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AN Exclusive: Dr. David Geier talks Tommy John surgery

Dr. Geier gives his thoughts on pitchers getting their second Tommy John surgeries, as well as the role of youth sports in pitching injuries.

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Last week, I got the chance to talk with Dr. David Geier, an orthopaedic surgeon and sports medicine specialist from Charleston, South Carolina. The recent rash of Tommy John surgeries hit close to home for Athletics fans after the loss of Jarrod Parker, and Dr. Geier has a lot to say about injuries in sports. He recently wrote a book called Sports Medicine Simplified: A Glossary of Sports Injuries, Treatments, Prevention and Much More, which has a Kindle edition available for $4.99 at Amazon and a Nook version at Barnes & Noble. It's a thorough reference guide for every sports injury term you've ever heard along with photos (external and arthroscopic) of various conditions. He also has a blog about injuries, which includes a podcast that recently talked about Tommy John surgery.

Dr. Geier and I discussed various aspects of Tommy John, as well as injuries in general throughout the sporting world. Rather than condense it and try to paraphrase his answers, I decided to just present the whole thing verbatim. I'm going to be honest, it's quite long, but if this is a topic that interests you then it's worth a look.

AN: What are the challenges of having a second Tommy John surgery, specifically in ways that make it different from the first one?

DG: Well, there's a lot to it. I think the first point that would be important to understand is that we don't have that much data on the success rate of the second operation. But we suspect, very much like second ACL surgery, the success rates are much lower. We typically define success not in terms of being pain-free or full motion, like you would if it was you or me, but we define success in athletes as returning to sports at the same or higher level. We think it's probably not just lower, but significantly lower than it is for a primary surgery. We just don't have the numbers of players who have had a second surgery to really generate enough meaningful data, and certainly not enough long-term follow-up of those second surgeries that I think you're going to start seeing more of.

AN: Makes sense, not a whole lot of data to go with. Which means it also makes it difficult to say how this could affect how good he is upon his return because we just haven't seen that many guys.

DG: There's been some theories as to why it's harder, and the success rates of getting back. First, a little bit of what's involved in the first surgery. You're drilling holes, or tunnels, in the bone on each side of the elbow, and passing a graft up into it. So if the surgery fails, it can fail in the tendon that they use to make the new ligament or it can fail on the bone side. When you're going back in the second time, you're not dealing with a completely normal elbow like you might have been the first time. The bone could be a little bit weaker, there could be some wear and tear of the cartilage on the ends of the bone, wear and tear inside the joint, you'd have to use the graft a second time. All of those could certainly play a role in why it would be a harder operation.

AN: It's easy to forget when you're just looking at this as a fan that it's not just a matter of, "Did the surgery work or not?" As you say, there are 50 different things that could go wrong.

DG: And that's just the surgery side. The other side of it is the rehab, and this is a really hard rehab anyway. They're essentially not moving their elbow much at all for several months, and then they work to get their motion back and their strength back before they're doing a long-toss program and then ultimately throwing off the mound. So it's a very slow process, and to have to go through that twice, you would think that that would take a toll -- especially if they've never really gotten back to the same level they were before and it happens again. Then you're looking at two years, two and a half years, three years they've been out, and the weakness and all sorts of other rehab factor issues. It can be really tricky.

120079090Brandon Beachy of the Braves returned for only 30 major league innings between his two Tommy John surgeries

AN: This is going to be more of a guess than anything, but is there anything specific about that second one? Is it just that we haven't learned to come back from it yet, or is there really a hard roadblock that you won't ever overcome?

DG: I wish I could give you a more definitive answer. We know that the first surgery actually has relatively good success. Most of the studies put the return to pitching or return to sport at the same level somewhere between 80 and 94 percent, and most of the studies center around 82 to 84 percent. But that's still 6 to 20 percent who don't come back to the same level. Not that many of that percentage is necessarily re-injury as much as they never get all of their elbow motion back, or they never get their location or their command of their velocity. There's a lot to it, and so that's where it's really tricky. It's got a good success rate but it's not perfect, even if the surgery goes perfectly. It's more delicate and there are more variables involved, unfortunately.

AN: It seems like every year, more and more guys go down with this. And it's tough to say, has there actually been an increase in guys who are suffering this kind of injury or do we just know how to diagnose it now? Where we used to just say he blew out his arm, now we can just specify what it is? Are there actually more guys who are getting hurt in this way, and if so do you think there's any reason behind it?

DG: I think there is an increase. It's really hard to give you specific rates of increase because it depends on the level you're studying and we didn't really have injury databases and that type of thing until the last 10-15 years. There are a couple thoughts. One that I have to throw out there is we're better at diagnosing it then we were. We've got MRI capabilities, and sports medicine as a field has evolved. Where it used to be just general orthopedic surgeons who were team doctors, now everybody has done extra training in athlete care and surgery in athletes and so I think our detection of these injuries is much better. Before they might just get diagnosed with an elbow injury and we didn't really know what it was; now, we're very aware. It's very similar to how a lot of us think that that's a large part of the reason for the supposed rise in Lisfranc injuries in the foot. I think they've probably been around to a large extent for a while, and now with MRIs and suspicion of it we just recognize it more.

So there's that, but I think the other side of it is you have to look at the risk factors. Probably the biggest risk factor for Tommy John injury is overuse, just basically too many pitches over too long of a period of time. And it's not so much that they're getting overused in the majors, actually; I think that the damage starts much before that. It starts at the high school level and maybe into the college ages. This trend of kids playing one sport year-round as early as eight and nine years old, the pitches start to add up over time and the current major leaguers are the group that were probably in that first generation that started playing one sport at a very young age. Whereas, I'm old enough to remember playing a different sport each season, and that's pretty rare now. So that probably plays a role in it, and the evolution of travel ball and kids playing for multiple teams in a season. I think that some of that has built up over a long time. Again, that's speculation, but we do know that it's related to overuse - over time it gradually frays, and then it finally gives. So if there's an increase, I think that would probably be the biggest reason - kids are throwing more than they ever have over the course of their careers.

AN: And that was the next thing I was going to ask, whether this was because they start pitching at 10 years old year-round, and all their bullets are spent by the time they make it to the majors. And it sounds like you believe in that.

DG: I do, and I think there's something the media doesn't share much about Tommy John injuries, the really scary rise that we're seeing. It's not good that the major league players get it obviously, but the scarier thing is the rate of increase of these injuries among high school kids. Up to the last 10 or 12 years, this was an injury pretty much limited to professional baseball players. You saw it occasionally in a few other sports, but you didn't really see it much other than pro athletes and especially professional pitchers and catchers that throw all the time. And the ages have gradually dropped. You see it now in the minor leagues, you see it with college kids, and you're seeing it more and more in high school kids. That seems to be the best evidence that this is related to overuse over the course of a career.

AN: Is there also maybe a quicker trigger finger for some of this? I've read that it's got to be, I forget, a half or two-thirds of the ligament has to be torn before they recommend surgery. Are there guys getting it with smaller tears, just saying, "Hey, let's just be safe and get this out of the way now rather than putting it off and having it happen next year?"

DG: Well, the important point to make would be that every case is different and so every pitcher and the doctor and the team have to weigh the risks and benefits differently. I will say that partial tears are somewhat of a grey area. The complete tears, we know that the elbow soreness, and the drop in velocity, and the drop in command of your pitch and the location of your pitch, usually prevents you from being a really successful major league pitcher, so you end up having it done. But if there's a partial tear, that's a lot less predictable. There are studies that show that those don't do particularly well, and then some that say PRP (platelet-rich plasma) might help.

The problem, and I think this is what you're getting at, if you're a major league team and it's April and you've got a guy that's got -- and I'm just gonna throw out 50 percent, the percentage is even debatable - do you give it six weeks of rest and maybe a PRP injection and see how you do? And if he gets back, great, you've avoided a surgery, you've avoided him being out a year just by sitting him for six weeks? But the risk is he ends up having surgery six or eight weeks later and his time before he can play is that much longer -- it's not the date from injury, it's from the time the surgery is done. So there comes a time-of-the-season factor to it. There's a lot of, unfortunately, those type of considerations that go into it. But I don't know that people have a quicker trigger, they're just thinking of the ramifications outside of just the athlete.

Those are tough discussions. A lot of the time, at the major league level, especially as you get down in the college and high school kids, is, can I throw three more starts because my team's competing for the state championship and I don't want to miss that? Can I go another month, or month and a half? And there are just so many variables.

175753680Matt Harvey of the Mets initially considered rehabbing his partially torn UCL in 2013, but ultimately opted to repair it surgically.

AN: And college coaches have taken a lot of flak lately too for overworking guys. When you're job is to go to the College World Series, and you get no extra credit for your guy staying healthy in the future after he's drafted, then there it is.

DG: There's no question that coaching plays a role in this. And really, it's at all levels. You could make a good argument with the high school coaches being the same way. They don't care if they overuse a kid because the problems very likely aren't going to develop until the kid's gone. They need to win now so that those other parents will bring their kids to play for them. The benefit of using a kid over and over is higher than the risk because they don't see it. Especially at the youth level, even at the high school level, a lot of these teams only have one or two good pitchers. So if they're going to win, they're going to have to pitch those kids all the time. That's just the nature of it, and it's unfortunate because it's short-sighted, but you're right that the incentives are not lined up. It's not necessarily in the best interest of the kid in the long run. But it isn't just coaching either. You've got parents that are pushing kids to play all these travel teams, and there are a lot of factors involved and a lot of influences and I think there's not enough thought long-term.

AN: Going off the question of if there are more of these surgeries happening, is there also an increase in the number of second surgeries? Off the top of my head, here's (Jarrod) Parker, we've got Kris Medlen and Brandon Beachy on the Braves, I think of Brian Wilson just a year or two ago and Joakim Soria a couple years before that, all having a second surgery. It just doesn't seem like a thing that used to happen a lot. Does the procedure need to adapt a bit, is there some way it can be made better, is there a reason why it's not getting the job done? Or again, is this just that I'm paying attention the percentages now and I wasn't 10 years ago?

DG: As for the first part, is it more common now? It probably is, as we're starting to have pitchers who had it and now are pitching three and four and five years later and not just one year later. It would make sense that if they're going to fail then they're not necessarily going to fail right away since it's an overuse injury. So what we don't know is how long they're going to last. But the second part of the increase that's worth commenting on is that it's very easy to focus on what we see in front of us. I don't know how much you follow the NFL, but a few years ago there was that spike in Achilles injuries one preseason and everybody was wondering what was happening. But looking now two years later, it looks like that was just a normal fluctuation and it wasn't really all that unusual. I agree that it seems like this spring we're hearing about it a lot, but until you're five or more years out from any "spike" in injury, it's a little harsh to say. But I think that it probably is because players are pitching longer after their first surgery.

As for what we can do to get it better, I will tell you that that's being done all over the country. Surgeons really have made careers doing these surgeries and they're constantly refining the techniques and they're collecting the data and studying them, so our goal is absolutely to make them last longer and give pitchers normal careers and longer careers afterwards, and there's no question that we still have a ways to go but we're working on it. That's true if you look at any major surgery, we continue to get better at them but it's a process.

AN: How about position players? Twins prospect Miguel Sano just went down, and Carl Crawford had one a couple years ago. When position players have this injury, how is it different for them to come back? Especially, does it affect their hitting at all?

DG: Everybody reacts differently. The outfielders and the catchers and some of the infielders like third base are at risk, but you would think that they would, in theory, be able to get back a little more reliably just because they're not having to worry about command and velocity of their throws like the pitchers are. But the batting is a little less predictable. Generally guys get back and do it well, but I can tell you that, especially as that ligament is starting to tear and starting to fail, they start getting pain on the inside of their elbow when they make contact with the ball. And that's not a surprising complaint to hear. But generally, they restore the stability to the inside of the elbow and they come back pretty well. I don't want to say it's easier because it's just a different set of challenges, but typically they've done pretty well.

AN: Whenever you hear the words "going to visit Dr. James Andrews," you pretty much know that's the code for "he's having Tommy John next week." Is there one thing in particular that, more often than the others, makes you think, "oh, that guy's going in soon"?

DG: Well, a lot of times what you're hearing reported from the media is somewhat due to lack of translation. But when you hear "forearm tightness" or even the more formal injury, flexor pronator strain, which is a strain of the muscles right over that ligament, at least it makes you worry that there may be underlying damage. Is it truly that the muscle is just tight like you say and is just inflamed or is there some sort of structural damage to the elbow under it that's causing that muscle to work too hard? If you go back and look at all the press releases of Stephen Strasburg in the week before he went down, he was out for a start due to a flexor pronator strain and then shortly thereafter he went down with the Tommy John injury. Those would be words that would at least concern me, but there are pitchers who get flexor pronator strains and do fine. But any kind of medial (inside) elbow pain is worth looking at closely and being very careful with.

20130808_mje_ag5_770Stephen Strasburg of the Nationals was initially diagnosed with a flexor pronator strain prior to his Tommy John in 2011.

AN: Yeah, it reminds me of hockey players. They'll go out with an "upper body injury" - thanks for being specific on that, fellas! They say something that will explain vaguely what's wrong.

DG: You're probably going to see that more and more. I don't know about baseball, since the teams are usually pretty transparent and honest with the media, all things considered. But if you look at college football, where in the Pac-10, when Lane Kiffin was there and Steve Sarkisian when he was at Washington, they were very open that they weren't going to release any medical information to the media. Some of it was gamesmanship, not letting the opponent have an advantage, and you see that to a certain extent in football - they're obligated to release an injury report to the NFL, but they're not being super forthcoming in the media. I think you're starting to see a little bit more of that, and I understand the patient confidentiality, but I think it's a tough thing. You don't want to get second-guessed by fans and sports talk radio and that kind of thing, so it's the nature of 24/7 cable and internet sports coverage.

AN: It does make a little more sense in a contact sport, too. If I go and tell my football opponent that this guy's got a bad knee, they're going to go run at his knee. But if I just say he's hurt, then maybe, like you say, a little bit of gamesmanship. Whereas in baseball, your pitcher is going to throw balls until he gets hurt, I know that, I can't do anything about it. Maybe I can be more patient and work his pitch count up, but that's about the only thing I can do to target that.

DG: I hadn't thought of that. Of course, you'd have to get somebody who studies it to really tell if they answer differently, but it seems like the information is more forthcoming in baseball than you sometimes get in other sports. After this, I'm doing an interview about Cam Newton and his ankle injury, and it was a whole lot harder trying to figure out what he had then all of these Tommy John injuries where they're pretty open about it. It does seem like it's a little different in baseball, so maybe it's the competitive advantage thing like you say.

AN: A's fans have learned now, if one of their pitchers goes day-to-day with a sore forearm, they've learned to just write him off for the season and be happy if he comes back. And unfortunately, it's not much of a joke anymore because it tends to actually be the way it goes.

DG: Well unfortunately, that's not just the A's fans. That's across baseball. Thomas Boswell of the Washington Post analyzed the NL East and basically took all of the teams that had led the league in innings pitched by their starters for the season and then the very next season that team would have one or two big injuries to their pitching staffs and it would ruin their season. It's amazing how fast these injuries change a team. I mean, the A's are a great example of the pitchers last year and the pitchers this year, and Billy Beane in that Grantland article talked about it. It's really a tough thing to get a handle on.

183573369Jarrod Parker's injury changed the complexion of the Athletics' rotation just weeks before Opening Day.

AN: One more thing for you. Are you familiar with the Verducci Effect? That the warning sign is if a young pitcher, from one year to the next, increases his innings total by more than 20 percent over his previous career high, then that was a huge red flag that he could get hurt that year or the year after? It's been largely disproven, but it's still something that people like to cite and it at least logically has some merit. You've already made clear that these things are case-by-case, but what do you think of that?

DG: The main point would be that you really need a lot of data to really say there's something to that or not. And the problem is that most of the time you only have data from when they entered professional baseball, minors and major leagues, and so they just don't keep that good of records of it at the college and the high school levels. There probably is something to it in principle. Whether or not there is a certain number is a little harder to say, but I think the analogy would be very similar to what we tell weekend warriors who are training for marathons or for 10K's or people starting a new weight-lifting program, where we say, "don't increase your training more than 10 percent per week." It's all based on giving your body enough time to adjust to added demand. If you increase too fast then your body hasn't had enough time to recover from the extra microscopic damage and hasn't had time to form new bone or new tendon or whatever it is, and so you're more likely to get hurt. So there may be something to it, but I think you would really need to see not just numbers from earlier ages but just the volume of pitchers you would need to really assess whether that's real or not. But I'm sure that people are collecting that data, I have no doubt.

AN: But, numbers aside, you would generally support the concept of working new pitchers up slowly? People complain that young pitchers get babied; no wonder they get hurt, because you never let them build their arms up! But it sounds like you would generally support, like in marathons, work it up relatively gradually, rather than, "Hey, you were in the minors last year, this year you're throwing 210 innings until you drop."

DG: Yeah, I agree. I believe it's Nolan Ryan who completely disagrees with that, but I think the problem is we don't really know. Boswell made that comment about Kris Medlen and Strasburg, that everybody is saying that they handled Strasburg poorly and pointing at how the Braves handled Medlen. They dragged his innings out over a much longer period of time so that they were able to use him longer and he had no problem. But then Medlen gets hurt again. We don't know the way to do it, honestly. We really don't. We're continuing to look at that, all the statistical people in baseball are working on that, but we don't know the right way to do it, unfortunately. But generally, I think I would support a more gradual progression of an athlete's pitches and innings and times pitching consecutively rather than just throwing him out there and just go til you drop.

Dr. David Geier is an orthopaedic surgeon and sports medicine specialist in Charleston, South Carolina who recently started his own practice after spending eight years as Director of MUSC Sports Medicine at the Medical University of South Carolina.

He writes a regular newspaper column for The Post and Courier. He also contributes articles as the Orthopedics Category Expert for He also writes articles and columns for Bleacher Report, STOP Sports Injuries, Be Active Your Way, Outpatient Surgery Magazine, Becker's Orthopedic Review and others.