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Tuesday, March 11, 2014

MLB Pitchers Don’t Regain Performance Level after Tommy John Surgery

Take that Michael the Kay and your daily “pitchers sometimes throw harder after Tommy John surgery!” jive.

Major League Baseball players who undergo Tommy John surgery are less likely to regain the performance level they had before surgery, according to a Henry Ford Hospital study.

The study is the first to show a link between the surgery and declining pitching performance at the professional level. It also involved the largest cohort of professional pitchers to date to examine the issue.

Researchers analyzed pitching statistics of 168 MLB pitchers before and after surgery between 1982 and 2010 and found diminishing returns in three major pitching categories: Earned runs average (ERA), walks and hits per inning pitched (WHIP) and innings pitched (IP). The findings:

• ERA increased 4.15 to 4.74.
• WHIP increased 1.40 to 1.48.
• IP declined 59 to 50.

“Tommy John surgery is an effective surgery and most pitchers get back to pitching after surgery. But it’s not going to improve their level of performance,” says Vasilios (Bill) Moutzouros, M.D., a Henry Ford orthopedic surgeon and the study’s senior author.

“There’s been a perception that the surgery will make you better. Our findings debunk that perception. Eighty to 90 percent of major league pitchers will get back to pitching at the major league level but they just won’t be as effective as they were before injury.”

Oooh, look…win percentage!

Drs. Moutzouros and Keller used paired analysis, generalized estimating equation model and other commonly used research tests to evaluate the data. Other highlights:

• UCL pitchers were “statistically better” than the control group in ERA, WHIP, IP and win percentage in the three years and two years before surgery.
• In the year before surgery, UCL pitchers’ performance declined significantly.
• After surgery, the control group was either superior in nearly every performance measure or no difference observed.
• A predictor of surgery is MLB experience. Sixty percent of pitchers required UCL reconstruction within their first five years in the MLB.

Repoz Posted: March 11, 2014 at 05:36 AM | 56 comment(s) Login to Bookmark
  Tags: tommy john surgery

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   1. Dr. Vaux Posted: March 11, 2014 at 06:45 AM (#4669358)
I suppose I should RTFA, but . . . did they control for age at the time of the surgery? How good the particular pitcher was before the surgery? The fact that healthy(ish) pitchers also tend to decline? The innings pitched totals given in the excerpt indicate that most of the pitchers in the study were relievers, and, judging from the "before" total, marginal ones at that. How about young, good pitchers who have Tommy John surgery?
   2. cercopithecus aethiops Posted: March 11, 2014 at 07:36 AM (#4669363)
Yes, you should RTFA, although it will only tell you so much since the actual study hasn't been published yet.

The cohort of 168 pitchers pitched in at least major league game after undergoing UCL reconstruction between 1982 and 2010. Data collected included the year of surgery, pitchers’ age, years of MLB experience, height/weight, body mass index, pitching arm injured, pitching role, pitching statistics, and whether the pitcher returned to MLB pitching after surgery. This was then averaged for the three years of pitching before UCL reconstruction and for the three years after returning to play.

For comparison, researchers collected similar data of 178 MLB pitchers in a control group with no prior UCL reconstruction and age-matched them with a corresponding UCL reconstruction pitcher. Performance was determined using three years of statistics before their “index year” (their roster year of either 2004 or 2005) and three years after their “index year.”
   3. Infinite Joost (Voxter) Posted: March 11, 2014 at 07:50 AM (#4669367)
Sixty percent of pitchers required UCL reconstruction within their first five years in the MLB.


And this is why you always trade Taijuan Walker for David Price.
   4. Jim Wisinski Posted: March 11, 2014 at 09:11 AM (#4669392)
Nvm
   5. if nature called, ladodger34 would listen Posted: March 11, 2014 at 10:20 AM (#4669433)
FWIW, Will Carroll has asserted (via Andrews and Jobe) that players who have had Tommy John surgery don't throw harder after the surgery. They simply regain the velocity they had prior to being injured.
   6. Cat Named Manny Posted: March 11, 2014 at 11:46 AM (#4669511)
This puts a significant dent in the "TJS=PED" argument, doesn't it?
   7. Publius Publicola Posted: March 11, 2014 at 12:04 PM (#4669518)
But, but, but...I thought it was performance enhancing, just like steroids!!
   8. Publius Publicola Posted: March 11, 2014 at 12:05 PM (#4669521)
This puts a significant dent in the "TJS=PED" argument, doesn't it?


It's more like incinerating a 6 month old corpse.
   9. Publius Publicola Posted: March 11, 2014 at 12:08 PM (#4669523)
FWIW, Will Carroll has asserted (via Andrews and Jobe) that players who have had Tommy John surgery don't throw harder after the surgery. They simply regain the velocity they had prior to being injured.


Let's see, who has more credibility- Will Carroll or orthopedic surgeons/clinical researchers? Hmmm..., that's a tough one. I just can't decide...
   10. jmurph Posted: March 11, 2014 at 12:11 PM (#4669527)
This puts a significant dent in the "TJS=PED" argument, doesn't it?


I'm not sure how I feel about that particular argument, but no, this would not put a dent in it. The TJ=PED argument does not start with the old, pre-injury ability as the baseline, it starts with the ruptured-ligament as the baseline. TJ is then the performance-enhancing surgery that enables the injured pitcher to pitch again. Without it, he can't pitch.
   11. attaboy Posted: March 11, 2014 at 12:12 PM (#4669529)
'While the cause of UCL injury is not fully known, orthopedic specialists theorize it’s due to overuse and stress on the elbow, pitching velocity and joint motion'

These guys ought to be brain surgeons not orthopedic specialists! Imagine how long it must have taken to theorize this!
   12. attaboy Posted: March 11, 2014 at 12:13 PM (#4669530)
'“We even have parents who come into our clinic asking if their children can have the surgery even before they injure anything because they think potentially it can make them better...'

And the clinic ought to call child services and have the children removed from these home!
   13. Publius Publicola Posted: March 11, 2014 at 12:19 PM (#4669532)
The TJ=PED argument does not start with the old, pre-injury ability as the baseline, it starts with the ruptured-ligament as the baseline.


Ehh, no it doesn't. If a procedure is restorative, it returns the patient back to a pre-injury baseline, not the post-injury baseline.
   14. Rickey! trades in sheep and threats Posted: March 11, 2014 at 12:19 PM (#4669533)
This puts a significant dent in the "TJS=PED" argument, doesn't it?


What would their numbers have been absent the surgery again? Something like "DNP" across the board, right?
   15. jmurph Posted: March 11, 2014 at 12:27 PM (#4669538)
Ehh, no it doesn't. If a procedure is restorative, it returns the patient back to a pre-injury baseline, not the post-injury baseline.


Not what I said. The argument, as Rickey alludes to in #14, is that the performance of a pitcher who has blown out his elbow would be dreadfully terrible, if he could manage to throw a ball at all. Thus, the TJ surgery is performance-enhancing from that baseline. The argument does not need TJ to make a pitcher better than he was pre-injury for it to make sense logically, it just needs TJ to make him better than he was with a blown out elbow.
   16. ellsbury my heart at wounded knee Posted: March 11, 2014 at 12:28 PM (#4669539)
This puts a significant dent in the "TJS=PED" argument, doesn't it?


Well, it's kind of like a PED if it allows a player to actually continue to play baseball when they otherwise couldn't. PEDs seem like they have a couple different kinds of effects: 1. helping a healthy player become stronger/faster than they otherwise would be 2. helping an injured player recover faster to their pre-injury baseline ability than they otherwise would, 3. allowing older players to play longer than they otherwise would. Of course, #1 is the real problem, and that ability is the defining PED effect, although 3 might also carry some slight moral heat as well. If you squint I think you could argue that TJS fits into category 3, although I'm not sure I'd make that argument.
   17. SoSHially Unacceptable Posted: March 11, 2014 at 12:37 PM (#4669546)
Thus, the TJ surgery is performance-enhancing from that baseline. The argument does not need TJ to make a pitcher better than he was pre-injury for it to make sense logically, it just needs TJ to make him better than he was with a blown out elbow.


How would that distinguish TJ from any virtually every other kind of medical procedure?

   18. jmurph Posted: March 11, 2014 at 12:48 PM (#4669553)
How would that distinguish TJ from any virtually every other kind of medical procedure?


Well again, as I said, I'm not sure I buy the argument- I'm not sure, for instance, what that argument really has to say about Barry Bonds or Ryan Braun, who as far as I know can't really point to an injury-case for any alleged usage. But I do at least understand the logic of the argument, which is something Kevin was intentionally ignoring.
   19. Rickey! trades in sheep and threats Posted: March 11, 2014 at 12:50 PM (#4669554)
Ehh, no it doesn't. If a procedure is restorative, it returns the patient back to a pre-injury baseline, not the post-injury baseline.


Which is just you begging the question. What is Kris Medlen's assumed performance baseline today? Today. Not last year. Not 2010. Today?

TJ surgery enhances the performance of pitchers with torn UCLs from zero/did not pitch to "something." If you don't understand that that is in fact an enhancement of their performative abilities, you're hopeless on the subject.
   20. cardsfanboy Posted: March 11, 2014 at 12:55 PM (#4669558)
This puts a significant dent in the "TJS=PED" argument, doesn't it?


No. The argument is doing something that allows you to perform better than you would have without the enhancement...Without Tjs you are probably out of baseball, the fact that you are pitching is evidence that it enhanced performance. (or what post 10 said)

(mind you, I don't make that argument, just like lasik isn't performance enhancing etc...but this study doesn't put a dent into the ped-tjs argument)
   21. Lance Reddick! Lance him! Posted: March 11, 2014 at 12:56 PM (#4669559)
Researchers analyzed pitching statistics of 168 MLB pitchers before and after surgery between 1982 and 2010

Obviously, the best way to judge the efficacy of current surgical techniques and rehab procedures is to throw thirty-year-old cases in the mix. ####### clowns.
   22. Greg Pope thinks the Cubs are reeking havoc Posted: March 11, 2014 at 12:57 PM (#4669560)
If you squint I think you could argue that TJS fits into category 3, although I'm not sure I'd make that argument.

I'm pretty sure it falls squarely into category 2. And if that was the only category that steroids helped with, you'd see a lot less complaining about steroids.
   23. theboyqueen Posted: March 11, 2014 at 12:58 PM (#4669562)
There are many confounders here that make a retrospective study like this difficult to evaluate, but to me the most amazing piece of data is the aforementioned:

Sixty percent of pitchers required UCL reconstruction within their first five years in the MLB.


At the very least, we can say that a MAJORITY of pitchers lost at least a year of productivity to undergo surgery/rehab. This seems like a problem, no?
   24. snapper (history's 42nd greatest monster) Posted: March 11, 2014 at 12:59 PM (#4669563)
TJ surgery enhances the performance of pitchers with torn UCLs from zero/did not pitch to "something." If you don't understand that that is in fact an enhancement of their performative abilities, you're hopeless on the subject.

Then anti-biotics and appendectomies are performance enhancing. You can't pitch if your dead from strep or a burst appendix.
   25. SoSHially Unacceptable Posted: March 11, 2014 at 12:59 PM (#4669565)
Well again, as I said, I'm not sure I buy the argument- I'm not sure, for instance, what that argument really has to say about Barry Bonds or Ryan Braun, who as far as I know can't really point to an injury-case for any alleged usage. But I do at least understand the logic of the argument, which is something Kevin was intentionally ignoring.


But I've never seen anyone offer that arthroscopic surgery or surgery to repair a torn ACL* is the same thing as PED usage, as has been suggested of Tommy John surgery. So there must be something that distinguishes them, otherwise PEDs is basically all modern medicine, which seems pretty pointless.

I'd say just because some things share some characteristics does not mean they share all. I've become convinced there's no meaningful difference between amps and steroids, for example. But the rest of the equivalencies tossed out seem to be pretty desperate attempts that fail in one or more crucial areas of difference.

* And it better not be considered that, as SoSHina is still in the recovery phase from her surgery this past summer.
   26. theboyqueen Posted: March 11, 2014 at 01:00 PM (#4669566)
Obviously, the best way to judge the efficacy of current surgical techniques and rehab procedures is to throw thirty-year-old cases in the mix. ####### clowns


Wow. What are you like at the dinner table?
   27. Rickey! trades in sheep and threats Posted: March 11, 2014 at 01:04 PM (#4669573)
Then anti-biotics and appendectomies are performance enhancing.


Of course they are. That's the entire point. We accept a gigantic set of "unnatural" performance enhancement because it's just part of the scenery at this point. My favorite go to here is that Chipper Jones played the last season of his career with the ligament of a GODDAMNED CORPSE in his leg. Joe Posnanski likes to expand the commentary on the issue to general public use of performance enhancement and call out Viagra's sponsorship of MLB gamecasts. Either works. But then some of us want to draw an arbitrary line on "PEDs" (without really defining them very well, natch) in order to morally shout down players we don't like.

It's bullshit.
   28. Arbitol Dijaler Posted: March 11, 2014 at 01:11 PM (#4669576)
Which is just you begging the question. What is Kris Medlen's assumed performance baseline today? Today. Not last year. Not 2010. Today?

TJ surgery enhances the performance of pitchers with torn UCLs from zero/did not pitch to "something." If you don't understand that that is in fact an enhancement of their performative abilities, you're hopeless on the subject.


And this is just you begging the question.

Not agreeing or disagreeing with either of you. Just saying.
   29. if nature called, ladodger34 would listen Posted: March 11, 2014 at 01:13 PM (#4669578)
Let's see, who has more credibility- Will Carroll or orthopedic surgeons/clinical researchers? Hmmm..., that's a tough one. I just can't decide..


Apparently you missed the "via Andrews and Jobe" part of my comment...
   30. Rickey! trades in sheep and threats Posted: March 11, 2014 at 01:14 PM (#4669579)
And this is just you begging the question.


Fine. Then let's ask the question. At what point does basic medical science become "performance enhancement," and why? What is the rational basis? I will dismiss out of hand the weak argument to "restorative" process versus "enhancement." There was a pitcher a few years back who had an external insulin pump that had to be cleared with MLB for uniform violation reasons. That guy's natural performance level is something less than "Major League Reliever." Yet he was cleared to have the pump. Why?
   31. Rickey! trades in sheep and threats Posted: March 11, 2014 at 01:15 PM (#4669580)
Apparently you missed the "via Andrews and Jobe" part of my comment...


Noted, but the Andrews/Jobe clinic probably has some incentive to argue greater benefit than double-blind sampling might suggest.
   32. if nature called, ladodger34 would listen Posted: March 11, 2014 at 01:17 PM (#4669581)
Well, apparently, Sam.. this "double-blind" sampling seems to indicate that Tommy John pitchers are worse off in the long run.
   33. jmurph Posted: March 11, 2014 at 01:17 PM (#4669582)
But the rest of the equivalencies tossed out seem to be pretty desperate attempts that fail in one or more crucial areas of difference.


I don't have very clear thoughts on any of it, but I think I mostly buy the injury case for what we think of as PEDs. In that narrow aspect of the argument, I think the TJS = PED people have a point. The aim of TJS is to restore you to some semblance of your pre-injury abilities; if there is a course of a currently banned drug that could achieve the same result, how could we logically disallow that?
   34. SoSHially Unacceptable Posted: March 11, 2014 at 01:20 PM (#4669585)
In that narrow aspect of the argument, I think the TJS = PED people have a point.


Sure if you narrow it. The point is, if you take everything into account, a lot of these equivalencies fall apart.

   35. jmurph Posted: March 11, 2014 at 01:25 PM (#4669590)
Sure if you narrow it. The point is, if you take everything into account, a lot of these equivalencies fall apart.


Agreed. But is there a really good answer to my question in 33? And I think the Lasik issue presents the same kind of dilemma.
   36. Voros McCracken of Pinkus Posted: March 11, 2014 at 01:30 PM (#4669594)
Did they control for offensive levels in different leagues?
   37. Never Give an Inge (Dave) Posted: March 11, 2014 at 02:21 PM (#4669623)
Then let's ask the question. At what point does basic medical science become "performance enhancement," and why? What is the rational basis? I will dismiss out of hand the weak argument to "restorative" process versus "enhancement."

"Performance enhancing" is fine with me as long as it's deemed safe and legal by the FDA or relevant regulatory body. I think people on both sides trying to raise the issue of "restorative" versus "enhancement" are deliberately clouding the issue.
   38. Never Give an Inge (Dave) Posted: March 11, 2014 at 02:28 PM (#4669625)

Noted, but the Andrews/Jobe clinic probably has some incentive to argue greater benefit than double-blind sampling might suggest.

The study of overall baseball performance doesn't necessarily refute the Andrews/Jobe claim about velocity. But with PITCHf/x data I think that claim should be pretty easy to test now.
   39. Publius Publicola Posted: March 11, 2014 at 02:48 PM (#4669636)
TJ surgery enhances the performance of pitchers with torn UCLs from zero/did not pitch to "something." If you don't understand that that is in fact an enhancement of their performative abilities, you're hopeless on the subject.


Sam, if YOU don't understand the difference between therapeutic and non-therapeutic, then you're hopeless on the subject.

Of course they are. That's the entire point.


No it isn't. The point is that antibiotics and appendictomies are therapeutic, even lifesaving. PEDs are nothing of the kind. They are non-therapeutic, and there are significant health risks associated with them.
   40. Publius Publicola Posted: March 11, 2014 at 02:56 PM (#4669644)
I think people on both sides trying to raise the issue of "restorative" versus "enhancement" are deliberately clouding the issue.


Bingo.
   41. Greg Pope thinks the Cubs are reeking havoc Posted: March 11, 2014 at 02:57 PM (#4669645)
"Performance enhancing" is fine with me as long as it's deemed safe and legal by the FDA or relevant regulatory body. I think people on both sides trying to raise the issue of "restorative" versus "enhancement" are deliberately clouding the issue.

This is honestly my position. I don't know how safe steroids are, and I don't know how safe Lasik is. There are people whose job it is to know. And I work in an FDA regulated industry so I know that the regulations don't always make sense and experts can be wrong. But if this is the rule, then the field is level.
   42. Publius Publicola Posted: March 11, 2014 at 03:07 PM (#4669655)
There are people whose job it is to know.


Yeah but what do they know? They only spend their lives and careers on this stuff. It's not like they have real knowledge, like from googling quotes of Charles Yesalis from their mom's basement.
   43. if nature called, ladodger34 would listen Posted: March 11, 2014 at 03:19 PM (#4669669)
You know what I think... there are folks who at least research this stuff and have all come to a pretty nice conclusion that at best the folks who have had Tommy John surgery will regain their velocity prior to the surgery. AT BEST!

Will Caroll might not be a favorite around here, but he has researched this stuff way more than most of the chucklefucks here have.
   44. JoeC Posted: March 11, 2014 at 03:30 PM (#4669683)
Sixty percent of pitchers required UCL reconstruction within their first five years in the MLB.


At the very least, we can say that a MAJORITY of pitchers lost at least a year of productivity to undergo surgery/rehab. This seems like a problem, no?


It's not completely unambiguous from the article, but it sounds like that's 60% of the study cohort - that is, 60% of the pitchers requiring surgery needed it within their first five years, as opposed to before their debuts or later in their careers. If they're able to say that, they must have some good sources for all TJ surgeries done on college kids/minor leaguers who later made the majors.

I hope they publish the full cohort populations so that they can be reanalyzed with the proper aging/league/park adjustments...
   45. cardsfanboy Posted: March 11, 2014 at 03:30 PM (#4669684)
You know what I think... there are folks who at least research this stuff and have all come to a pretty nice conclusion that at best the folks who have had Tommy John surgery will regain their velocity prior to the surgery. AT BEST!

Will Caroll might not be a favorite around here, but he has researched this stuff way more than most of the chucklefucks here have.


Not on any side here, but people oftentimes go into research with a conclusion reached (that is why we have junk science declaring vaccines and a host of other crap causes autism etc.) Just being an expert doesn't mean you aren't subject to reading towards your bias in a study (MGL had a study on ace pitchers in which his conclusion contradicted his numbers, but he held fast to it)
   46. Publius Publicola Posted: March 11, 2014 at 03:33 PM (#4669691)
Will Caroll might not be a favorite around here, but he has researched this stuff way more than most of the chucklefucks here have.


No he hasn't. He, and you apparently, might think he has but he hasn't.
   47. AROM Posted: March 11, 2014 at 03:43 PM (#4669710)
It's not completely unambiguous from the article, but it sounds like that's 60% of the study cohort - that is, 60% of the pitchers requiring surgery needed it within their first five years, as opposed to before their debuts or later in their careers.


Thanks for the clarification. I know it's common, but I don't think 60% of pitchers need the surgery.
   48. if nature called, ladodger34 would listen Posted: March 11, 2014 at 03:58 PM (#4669725)
No he hasn't. He, and you apparently, might think he has but he hasn't.


Well, then Kev, by all means present your research.
   49. Rickey! trades in sheep and threats Posted: March 11, 2014 at 04:40 PM (#4669776)
Well, then Kev, by all means present your research.


Whether or not X has a body of research available has zero implication as to whether or not Y has one.
   50. cercopithecus aethiops Posted: March 11, 2014 at 07:02 PM (#4669841)
It's not completely unambiguous from the article, but it sounds like that's 60% of the study cohort - that is, 60% of the pitchers requiring surgery needed it within their first five years, as opposed to before their debuts or later in their careers.


That is absolutely what it means. Nowhere near 60% of all MLB pitchers ever have TJS. Carrol wrote a piece last year about an "alarming increase" to about 1/3 of then-current MLB pitchers being TJS survivors.
   51. greenback calls it soccer Posted: March 11, 2014 at 07:18 PM (#4669846)
Carroll wrote a piece last year about an "alarming increase" to about 1/3 of then-current MLB pitchers being TJS survivors.

Yeah, but most pitchers don't last five years in the majors.

I'd want to control for salary. I guess that's addressed somewhat with the pair-wise analysis, but I've seen enough veterans rushed back to the mound on the theory that they're not being paid $15 million per year to pitch simulated games.

That said, there's a survivor's bias to this study, but I'm not sure which way the bias pushes:
The cohort of 168 pitchers pitched in at least major league game after undergoing UCL reconstruction between 1982 and 2010.

   52. cercopithecus aethiops Posted: March 11, 2014 at 07:43 PM (#4669855)
but most pitchers don't last five years in the majors


So? I'm not sure what this has to do with the validity of the study. The 60% comment is just an observation about when pitchers who had TJS suffered their UCL tears. It's not the central finding.

there's a survivor's bias to this study


Hard to do a study of how well TJS subjects perform in MLB that wouldn't have a survivor's bias. A study of how many make it back at all should be easy enough.
   53. greenback calls it soccer Posted: March 11, 2014 at 07:55 PM (#4669865)
Hard to do a study of how well TJS subjects perform in MLB that wouldn't have a survivor's bias.

Guys not making it back could be treated as replacement level, or slightly worse. It's better than ignoring them.

I'm not sure what this has to do with the validity of the study.

True enough...

The 60% comment is just an observation about when pitchers who had TJS suffered their UCL tears. It's not the central finding.

Well, it's complementary to the central finding. It implies most of the best pitchers will decline from UCL tears alone, which is kinda amazing, considering a UCL tear is supposed to be much less dangerous than rotator cuff or labrum tears. I guess that's like comparing alcohol to heroin though.
   54. ptodd Posted: March 11, 2014 at 10:45 PM (#4669938)
The wording is ambiguous but I read the 60% as being 60% of all pitchers needing TJ surgery needed it within their first 5 years and not 60% of all MLB pitchers needing the surgery with 5 years.

Using data gong back to 1982 may not take into account improvements in the technique. Also, ERA and WHIP may be problematic for pitchers who had the TJ surgery in the early 90's and faced the juiced ball era in their recovery years. The author should have used ERA+

I would like to see more data on the control group as well as this not only has to be aged matched but also matched for the run environment which has changed significantly from 1982-2010.
   55. cercopithecus aethiops Posted: March 11, 2014 at 11:22 PM (#4669948)
I think it's safe to say that the authors of this study know more about surgery than they do about baseball.
   56. theboyqueen Posted: March 11, 2014 at 11:23 PM (#4669949)
Honestly it's kind of pointless to speculate on methods until the actual study is published. It's hard to draw any conclusions from this press release.

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