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On Wednesday, we had a news story involving Drs. James Andrews and Glenn Fleisig and Tommy John surgery. Normally when that’s the case, it means that someone’s season is over (and sadly, that’s been happening a lot lately). But this time, it was the good doctors responding to what they termed an “epidemic” of ulnar collateral ligament transplants (the actual name for Tommy John surgery) and offering some helpful tips to prevent the elbow injuries that require the procedure.

I have absolutely no expertise in orthopedics, but I’ll trust that these guys know what they’re talking about. Their recommendations ranged from the obvious (exercise, rest, and nutrition are vital to a pitcher’s health) to the more earth-shaking (think twice about winter league baseball—can you do a winter league without pitchers?). To my untrained eye, the recommendations all make sense if the goal is to prevent UCL tears. Now, if all teams and pitchers would simply follow their recommendations…

Oh, if only making people healthier were that easy! We’d have a country filled people who had healthy weights, were non-smoking, were moderate drinkers, and about 50 other things.

So here comes the tough part. How on earth will we get pitchers to follow these rules? When reading through the steps that Drs. Andrews and Fleisig recommend, my first thought was about how many of these rules are broken on a regular basis. Not only that, but how many of them would be a hard sell to the actual players involved. Some of them would be easy enough—optimizing pitching mechanics is something that all pitchers want to do anyway. But I about spat out my drink when I read this:

“2. Do not always pitch with 100% effort.”

Well now, aren’t we contradicting just about every cultural message that a given pitcher has ever heard. Yes, he might have heard this advice from his pitching coach in the past, but we still live in a “Rah rah, give 110 percent all the time” culture. Consider the following: There’s a small fascination that people have with the idea that closers do not seem to pitch well in non-save situations. For example, sometimes a closer hasn’t pitched in five days and just needs an inning of work. Despite the fact that his team is actually down 7-1, he comes into the ninth. And he gives up two extra runs, not that it matters. I’m going to out on a limb and suggest that sometimes, that’s a pitcher not going 100 percent. He doesn’t need to, so why should he? Yet, when he’s asked about it after the game, it would be borderline heresy for him to say, “Yeah, I was just out there to get my work in. I wasn’t throwing everything 100 percent. Just trying not to get hurt.”

On top of that, there are plenty of incentives for a pitcher to give 100 percent all the time. When a pitcher is young, his job might not be to light up the radar gun, but if he’s being scouted, then there are probably a lot of radar guns behind home plate, and the more lights he turns on, the better the report. He might be able to get high school hitters out with less than 100 percent effort, but high school hitters vary so much from place to place that you can’t trust high school (or college) stats. You can trust velocity and movement, and that’s going to take some arm effort. Even in the minors, there’s the reality that minor league teams are more like American Idol than you might imagine. We might all be friends, but only one of us is going to get that meeting with the manager. If I throw at 90 percent to save my arm, and Larry throws at 100 percent, whom do you think the team will notice first? There’s an incentive for me and everyone else to throw at max effort.

In addition, the Andrews-Fleisig model calls for “open communication between a pitcher and [coaches] and medical staff” and says that “the pitcher should keep his trainer or coach up to date about any soreness, stiffness, and pain. That way when there is an issue, the player and team can consider rest, modified activity, or examination from the team physician to allow the elbow to heal and avert serious injury.” Just to be clear here, we’re asking for men to engage in open communication, to admit that they are in pain (despite all the cultural messages about playing through it), and to approach the people who control their playing time so that some of it can be taken away.

The reality is that if this plan is going to work, it’s going to take a complete change in organizational culture. While teams can’t control what happens at the amateur level, they can make it a point to scout for pitchers who have some idea of how to hold back a bit. Maybe some already do. It might also take some re-thinking of whether worshipping the radar gun is a good idea or whether, as Sam and Ben suggested on Thursday’s episode of Effectively Wild, teams might begin to prefer soft-tossers, like Mark Buehrle.

The part that teams can control is setting up a culture in which it’s okay to pitch at less than 100 percent, and in which players are rewarded for having the maturity not to air it out when the pitching coach politely asks them not to. They might have to make it clear that promotions are based, in part, on that maturity factor. But pitchers might still hesitate. Even if a team succeeded in building an ecosystem where restraint was a highly valued commodity, going at less than 100 percent will not make the stat sheet sing, and the wider market out there pays for what’s on that stat sheet. It might leave a pitcher in a situation where he’s thinking about scoring that one big contract. If he goes at less than 100 percent, he might not turn enough heads to make his money. If he goes all out all the time, he might blow out his elbow, but it might be the only chance he has to get paid, or to make the majors.

A progressive team might have to not only nurture a culture where “less than 100 percent” isn’t a dirty phrase when applied to the correct situations, but put their money where their mouth is and try to re-assure the pitcher, perhaps with a nice early extension, that they are committed to this plan and that he will get his money.

As for the issue of encouraging players to report their injuries, it is true that men, whether professional athletes or not, are famous for avoiding the doctor. Indeed, how many Tommy John stories have we heard that contain some reference to the fact that “He started feeling pain last month/year, but tried to pitch through it. It was only after Tuesday night’s game that the pain became unbearable and he had an MRI”? In order for a team to actually achieve “open communications,” it’s going to need to do some re-branding of what disclosing an injury is.

Thankfully, while male psychology provides a good amount of the problem, it also provides part of the solution. It’s no mistake that you often hear men in large groups (like, say, groups of 25) talking about how everyone in the clubhouse has banded together. That idea of a band—not in the musical sense, but in the sense of a group of people who are working together and who are loyal to each other—is a powerful one. A team that cultivates this feeling—dare I call it chemistry?—has a hidden edge if they play it right. Yes, it’s hard to admit that you might need to take a trip to the DL, but by hiding your injury, you are doing harm to the collective. If you simply admit what’s going on, it might not be great for you personally, but it will demonstrate that you are clearly a loyal and committed member of the band.

There are probably teams where this sort of re-branding of injury reporting is going on. The stakes are too high for there not to be—Tommy John does take 12-18 months for recovery, if you recover. (Plus, a torn elbow is not the only injury that needs preventing.) But it’s an interesting twist for the sabermetric audience—another very easily draw-able link between that lovely and nebulous idea of team chemistry and actual baseball value.

Yes, we have a nice roadmap for how to at least reduce the risk of elbow injuries. While it’s nice to have a map, you also have to know how to operate a car to get where you’re going. The actual implementation of the Andrews-Fleisig recommendations are going to be hard, and it’s going to take more than just monitoring pitch counts and investing in bio-mechanical analysis. This is something that has to be built into the very fabric of an organization.

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mdlockhart
5/30
I heard a panel discussion on MLB network recently about pitching. The baseball guys said there are good examples (Maddux) of people who learned that throwing as hard as you can is not necessarily the most effective way to pitch. Slowing down may produce more movement and therefore be more effective. We saw it in golf when Tiger Woods took something off his drive to stay in the fairway. Harder is not always more effective.
50cubs
5/30
This culture used to exist. It existed for most of baseball history. When I was growing up in the fifties, pitchers were supposed to "learn how to pitch", which meant, among other things, "pacing yourself". You weren't supposed to throw hard all the time, but save your best pitches for high-stress situations, which were then called "jams". If you threw hard all the time, you wouldn't be able to finish the game, and pitchers were trained to finish the game. Justin Verlander is a modern hard thrower who pitches this way. He saves his best stuff for late in the game.
Plucky
5/30
How much would it cost an ML team to simply implement a policy that every pitcher on the roster (perhaps extending down to AAA or AA) gets an MRI every other month, no matter what? That obviously could never be a solution at college or amateur levels, but for an ML team it could catch problems where a player is trying to hide an injury. Knowing the MRI is coming anyway might get players to be more frank with health staff
bornyank1
5/30
We talked about something like that on this episode of Effectively Wild.
BaseballFuries
5/30
It'd be cost effective (hell, MLB teams should OWN their own MRI machines) but the union would take serious offense at anything that took players who "feel great" off the field and reduced paydays.
Plucky
5/30
I seriously doubt union opposition would be a serious hurdle. We're talking about teams trying to fork over a decent chunk of money in the interests of player health. If the union is concerned teams will manipulate the results to stiff players, I doubt the owners would object to giving players the right to take the MRI results and get 2nd/3rd opinions, and then give them a grievance procedure if they object to being placed on the DL
therealn0d
5/30
Yep, you can pick one up at Home Depot for cheap...o wait
BaseballFuries
5/30
$250-$500K.
pizzacutter
5/30
I just googled "cost of MRI" and it turns out that no one really knows. Just grabbing a number, $2000 per MRI, which seems to be at least realistic, times 6 months times say 50 pitchers in the system is $600k. Teams could probably get a punch card where they get a free one with every 5 they buy deal and knock some of that cost off, so let's say that it's somewhere in the low-to-mid 6 digit range. That's the right order of magnitude. Now, for that to make sense, you'd have to make the case that the MRIs would give additional information that would save the team more than 600k (or whatever) in lost production. Would constant MRIs mean that they could intervene to actually prevent an injury or would it just document the inevitable decline into a shoulder or elbow injury? I don't have the expertise to comment on that one. Also, there's the side effect that no one enjoys an MRI... and if signing with this team means I have to do 6 of them a year... I'm going over to that other team.
therealn0d
5/30
You're overlooking the fact that MRI machines get scheduled use. There are very likely people that really very much need an MRI while a baseball player, you know, could wait. "This guy might be dying" vs "This guy might need to rest his arm."
BaseballFuries
5/30
Buying the mobile MRI trailer they stick onto the back of hospitals is only $250-$500K. Forever (not counting an MRI tech). I just can't see a "routine" MRI dinging someone who swears up and down their healthy being an acceptable outcome for the union. Though honestly I don't know what a "physical" entails for "signed pending a physical" Wasn't there a pitcher who just outright didn't have an UCL? Born without it?
BaseballFuries
5/30
(can't believe I typed "their" just... just ignore me.)
NoHRTyner
5/31
I believe you are referring to R.A.Dickey.
thegeneral13
5/30
It's an interesting idea, but I see a few issues. First, MRIs are going to give a lot of false positives. MLB pitchers are all going to have abnormalities in their arms, even when they are healthy. It's probably going to be difficult to separate normal wear and tear from the early signs of something more serious, and by the time something more serious is visible the injury has already occurred. Second, if you do see something abnormal that won't heal on its own (bone spurs, etc.), do you surgically repair them even if the pitcher says he feels fine? That's sort of in violation of the Hippocratic Oath. Third, MRIs can also miss a lot of things, particularly in shoulders. In many cases arthrograms are used for shoulders to help see better, but you can't do these regularly because they involve injecting fluid into the joint and you can't resume throwing until that fluid has dissipated. And even arthrograms miss enough things in shoulders that surgeons sometimes just skip them and do exploratory arthroscopy if they think there is a problem. In short, I think the false positives and false negatives are so prevalent with currently available technology that the most useful indicator is ultimately how the pitcher feels. Hopefully technology will improve or the research into variance in velocity, release points, etc. will bear fruit so injuries can be prevented without telling pitchers not to throw 100%!
SlackerGeorge
5/31
The other value of MRI in healthy individuals is developing baselines, such that abnormal results can be more easily diagnosed. These baselines in NFL players should help them learn more about brain injuries. Baseball should use whatever tools it can that make financial sense in order to better manage injuries. Not only to improve performance and extend careers, but to also help players avoid chronic pain and disability post-career.
dethwurm
5/31
Aren't there injury risks associated with NOT giving 100%? Changing mechanics and whatnot.