New science, strategy may halt rate of arm injuries

Matt Harvey will get a second opinion on his injured right elbow from renowned orthopedic surgeon Dr. James Andrews on Monday, hopeful that the partial tear in his ulnar collateral ligament won't require the Tommy John surgery that would all but eliminate his chances of pitching competitively in 2014.

However the surgical situation shakes out, Harvey's injury was a bummer for baseball. The sport, after all, has gone to great lengths to protect its arms with pitch counts and innings caps.

By and large, though, pitchers keep blowing out their arms at an alarming rate.

Will Carroll, a sportswriter specializing in medical issues, conducted a study for Bleacher Report that found that one-third of pitchers on Major League rosters on Opening Day this season had Tommy John surgery at some point. And the ever-rising tide of arm trouble has created the game's greatest economic inefficiency. Carroll has estimated that in the decade from 2002-12, teams spent $1.7 billion on pitchers on the disabled list

"It makes you sick," Reds pitching coach Bryan Price said. "You look at a guy like Matt Harvey, and he seems to epitomize the big, strong, hard-working young pitcher. Same thing with Stephen Strasburg. Washington couldn't have done anything better with how they handled him before he got hurt. They did everything right, and it still happens."

Now, we can explain away the arm injury epidemic any number of ways.

For one, we can point out that it's far from a new epidemic. Because while we tend to romanticize the likes of Walter Johnson or Tom Seaver or Nolan Ryan, baseball history is loaded with the untold tales of the guys who flamed out with fatigue or physical flaws that went undiagnosed or untreated. If anything, that paints a pleasant picture of the current medical marvels that allow Tommy John recipients to be back on a Major League mound as soon as a year after they go under the knife.

We can also say that the game is fundamentally different than it was in the workhorse days of yore. Guys throw harder (the Cardinals played a 16-inning game last week in which the eighth guy out of their bullpen was throwing 99 mph) with more variations of breaking pitches and, ergo, more stress on the arm and shoulder.

Furthermore, we can openly wonder whether year-round baseball at the youth level is compounding the problem, putting undue duress on young arms that can come back to haunt them eventually, if not immediately.

All of these arguments have merit. And the truth is, we can go around and around on this issue, only to throw our hands in the air and come to the conclusion that arm injuries are unavoidable because the pitching motion itself is unnatural.

But there are people inside and outside the baseball industry who aren't content with that conclusion. They believe the condition of arm conditioning is not quite what it could be and that while baseball will never eliminate arm injuries completely, it would do well to investigate new strategies to stem the tide.

Their arguments have merit, too.

The science

"I'm certain we're going to look back on what we did here in 2012, 2013 and not too far into the future and think that it was really primitive," said Dr. Marcus Elliott, a Harvard-trained physician specializing in sports science.

Elliott has worked with athletes in the Olympic Training Center and the Australian Institute of Sport, he's served as a physiologist and injury prevention specialist to the New England Patriots, he's been a consultant for the Utah Jazz and, more pointedly, he's served as baseball's first Director of Sports Science and Performance, for the Seattle Mariners.

Elliott, therefore, is well-versed in the pitch-count model and the somewhat arbitrary innings-limit ceilings being used in professional baseball today, and he struggles to understand their application.

"There are reasons guys end up tearing their ulnar collateral ligament or end up with repetitive trauma to a rotator cuff," Elliott said. "There are mechanical explanations for all these things. And we haven't spent a whole lot of time trying to understand what those reasons are."

At his Santa Barbara, Calif., lab, Elliott and his team seek to find those reasons. He conducts biomechanical analyses of athletes to discover where they are applying torques that are larger than they can handle. He follows Newtonian physics models to determine where people are going to get broken.

Elliott tells the story of his first year with the Mariners, when the club ran his tests on every member of the organization and came up with a list of the 10 players at the most risk for an injury. By season's end, seven of the 10 had, indeed, spent significant time on the DL.

So the following year, they did the tests again. And this time, the 10 targets -- primarily pitchers -- stayed back in Arizona when Spring Training camp broke so that Elliott and his team could develop objective measures for them.

"Some of them had inadequate shoulder mobility or not enough trunk stability or hip stability, so it affected their release point," Elliott said. "We took anywhere from three weeks to six weeks to keep working on these performance metrics so that they didn't have the pressure of going out to perform while they were huge injury risks."

The key here was personalizing the programs, suiting them to a certain guy's certain needs. It is a goal Dr. Glenn Fleisig, research director of the American Sports Medicine Institute, has also sought in his biomechanical studies of thousands of pitchers from all amateur and professional levels.

But the problem with these studies is that their findings are difficult -- and expensive -- to implement in organizations that employ literally hundreds of players. In baseball, it is easier to take broad preparatory concepts and apply them at large, rather than tailoring them to the individual.

"To people in the medical community," Elliott said, "the right approach is to be about building systems, understanding the system of the athlete in front of you when you're exposing him to the risks of the game."

And to people in the training community, the right approach is to have the body truly ready for the rigors of the game.

The strategy

"My guys don't get hurt," said Arizona State University associate head coach and recruiting coordinator Ken Knutson.

Knutson said it has been 13 years -- dating back to his time at the University of Washington -- since a pitcher in his program has had Tommy John surgery, and only then because the kid in question refused to follow Knutson's regimented warmup program.

Now, realistically, what Knutson is saying isn't entirely applicable to the professional level, and he'll be the first to admit as much. After all, the NCAA's leader in workload this past season threw 147 innings. Starters at that level work once a week. It's a totally different job description than it is in MLB.

But Knutson, whose most famous former student is two-time National League Cy Young Award winner Tim Lincecum, has sent his fair share of pitchers to the professional ranks -- 14 since the start of 2010, including five in the first two rounds of the First-Year Player Draft -- and he's seen the disconnect between what he preaches at the amateur level and what is employed in the pros, and it bothers him.

"My thing is getting a connection between my pitchers, emotionally and mentally, about how the arm and body works and what's good for them," Knutson said. "I tell them that the most important pitching coach in their life is them."

So Knutson drills in their head to proper way to train the arm and prepare. For his players, that begins with warmups that stray from the static stretching exercises used by every Major League club a couple hours before first pitch.

"We do a dynamic body warmup," Knutson said. "Movements and runs and agility things. We do a lot with body blades or shoulder tubes. We do some strength training with a two-pound medicine ball, then we go through some body movement and throwing heavy balls."

The specifics, for the purposes of this discussion, don't matter nearly as much as the intent, which is to get the body -- and, specifically, the arm -- functioning at a high level in training so that it is not revved up to another level in-game. That means being not only a strong thrower but an efficient one, understanding movement patterns and how the joints and muscles work.

To Knutson, the key is to throw more, not less. Not pitch, mind you, but throw.

"I think guys just don't throw correctly," he said. "[They] don't use their body. A lot of them are pitching out of their delivery, and that's it. They don't crow hop or use their body right. You want to get their bodies moving so they can use momentum and get their bodies to throw. Just doing those things on a day-to-day basis has a lot of carryover."

Alan Jaeger, a Los Angeles-based independent pitching instructor who advocates aggressive long-tossing, seconds that notion. He calls the arm a "living, breathing organism that is trying to evolve," and that evolution, he contends, requires an intimate understanding of how the arm cycles in and out of shape.

"You can't train someone in second gear and then ask them to perform in fifth gear," Jaeger said. "We're heavy into arm training and arm conditioning, and there's an art form to that. It's not just long toss or band work. There's real, deep insight needed into how you condition in the offseason, how you condition in-season, as opposed to a throwing program that's a model of the rehab program."

So, do Major League clubs, at large, have sufficient resources on hand to understand the distinctions between those two programs?

The specialization

"I think baseball's kind of at that point where they want people with a work ethic, they want people that are willing to go the extra mile," said Cubs Minor League pitching coordinator Derek Johnson.

And Johnson should know. The former associate head coach at Vanderbilt was a significant hire, for it's rare for a Major League organization to mine the college ranks when filling that type of position. But Johnson had earned esteem within the industry for grooming power pitchers like David Price and Mike Minor, and his ability to adapt to individual players' specific needs was lauded. So the Cubs gave him a shot.

"I think it's a shift that may end up happening more," Johnson said.

Johnson has spent his first season in the Cubs' system visiting the various affiliates and gleaning an understanding of the personnel. His goal in the future will be to implement programs that train arms to absorb the stress placed on them in-game and to do so on an individualized basis.

"That's the tough part," Johnson said. "Any strength trainer or athletic trainer will tell you guys are built differently. Where baseball is at now is: We bean count. We count pitches, we count innings. I think if that were that easy, you'd see a lot less injuries."

Injuries can arise when a player's pitching mechanics and physical preparation aren't in sync, and perhaps that's a gap a person with Johnson's level of expertise can help address.

"The way that I would look at is there are three people involved with a pitchers' health: the pitching coach, the athletic trainer and the strength and conditioning coach," Johnson said. "They have to be able to assess what is going on as much as they can inside of this guy, whether it's his arm or his leg or his core. Anything that can make him more mobile, more flexible, stronger, whatever. And I think sometimes those three people end up ... not working against one another, but maybe not understanding each other and what they can all bring to the table.

"If the pitching coach has good understanding of the training and conditioning, and the athletic and strength trainer have a working understanding of the mechanics, then you've got three people working in unison on this guy and not taking two steps forward and one back, which probably ends up happening way more than it should."

The strength coach focuses on implementing routines for the roster at large, the athletic trainer focuses primarily on rehab and the day-to-day bumps and bruises, and the pitching coach has a wide array of responsibilities, from tweaking mechanics to poring over scouting reports to monitoring bullpen sessions.

Given the proliferation of pitcher injuries within this context -- and the specialization of sport, in general -- perhaps the next logical step is for an organization to add an educated conditioning coach specifically focused on the maintenance and recovery of the arm itself.

"It's probably the next thing," Price said. "There's one of everybody now in this game. It's probably the next place to be. But I'll tell you this: One thing I do know is that none of us have figured out this pitching thing, top to bottom."

That's for sure. And Harvey's injury was another cruel reminder -- as if we needed one -- that the careful attention being paid to pitch counts and workloads isn't moving the needle on injury prevention. It doesn't mean those tactics totally lack value; it's just that they are a part of a bigger picture the game is still struggling to piece together.

Chances are we'll never fully grasp that picture. Diagnosed or not, major arm injuries have been happening since the beginning of baseball time. But be it through science, strategy or specialization, perhaps there are still relatively untapped methods of improving the condition of conditioning and reducing the rate of injury.