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Carpenter, Mulder, Clement: A Medical Perspective

 

So far so good.  The 2008 version of our beloved was supposed to “weather the storm,” “stay in it,” “hang on” until the starting pitcher calvary comes.  Sixteen games in, six games over .500? Grravy.

Question is, are the guys we’re waiting for actually worth the wait?  Matt Clement’s shoulder is STILL less than 100%.  We shouldn’t be surprised, really.  Matt’s throwing shoulder needed major reconstruction; including repairing the rotator cuff and tacking the labrum (the cartilage ring around the shoulder socket) back down.   Pitchers usually aren’t the same after labrum repairs.  In addition, Clement in the past has relied heavily on a sinker and slider.  Both pitches place a large amount of torque around the shoulder and elbow joints. 

We all know what Mark Mulder is trying to overcome.  Nobody, not ZIPS, not Bill James, not Chone, likes his chances.  Medically speaking, neither do I.   I question why he didn’t feel pain while pitching with a torn rotator cuff in 2006.  I question why his rotator cuff did not heal after his first surgery.  I question why he again pitched without pain despite the failed repair.  And yes, I finally admit, I question the medical/training staff’s rehabilitation techniques.  If Mark’s shoulder didn’t give him negative feedback (i.e. pain) when he had a TORN ROTATOR CUFF, how can anyone reasonably expect him to find the mechanics that made him so effective in Oakland?   So he’s now making rehab starts and we haven’t heard a negative “arm slot” comment yet.  Will Mark Muldoo make a triumphant return?  I just don’t see it.  Prove me wrong, Mark.  I beg you.

Now, on to Chris Carpenter.  This guy seems to be a medical marvel; recovering from multiple shoulder and elbow surgeries prior to winning a Cy Young.  He’s no spring chicken, however, at 32 years old.  Tommy John surgery, as far as the public is concerned, is a career rejuvenator.  The list of big-name pitchers who have successfully returned to form is long and distinguished (enter your own Top Gun quote here).  My question: is the surgery as good as advertised?   I did some digging to find outcomes research.  Before getting to that, to give VEB readers a better understanding of what these pitchers are up against, I thought I’d shed some light on what goes on during the course of rehab. 

Rehabilitation guidelines correlate with stages of healing.  Tendons and ligaments generally take 6-8 weeks to heal.  In most cases of TJS, a tendon from the forearm, the palmaris longus (sometimes they use a hamstring tendon or piece of the achilles), is cut out and looped between the two elbow bones in a figure-8 pattern to replace the torn ligament.  The tendon takes at least the 6-8 weeks to heal and essentially turn into a ligament.  Strengthening exercises for the shoulder, elbow, and wrist are progressed as appropriate during this 6-8 week window.  Subsequent milestones are as follows:

Advanced Strengthening Phase (Weeks 9-13) 

- In this phase, the athlete progresses with all strengthening exercises, begins power exercises (plyometrics), and resumes golf/swimming activities.

- Goals:

  1. Increase strength, power, endurance
  2. Maintain full elbow range of motion
  3. Prepare athlete for gradual return to functional activities
  4. Prepare athlete to begin to throw

Phase IV-Return to Activity Phase (Weeks 14-26)

- Goals:

  1. Continue to increase strength, power, and endurance of upper extremity musculature.
  2. Prepare athlete for full functional return.

- This is generally where the throwing program begins.  A sample program goes something like this:

Step

Distance

Throwing Schedule

Min./Session

Special Instructions

 

1

30-50 ft

30-50 feet

 

10 to 15

Easy tossing, no wind-up

 

2

50-60 ft

2-3 days/week

10 to 15

Easy tossing, no wind-up

 

3

30 ft

alternate days

10 to 15

Lob ball

 

4

40-50 ft

2-3 days/week

15 to 20

Lob ball with easy wind-up

 

5

60 ft

2-3 days/week

20 to 25

Lob ball with occasional straight throw at 1/2 speed

6

100 ft

2-3 days/week

20 to 25

Lob ball with occasional straight throw at 1/2 speed

7

150 ft

12-day cycle

20 to 25

Throw 150 feet on 5-6 bounces

 

 

 

 

 

 

12-day cycle: Throw 2 days, rest one (repeat 4 times)

8

150 ft

12-day cycle

30 to 35

Gradually increase to 150 feet and then decrease

9

60.5 ft

12-day cycle

30 to 35

Mixed with some long throws, 3/4 speed-full speed

10

60.5 ft

12-day cycle

30

Throw batting practice, 3/4 speed-full speed

 

11

60.5 ft

12-day cycle

25 to 30

Emphasize technique & accuracy, 3/4 speed-full speed

12

60.5 ft

12-day cycle

30 to 35

Gradually increase throwing time, 7/8 speed-full speed

13

60.5 ft

2 days/week

60 to 120

Game simulation including breaks between innings

 

According to most reputable sources, successfully completing this plan may be accomplished quicker than two weeks per step, but it is not recommended.  Optimal results are attained when the recovery is not hurried. 

 

Back to the outcomes research.  A study out of the University of Pennsylvania investigated whether Tommy John Surgery (TJS) is actually as successful as it seems to be.  To investigate the surgery outcomes, researchers compared 68 pitchers who had thrown in at least one major league game before requiring the surgery to a group of 112 randomly selected pitchers who never had this surgery (the "controls").

The results?

  1. 56 of the players, or 50%, were back on the mound by 18.5 months after surgery, with no change in their performance.
  2. Of 68 Major League Baseball pitchers who underwent the surgery between 1998 and 2003, most (82 percent) returned to play with no change in average earned run average or walks or hits per innings pitched.

Good news, right?  We have a better than 4 in 5 chance of getting our ace back, as good as new.  But when?

 According to this study, the AVERAGE rehab timetable for major league pitchers is 18.5 months.  Using that as a guide, I sought out major league starters who returned to start in the big leagues in less than 18.5 after ligament replacement surgery. 

Without further ado, the list, starting with the most recent cases I could find, their age when they had surgery, and their numbers in the last full season prior to the injury compared with their immediate results upon return:

Brandon Backe (28):  DOS 9/7/06  DOR:  9/4/07

             IP - K/9 - BB/9 - ERA+ - WHIP

2005   5.2  5.8   4.0        89         1.46

2007   5.2  3.5   3.5       117        1.33

-Backe made five rehab starts at AAA.  He then said this prior to his 1st start back: "I'm not totally over it, I'm not totally healthy. Next year I should be at 100 percent and good to go. It's kind of a show of hard work making it back this soon.''  Backe started 5 games in 2007, on regular rest. 

Randy Wolf (29):  DOS 7/1/05  DOR 7/30/06 

             IP - K/9 - BB/9 - ERA+ - WHIP

2004   6.0  5.9     2.4      105      1.32

2006   4.7  3.5     3.5       84       1.69

AJ Burnett (26):  DOS 4/29/03  DOR 6/3/04

             IP - K/9 - BB/9 - ERA+ - WHIP

2002   6.2   8.9    4.0     122       1.19

2004   6.0   8.5    2.9     117       1.33

John Lieber (32) DOS 8/8/02  DOR: ST 2004 

-Lieber rehabbed through the end of August 2003. He made three minor league starts and was not recalled in September.  The Yankees made a baseball decision not to pitch him out of the bullpen, even though he was available to do so.  In 2004, he threw 176 innings with an ERA+ of 104.

 Pat Hentgen (32) DOS 5/01  DOR: 9/8/02

              IP - K/9 - BB/9 - ERA+ - WHIP

2000   5.2   4.1    5.5       99        1.19

2002   4.5   4.1    2.9       55        1.33

 *Paul Byrd returned to starting after 13 months post-TJS, but he was buying HGH in that time period.*

 In many cases, starting pitchers returned to pitch as relievers 12-14 months after surgery.  Some notables:

  1. Ryan Dempster (26):  DOS 8/4/03  DOR 8/1/04
  2. Matt Morris (24):  DOS 4/13/99  DOR 5/30/00
  3. John Smoltz (32): DOS 3/00  DOR 5/17/01

So what conclusions can we draw from this? 

  1. Most starting pitchers don't successfully return to starting prior the 18.5-month point.
  2. The outliers (SP's who have returned to starting immediately at 12-14 months post-TJS) were younger than 30. 
  3. Most documented success stories of early return involve gradual transition to the MLB bullpen then back to a starter. 

Chris Carpenter turns 33 in April.  He underwent TJS on July 24, 2007.  He has a history of shoulder and elbow surgeries on the same throwing arm.  My conservative estimate, based on this research, is a return in 14 months, or late September 2008, probably coming out of the bullpen.  I don’t like his prospects as a starter in 2008.

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