guru Tom House said, can’t hold up against too many pitches and too little recovery.

Two key mechanical flaws can add more stress to the elbow. If a right-handed pitcher’s arm is at or below his elbow at the instant his left foot hits the mound, his arm is too late. The elbow takes the brunt of the extra force created by the dead space between the arm and body. The reverse is true, too, where a pitcher’s arm is too early.

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