Differing philosophies frame debate over pitching injuries

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The windup

BYU pitcher Blake Torgerson delivers a ball to home plate. Torgerson had to undergo Tommy John surgery. (Universe Archives)
BYU pitcher Blake Torgerson delivers a ball to home plate. Torgerson had to undergo Tommy John surgery. (Universe Archives)

Blake Torgerson was used to pitching through the pain. That’s the mindset of a pitcher.

This pain was different, though. Torgerson could barely move his arm for three or four days after he would pitch, a process that continued for three weeks. Seven innings and seven strikeouts into BYU’s conference game against Utah in 2009, Torgerson left the mound and a great performance behind. He would later learn he had been playing with a torn ulnar collateral ligament, rendering him unable to move his arm the following day.

When Torgerson realized that something was seriously wrong with his arm as it lay completely motionless by his side, a memory from three weeks prior now held more weight than before.

It was the second or third inning, and Torgerson stood face to face with a TCU batter. He threw a curveball when a distinctive, uncomfortable feeling lingered in his arm. It was the moment he now recognizes that he tore his UCL. Torgerson can’t explain how he managed to pitch during the rest of that TCU game and the three weeks following. To doctors, it’s a miracle that players even get one pitch fired off at the velocity that fastballs are now thrown.

The UCL is a triangular band that unites the upper extremity of the arm to the lower at the elbow. People who tears this ligament, as Torgerson did, can choose to have UCL reconstruction commonly referred to as Tommy John surgery.

The procedure reassembles the connectivity of the arm by replacing the torn UCL with a muscle or tendon from somewhere else in the body. The surgery is most popular among baseball payers, helping to prolong their careers.


Running up the pitch count

The elbow is the main component of any overhead throw, and thus the most vulnerable — especially those clocked at 90-95 miles per hour. The elbow accounts for 16 percent to 22 percent of all MLB injuries, and the last two decades have shown an upward trend of Tommy John surgeries among major league baseball players. In 1996, only 10 players received surgery, but 30 went under the knife in 2014. The MLB saw a peak of 45 players replacing their UCLs in 2012.

Unfortunately for humans, bodies can only move in certain ways with so much pressure before they break down. The arm placed at a 90-degree angle and pushed back is put under 100 newton meters of torque. The stress is equal to the force of holding five bowling balls while the arm is in this position. As the pitcher steps forward, his arm whips back and the UCL withstands just more than half of the force, at 55-newton meters. The elbow withstands this process of pressure with every single pitch thrown. According to orthopedic specialist Dr. Glenn Fleisig, the UCLs of cadavers, when tested, break at 32 newton meters.

“The stress put on the ligament is close to the ultimate load it can bear,” said Dr. Derek Ochiai, an orthopedic surgeon at Nirschl Orthopaedic Center in Virginia.

The increase in reconstructions also exists outside of the majors. In a study conducted by Dr. Brandon J. Erickson of Rush University Medical Center, 51 percent of the 187 elbows operated on at a single institution from 2004-2014 belonged to collegiate athletes. Fifteen-to 19-year-olds made up 57 percent of the patients operated on, making them the largest group to receive the procedure. The average patient age dropped from 29 to 19 over the 10-year analysis period.

Fleisig is most recognized for advocating the protection of the next generation of youth baseball players.

In a study he conducted on behalf of the American Sports Medicine Institute, Fleisig followed 481 youth baseball pitchers aged 9 to 14 for 10 years. He found that the kids who pitched more than 100 innings in a calendar year were 3.5 times more likely to be injured.

The study also concluded that a youth pitcher has a 5 percent risk of serious arm injury within 10 years of pitching. Little League baseball adopted pitch counts in 2007 to reduce the risk of injury down the road for the kids. A pitch count stat was also adopted by the MLB in 2007.

There are still mountains to climb in Dr. Ochiai’s eyes. Pitch counts may be kept in one league, but the majority of youth travel teams don’t track pitches. If they do, they aren’t restricted to any limits that requires them to take out a pitcher after a certain number of pitches.

“People think that that is giving them a tentative advantage because they are gaining more experience and game time exposure, but those guidelines are meant to try to limit as much as possible the stress on at least the developing elbow,” Ochiai said.


Going against the grain

Jeremy Thomas is in his fourth season as BYU’s pitching coach and he holds a different standpoint concerning throwing amount. To him, more is better. His ideology looks at pitching as a race — a long and grueling one.

“What I like to do with our guys and what I tell the young kids is this: you should train your arm like you’re training for a marathon, and as if the game was a 10K or five miles, right?” Thomas said. “If you’re over-training, it’s easy to step back. So, for us that means throwing between 200 and 300 throws a day. When we go in a game they’re only throwing max 100 throws. Game day is a day off for us, and when that happens we find that our guys’ arms feel better.”

Thomas’ perspective is unique to the majority of experts, but it’s not be unfounded. In his combined four seasons at BYU and five at Dixie State prior, Thomas hasn’t had a player go down to Tommy John surgery yet — that is, players who have gone through his throwing program.

He’s dealt with only one player at BYU who had the surgery and the player happened to be at BYU before Thomas was brought onto the staff. Two years before his arrival in Provo, BYU lost three seniors at the same time to Tommy John, one of whom was Torgerson.

Thomas doesn’t take preparation lightly.

“We should warm up to throw; not throw to warm up,” Thomas said. “A lot of times people lift weights, they’ll stretch out before and then they’ll lift, and a lot of times they’ll stretch out afterwards so they’re not stiff the next day. But how many baseball players do you actually see stretch afterwards, after a game? I’m constantly preaching to our guys if they do that work before and after, it’s going to reduce the risk of injury by a lot.”

The increase of Tommy John surgeries in the MLB points to a breadcrumb trail that leads to the feeder systems below it. Every pitcher has frayed ligaments, and those frays started to appear long before they ever saw the majors.

“The reason why I think a lot of guys have problems in the majors and you get so many surgeries is, a high school season is so long; a college season is 50 games,” Thomas said. “Then all of a sudden, these guys go into the pros and they’re having to learn to play 100-160 games, and so what’s happening, once again, their arms aren’t properly prepared.”

Thomas believes the inevitable stress put on the elbow by pitchers is something the body can handle if it’s embraced and prepared for rather than fought. Nearly all of his philosophies lead back to throwing more, not less.


Fighting through 

Torgerson was about 15 months out of Tommy John surgery and feeling good. Rehab had been a slow and steady process, but he did exactly what they told him to do. During a squad scrimmage in the fall, Torgerson felt another twinge in his elbow. An MRI showed a partial tear in his reconstructed UCL.

Torgerson opted not to receive a second surgery, so he did what he was used to: he pitched through the pain. The last time Torgerson ever faced a batter was on the road against Arizona State. Six innings later, Torgerson got the win in his final start and said goodbye to the game – and to the pain.

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