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.
"Laws of physics apply to the human body," House said. "When the energy gets to the elbow and the elbow isn't in a position to deliver the forearm, the elbow is what pays the extra price."
Dr. Neal ElAttrache, the Los Angeles Dodgers team physician, sees velocities increasing (Strasburg averaged 97.3 mph on his 620 fastballs for the Nationals last season), without corresponding improvement to poorly conditioned core muscles. Significant elbow stress can follow.
Altchek compares the additional force to a golfer using a stiffer club shaft to carry the load of a more powerful swing. But a pitcher's elbow can't compensate for the increased load like a new club shaft.
"Their ligament," Altchek said, "is not necessarily bigger, stronger and faster."
To repair a ruptured ligament, doctors follow much the same procedure Jobe used for John on Sept. 24, 1974. Today's version is less invasive and takes around an hour. That has decreased recovery time from 12 to 18 months to nine to 12 months. Strasburg's return to Nationals Park one year and three days after Dr. Lewis Yocum fixed his elbow, isn't unusual or rushed. The extended recovery is required to wait for the grafted ligament to mature and gain the elasticity needed to handle the load of pitching.
Jobe's great leap forward transplanted the forearm's palmaris longus tendon, which helps wrinkle the palm, into the damaged elbow. The tendon has a higher tensile strength than the UCL, but isn't necessarily better. Fourteen percent of the population doesn't have the tendon; part of the hamstring is used then.
The new tendon is looped through holes drilled in bone. Altchek developed a "docking" method that shrunk the size of the holes and the number of times the tendon is woven through.
To simplify the procedure, the ulnar nerve usually isn't relocated and muscles and tendons on the inside of the elbow are split, instead of detached, to reach the ligament.
A study Altchek contributed to in 2006 tracked 100 overhead-throwing athletes who underwent Tommy John surgery. Ninety percent returned to compete at the same level or better than before the injury. ElAttrache estimates 10 percent of Tommy John patients re-rupture their ligament, something fixed with a similar procedure.
"There always the chance of it happening again, but if you've never had it done before you think, 'That will never happen to me,' " Zimmermann said. "Then all of a sudden it does."
The surgery's persistent myth is of the new ligament being a super-charged rubber band allowing pitchers to throw harder. Untrue, doctors say. Of nine random pitchers who had Tommy John surgery, six increased their velocity in the first full season after surgery. There weren't dramatic jumps. Josh Johnson's improved from 92.4 mph to 93.5 mph, for example. During six minor league rehabilitation starts, Strasburg's fastball ranged from 92 to 99 mph.
A rigorous, structured yearlong rehabilitation program is one cause of a jump in velocity. Conditioning improves. Mechanics are scrutinized and improved (major league teams frequently - and discreetly - send injured pitchers and prospects to ASMI for biomechanical analysis, where 50 elements of their delivery are measured by frame-by-frame cameras and computers). And the gradual nature of the injury means they're no longer pitching with a slowly failing ligament.
The leaves are changing color, but Strasburg feels as if he's in the middle of spring training. He's thrown 14 1/3 innings in the past year and struck out 25 batters. But his curveball, the last pitch to return after the surgery, is erratic. And his endurance still is building.
"This surgery is really a roller coaster. If you sit there and ride all the highs and lows, you're never going to get out of it," Strasburg said. "You have to look at one month at a time, instead of one day at a time."
ElAttrache does 25 to 40 Tommy John surgeries each year. Yocum does about 50. Dr. James Andrews, who founded ASMI, performs even more. Same with Dr. Tim Kremchek. One surgery each month is a significant number.
"Now we're seeing guys come into professional baseball who had the procedure done when they were younger and were able to continue on," ElAttrache said. "That story is still being written ... those careers have yet to be defined for how important they're going to be in baseball."
Tuesday night, Strasburg and his rebuilt right elbow join the list.
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