A few years back, ESPN's Jerry Crasnick wrote an article on pitchers attempting to come back from corrective shoulder surgery. The piece, which includes a description of Chris Carpenter's labrum injury and the post-surgery scar tissue he overcame as well as Carp quotes, includes this useful background on the shoulder and typical pitcher injuries from Dr. Keith Meister:
"The stresses and loads that the shoulder sees are far more complex than what the elbow sees, and the patterns of movement are more complex, so the problem becomes much more complex,'' Meister said. "If we have to rank them in order of problematic, it's rotator cuff, labrum, then elbow ligament. The rotator cuff is the 'tire tread' of the shoulder, so to speak, so when you wear the tire tread out, more often than not the shoulder goes.''
The shoulder is a shallow, ball-and-socket joint -- often compared to a "a golf ball sitting on a tee'' -- held together by the labrum and rotator cuff, and it's subject to extreme forces. The elbow is a "hinge'' joint, subject to less movement and protected by bone. While ulnar collateral ligaments can go in a flash, they're less susceptible to erosion over time.
"Superficially, 90 percent of scopes or rotator cuff surgeries are just a cleanup,'' said Jamie Reed, the Rangers' medical director and head athletic trainer. "You're not repairing or fixing anything. It's like when you take a rope and go over the corner of a table, back and forth, and get all that fraying. It's the same when you get inside a shoulder. It starts to clog up and get inflamed, and that's where a lot of guys have shoulder pain and discomfort. You're basically getting that tissue that needs to be debrided out of the way.''
Jaime Garcia has required all three surgical repairs listed by Meister. First, Garcia made it back from Tommy John surgery. Then rotator cuff and labrum injuries plagued him for two season. He first opted for conservative treatment, but ultimately required surgery. Garcia was back and pitching again last spring training and made seven starts for the Cardinals in 2014.
As Carpenter shared with Crasnick, Garcia might be considered one of the positive coin flips:
"With your elbow, you go through the program, get the range of motion back and do some wrist [exercises], and the pain goes away, everything feels good and off you go,'' Carpenter said. "When you get into the shoulder, it's a flip of the coin.
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Like Carpenter, Garcia's return from shoulder surgery hit a bump in the road that is something more akin to a boulder: thoracic outlet syndrome. Carpenter experienced nerve irritation in 2004 that ended his season in September and prevented him from pitching in the playoffs. But he didn't require thoracic outlet release surgery until eight years later.
For those unfamiliar, thoracic outlet syndrome is a condition impacting the nerves or blood vessels that pass from the torso to the arm, hand, and fingers beneath the shoulder. The nerves and blood vessels become contracted—often between the first rib and collar bone, which is why Carp had a rib removed—which oftentimes results in tingling, burning, or numbness in the extremities.
Given the symptoms, it's easy to see how this condition would make pitching effectively difficult. But thoracic outlet release is not a surefire cure that will enable a pitcher to take the mound and pitch effectively again. That's not to say the procedure ends careers, just that it has ended some. For every Kenny Rogers there's a Carpenter.
The question now of course is which list Garcia will find himself on. After having his rotator cuff debrided, labrum stitched, and thoracic outlet expanded, will he be physically capable of pitching at the major-league level again?
It's early spring, which means bullpens and game appearances often includes positives and negatives. Right now, it's safe to say that the positive to Garcia's early-spring pitching is the movement. Tony Cruz, who caught Garcia, and Mark Reynolds, who stood in while the lefty threw earlier in camp, gave his stuff positive reviews, according to a Rick Hummel report in the St. Louis Post-Dispatch:
Catcher Tony Cruz, who admitted he always has had difficulty catching Garcia’s darting deliveries, said he was pleasantly surprised by Garcia’s velocity, movement and offspeed stuff.
"I wouldn’t say he was like he was when he was good, but he looked good for what he’s gone through," said Cruz. "I was happy the way he threw the ball. He’s got nasty stuff."
Longtime opponent Mark Reynolds noted that Garcia wasn’t able to come inside as much as Garcia would have liked, but he said, "The ball was moving all over the place."
After watching Carpenter try in vain to pitch effectively post-thoracic outlet release with flat offerings that did not possess much bite, the positive reviews of Garcia's movement were heartening. Of course, command was a question (even if pitching coach Derek Lilliquist cast aside Michael Wacha's command problems in the same session by noting that nobody's command is in midseason form at the end of February). After Garcia threw 20 of 41 pitches for strikes during his first spring start, command is still an issue.
(Seriously, though, that movement.)
Per Brian Stull at STL Baesball Weekly (with audio embed), Garcia chalked up his command issues to adrenaline:
"Today it got away from me a little bit," said Jaime, who noted the extra adrenaline and excitement of a first start could’ve played a part. "The movement was a little too much. It’s just a matter of being able to control that and just gotta be able to a better job of that next time."
It's probably too early to count on Garcia being healthy, but it's the exact right time to feel optimistic. Garcia is pitching again with good movement. Now all we need is for the command to follow suit.