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Injuries Increase As Pitchers Throw Harder, Faster And Younger


This is FRESH AIR. I'm Terry Gross. Major League Baseball gets underway this weekend, and our guest, sports writer Jeff Passan, says before the season's over, about half the game's pitchers will be on the disabled list because of injuries. In his new book "The Arm: Inside The Billion-Dollar Mystery Of The Most Valuable Commodity In Sports," Passan says pitchers are throwing harder and faster and starting younger, and more and more are getting surgery to repair a torn elbow ligament. The operation is called Tommy John surgery, named after the Los Angeles Dodgers sinkerballer who got the first such surgery in 1974.

Passan writes that major league teams spend a billion and a half dollars a year on pitchers but know relatively little about what's causing arm injuries or how to prevent them. And, he says, there's plenty of evidence that the competitive pressure on kids to throw harder and longer is making them more vulnerable to injuries. Jeff Passan is a baseball columnist at Yahoo Sports and the co-author of a previous book about college football. He spoke with FRESH AIR contributor, Dave Davies.

DAVE DAVIES, BYLINE: Well, Jeff Passan, welcome to FRESH AIR. When this elbow ligament goes - the ulnar collateral ligament - what does a pitcher experience?

JEFF PASSAN: You know, it's different depending on the pitcher. Some pitchers, it is abject pain. They know that they have heard something sounding like a pop, that they felt something. It could be shooting down their arm toward the wrist, shooting up their arm toward the shoulder. It can be excruciating at times. You see guys jump off the mound not just because it physically hurts, but because psychologically they understand that their arm is done and that they're going to need surgery of some kind. It's almost a preternatural feeling.

On the other hand, there are some pitchers who say, well, I felt something in there, but I'm going to keep trying to pitch through it. And you can almost always tell when there's a significant drop in their velocity on their fastball. You know, a pitcher that normally throws 93 or 94 is sitting there at 88 or 89.

DAVIES: Well, the surgery to fix this is named for Tommy John, the Los Angeles pitcher of the '70s. Tell us about his injury. What happened?

PASSAN: Tommy John was a sinkerballer, and he never threw particularly hard, you know - normally around 82 or 83 miles per hour. But the wear and tear on his arm was significant enough that one day he just could not throw anymore without there being pain. And so he went to visit Dr. Frank Jobe, who was baseball's legendary orthopedist. Now, Dr. Jobe had gotten the sense that this surgery might work - taking a tendon from the wrist, drilling holes into the elbow, and essentially making a new ligament there.

The body turns tendons into ligaments within an 18-month process. The surgery had been done before in the ankle area, but this was the first time that it was done ever on the elbow. And Tommy John took 18 months but came back and had every bit as good of a career after his surgery as he had had before it.

DAVIES: It's remarkable - something like 300 starts after getting his elbow reconstructed.

PASSAN: Yeah. You know, back then, this was such a novel thing. Frank Jobe - when he opened up Tommy John's elbow - did not know what it was going to look like, did not know what was going to be in there, did not know how it was going to take. And Tommy John for the first six months was miserable because he actually - his hand was formed into a claw. You know, they had hit a nerve there, and his left hand was not working. So not only was he concerned that he wasn't going to pitch again, he was concerned that the rest of his life he was going to have a disabled hand.

And so they went back in, they fixed the nerve issue, and over the next 12 months, Tommy John went out and did his own thing. He really set the protocol for how to rehabilitate an ulnar collateral ligament transplant surgery, and he was back on the mound and almost every bit as good as he was before the surgery.

DAVIES: You've spent a lot of time learning about the arm and studying pitching motion, and there's - I don't know if we can do this without pictures - but there's a point in the book where you describe the motion of the shoulder and its relationship to the elbow in delivering an effective fastball. Can you describe that?

PASSAN: The way that throwing anything not just the ball but any overhand throwing works is through something called the kinetic chain. And the kinetic chain is essentially the building up of energy because every part of your body is intertwined and all of that energy loading into a particular place. And when you're throwing something overhand, it starts down at your feet, your ankles up through your backside, all the way up your back, and the energy goes into the shoulder. And when the energy is in the shoulder, imagine a rubber band being pulled back as far as it possibly can and as tight as it actually can. That's what happens when your foot lands and when your hips start to turn. Your arm almost lays back flat and parallel to the ground. And at that point, once it reaches as far as it can go, the motion going forward is the fastest movement the human body can make. It is 8,000 degrees per second. It's faster than an eye blink, and that's called the internal rotation of the shoulder.

When the shoulder is internally rotating, all of that energy goes down the arm and into the elbow and onto this ulnar collateral ligament which is just a 2-inch triangular band of flesh. And unlike shoulder muscles which can be strengthened, ligaments cannot be. And so all of this pressure going onto the ligament time after time after time will wear you down. The harder you throw, the more force is going down there. The less conditioned you are, the likelier it is for your shoulder to go as well as your elbow. And the pitching motion - it is - to me, the fallacy is that it is an unnatural motion. It's far from that. It's the opposite of that. Humans evolved into overhand throwing just so they could go hunt and gather. So it, to me, is the epitome of something that is natural. What it isn't natural to do is throw a hundred pitches every five days.

DAVIES: Now, how common has this surgery become among ballplayers?

PASSAN: It's not just common among major league players; it's common among players, period. The estimates are about a quarter of pitchers at any given time on major league rosters have had Tommy John surgery. And I actually expect that number to grow in the coming years because of what's happening throughout baseball. And this is the thing that frankly compelled me to write this book. I have a son. He's 8 years old now. He's just starting pitching. And within the next five or six years, he will know kids who have undergone Tommy John surgery, and that's not an exaggeration.

This is a frightening thing because there are 13 and 14 and 15 and 16-year-old kids who are having this surgery that for a long time was just limited to major league and minor league and at the very least professional players. But the number of kids who have had surgery has spiked significantly in recent years to the point where more than half of Tommy John surgeries now happens with teenagers. And I'm hoping that this book is an alarm for parents and for coaches out there who don't quite understand that the amount of pitching you do as a child could significantly damage you for years to come. And maybe - just maybe - they will start listening because ultimately the responsibility is as much on parents and coaches as it is on Major League Baseball adjudicating this from the top down.

DAVIES: There's not a lot of hard data and hard science behind some rules like the 100-pitch limit, but you're saying it is clear that throwing too much when you're a kid makes you more susceptible to injury.

PASSAN: Unquestionably at this point, yes. There is hard data on that. The American Sports Medicine Institute has run multiple studies, you know, a 10-year long study on pitchers following them throughout their youth careers. And what this study showed is that pitching when you're young excessively is truly injurious. It's harmful, and the number of kids who end up pitching too much when they're younger and staying healthy is far outnumbered by the ones that just can't go anymore. And so the incentive is there for change. And Major League Baseball is helping in some respects.

Baseball turned a blind eye to this for a while, but within the past few years, they've really taken the right steps between establishing the Pitch Smart program which encourages pitch limits for certain ages - every age starting at 8 years old that says what is healthy for a kid to go out and do, how often he should pitch, how many pitches he should throw, how many days off, he should take. And beyond that for the major leaguers, they've been collecting injury data for about half a decade now that they're sending to epidemiologists at Johns Hopkins who are looking it over and trying to find some sort of correlation between injuries and something that we just don't know yet.

DAVIES: Jeff Passan's book is called "The Arm." We'll continue our conversation after a short break. This is FRESH AIR.


DAVIES: This is FRESH AIR. And if you're just joining us we're speaking with Jeff Passan. He is a sports writer and a columnist for Yahoo Sports. His new book is called "The Arm: Inside The Billion-Dollar Mystery Of The Most Valuable Commodity In Sports." Decades ago major league pitchers threw a lot more innings than they do now. And you described talking to Sandy Koufax, the great Dodger, about his experience and his endurance and the toll it took. Tell us a little bit about that.

PASSAN: Sandy Koufax was a warrior. And he would go out there and pitch no matter how much his arm hurt. There were times when he woke up in the morning and he would look at his left arm and the entire upper arm would be black and blue. And I mean the entire thing. It was almost like it had been painted like a fatigue. And his arm was rebelling against what he was doing to it. The amount of pain pills that he took, the number of times he went in with Robert Kerlan and got a giant needle stuck into his elbow and the fluid drained from it - it's sad in hindsight and in retrospect.

DAVIES: You know, it's generally understood that once a pitcher gets to around a hundred pitches in a big league ballgame, it's time to think about getting him out of there. Sandy Koufax would drain his elbow and just go through this miserable pain and then go out and throw how many?

PASSAN: (Laughter) Two hundred sometimes. I mean, there - you know, there were outings where he would throw 130, 140, 150 pitches. And the number 100 that is standard these days I don't really think is based on a whole lot of science. I think that as time has gone on and as we've seen the number of arms get injured as do get injured - and as the salaries have gone up - the human instinct is to go into protective mode. It's that if we're doing a lot of something and that's bad, doing less of it is good. And that's not necessarily true with baseball players.

I think with younger pitchers, certainly keeping them on pitch counts is the right thing to do because they're still growing into their body. They still don't understand what the right type of soreness is versus something that could be harmful. But when you have an older pitcher, like Clayton Kershaw with the Los Angeles Dodgers or Madison Bumgarner with the San Francisco Giants, I firmly believe they could go out there, throw 120 pitches every time and stay healthy.

DAVIES: When we look at pictures in the past, where they threw a lot and were paid a whole lot less, I mean, I wonder if what you had was a herd of arms coming in and lots of them blew out, were injured, but the teams really didn't care because they weren't expensive and they could be easily replaced.

PASSAN: That's 100 percent correct. And you talk to any great pitcher and he has a teammate who was better than him in the minor leagues. With Sandy Koufax there was Karl Spooner, who struck out 27 in his first two outings for the Dodgers back in the mid-50s and barely ever pitched again - got hurt. And what's amazing is that we know so much more now and the players still are getting hurt. You talk to Jim Palmer, there was Steve Kariya - had much better stuff than Jim Palmer did. And Jim Palmer was pitching in World Series games at 20 years old. So you had this generation of players who went down and there were no fixes for it.

DAVIES: One of the most influential agents in the game is a guy named Scott Boras. And he's had some pitchers that he's really tried to limit the work of - Stephen Strasburg of the Washington Nationals. You want to tell us about what he was trying to do and how it worked out?

PASSAN: Well, Scott Boras has a think tank, really, at his agency. And they have done some significant analysis on what happens to pitchers who throw too much when they're young. And the result tends to be their careers don't last much past 30. And so he wants to limit not just the number of pitches that these players are making but the number of innings that they are throwing as well. And so whether it is Strasburg, whether it is Matt Harvey, whether it's Jose Fernandez - these are all players of his who have undergone Tommy John surgery. And when they've come back, Strasburg was under an innings cap where he ended up missing the playoffs and the Nationals lost. And many still look at Strasburg and say, well, maybe he should've pitched.

DAVIES: I just want to understand what you're saying. This is a team that gets into the playoffs and their best pitcher is on the bench - not performing - to preserve his arm?

PASSAN: That is correct - and controversially, I might add, because we don't know whether that's the right move. The - one thing that I've learned in studying this subject is that it is foolish to try and make assumptions. I would've assumed that the fewer innings you throw or the fewer pitches you throw, the less likelier you are to get injured. And history, frankly, has not proven that because pitchers now - starting pitchers - are throwing fewer innings than ever at the major league level and they're still getting hurt. And so with Stephen Strasburg, for all we know he might have gone out and pitched the Nationals to the World Series that year and might still be healthy these days. But we just don't know whether that would've happened and there simply aren't enough cases to test that and to say for certain whether there is any kind of a correlation there.

DAVIES: You say there's certain things we know. We know that kids pitching too long too young tends to increase injuries. But you say there's a lot we don't know. What do we need to learn about the relationship between what arms do and how they break down? And how do we find out?

PASSAN: I think there have been enough advances in recent years to give us a decent sense. For example, there is a product called Kinatrax. And Kinatrax can - what it does is with cameras positioned around a stadium or around a baseball diamond - whatever it may be - allows you to see the movements and the joint angles of every single millisecond a pitcher is throwing a ball. And so if we can take that data and put it into a massive database and allow people far smarter than I to try and find patterns, maybe we can get a sense of which people - because of how they throw - are at risk for injuries and identify those earlier and make changes. Now, changing a delivery is not an easy thing to do. But if you know you're at risk for injury long-term, the likelihood of you doing it is far greater than someone coming up to you and saying, hey, you should probably change your delivery. Another part is understanding that the elements surrounding the ulnar of collateral ligament. For example, Dr. James Buffi was a graduate student at Northwestern. And when he was younger he played baseball and was always fascinated at the ability of people to generate the same type of pitch, whether it's a 95-mile-per-hour fastball from a guy who stands 5-foot-9 or a guy who stands 6-foot-5. And Dr. Buffi did his research - his doctoral research - in the muscles of the forearm and their ability to stabilize the elbow joint. And what that means is he came to the conclusion, through musculoskeletal modeling, that strength in the forearm muscles has the ability to lessen the impact on the ulnar collateral ligament. All of which is to say there could be exercises that we could do to strengthen the forearm muscles that might prevent the ulnar collateral ligament from snapping eventually.

DAVIES: You know, baseball is 30 teams that have - that are independently owned and have their own coaching staffs and their own priorities and their own medical records of their players, which they don't necessarily share. To what extent is major league baseball, overall, doing what it should be doing to give us useful data?

PASSAN: Major League Baseball as an organization itself, the commissioner's office, is doing good work. Major League Baseball teams, on the other hand, are doing everything they can to figure out the arm and not tell anyone about it. And that's where the inherent conflict is here because teams understand that the first one to find out what is causing arm injuries is going to win a World Series because of it. The idea that you can bring up pitchers who are healthy and keep them healthy and know that these pitchers aren't going to be drags on your payroll or that you can take these raw arms coming out of high school and college and turn them into major league commodities who you know will be there - there is such great power in that. And so Dr. James Buffi, who I was just talking about, got hired by the Los Angeles Dodgers. And any breakthroughs that Dr. Buffi has from now on will be property of the Los Angeles Dodgers. The Dodgers have an eight-billion-dollar television contract. And their not just using that TV money to go out and buy players. They started a think tank full of quantitative analysts, like Dr. Buffi, who are trying to figure out the mysteries of this game that we just don't know even 150 years after its beginning.

DAVIES: So the arms race goes on.

PASSAN: That's good, Dave. That's good (Laughter).

DAVIES: Sorry, sorry, sorry. Jeff Passan, thanks so much for speaking with us.

PASSAN: Dave, the pleasure was mine. Thank you for having me.

GROSS: Jeff Passan is the author of "The Arm" and writes a baseball column for Yahoo Sports. He spoke FRESH AIR contributor Dave Davies, who is also WHYY's senior reporter. After we take a short break, I'll talk with journalist Jacob Bernstein, who has directed an HBO documentary about his late mother, the writer and director Nora Ephron. I'm Terry Gross and this is FRESH AIR. Transcript provided by NPR, Copyright NPR.