"Pitching is an unnatural act that invites injury.
The stress that it places on the bones of the shoulder, arm, and back is immense.
The strain it places on the 36 muscles that attach to the humerus, clavicle, and scapula is remarkable.
It is widely accepted by sports medicine practitioners that every pitch causes at least some amount
of damage to the system"
-"The Injury Nexus," by Nate Silver and Will Carroll, The Baseball Prospectus, Feb. 26th, 2003
That's a pretty lofty set of questions to answer, and we don't have any medical training beyond basic first aid/CPR/Defib, so we'll rely on the internet to help answer some or all of these questions.
The most common pitching injuries occur to the elbow or shoulder. In the elbow, the Ulnar Collateral Ligament often starts with a small tear that slowly grows over time, until a major tear takes place. "Tommy John" surgery is used to correct this, taking a ligament from somewhere else in the body to replace the torn UCL. In the shoulder, injuries can occur to the capsule/ligaments, the rotator cuff, and the labrum. Sometimes rest and physiotherapy overcomes these injuries, and sometimes surgery is the only answer.
Is There a Way to Predict These Injuries ?
Rany Jazayerli of BP coined the term Pitcher Abuse Points as early as 1998. Jazayerli studied pitch counts and injury data, and came to the conclusion that the number of innings or pitches thrown is not the issue - it's the number of pitchers a pitcher throws after he becomes tired, when his mechanics get sloppy, his muscles are sore, and his body isn't able to handle the stress of each successive pitch. All of these factors put increased risk on the major components of a pitcher's arm - the bones, muscles, ligaments, and tendons involved in the process of throwing a pitch. Jazayerli developed a point system (Pitcher Abuse Points) to determine the wear and tear on a pitcher's throwing arm over a season.
Here's how his first point system looked:
pitches 1-100 0
pitches 101-110 1
pitches 111-120 2
pitches 121-130 3
pitches 131-140 4
pitches 141-150 5
Using this method, a 115 pitch outing would result in 20 PAP's, a 120 pitch outing is worth 30 points, etc. Of course, no one throws anywhere close to 150 pitches in a game anymore (or even approaches it), so his points system is a little outdated. His first list in 1998 was populated by veteran pitchers like Randy Johnson, Roger Clemens, and Curt Schilling. The "young" pitchers on his most "abused" young pitchers list featured names like Bartolo Colon, Livan Hernandez, and Jesus Sanchez, 2 of whom went on to have fairly long careers despite the early apparent misues. So, although Jazayerli was among the first to systematically study pitch and inning counts and their relationship to injury, it's hard to say that his first efforts made a definitive link between the two. Just the same, a strong correlation between pitcher fatigue and injury risk was established.
Sports Illustrated writer Tom Verducci took this concept one step further when he developed the Year After Effect (sometime mistakenly called the Verducci Effect; he didn't coin this latter term). Citing the research of Oakland pitching coach Rick Patterson, Verducci noted that a number of pitchers under the age of 25 experienced arm problems when their innings pitched increased more than 30 from the previous season. Verducci freely admits that this is not a scientific study, but he does use the rule of thumb approach to identify young pitchers who are at an increased risk of injury to a jump in IP of more than 30 from the year before. Other researchers have debunked Verducci's lists, and even though it doesn't factor in pitch counts like Jazayerli's PAP does, the Year After Effect is still a good guideline, and most clubs (like the Jays), follow that principle.
To that end, here's a quick look at the increase in IP for a number of Jays pitching prospects (under the age of 25) over the last several years:
pitcher 2009 IP 2010 IP 2011 IP 2012 IP
Kyle Drabek 158* 162 154 71 (*limited to 32 IP in '08)
Drew Hutchison - 68 149 74
Chad Jenkins - 141* 167 114 (*92 IP in college '09)
Deck McGuire - - 104* 144 (*112 IP in college '10)
John Stilson - - - 104* (*91 IP in college '11)
Sean Nolin - 21* 108 101 (*84 IP in college in '10)
Aaron Sanchez - 25 54 90
Roberto Osuna - - 19 43
Daniel Norris - - - 42
Chase DeJong - - - 12
Tyler Gonzales - - - 15
While the list above is not meant to be comprehensive, a few things do jump out. First of all, given Hutchison's huge jump in IP between 2010 and 2011, it shouldn't come as a surprise that his UCL gave out in 2012. Even though he has an advanced feel for pitching which prompted his rapid rise to the major league rotation (as did a lack of depth in the system), Hutch must have thrown a lot of pitches when he was past the point of fatigue. Sean Nolin also had a huge increase in innings from his first pro season to his second, although he did throw 84 innings in his final college campaign. Of note are the IP for Roberto Osuna (more on him later) and Daniel Norris - Osuna is currently out with a torn UCL, while Norris is about to surpass his IP from last year after only the 2nd month of the season. It will be interesting to see what happens with both. Osuna is currently rehabbing in Florida, and has thrown off a mound, and word was received just today that he was on his way back to Lansing. And we wonder if and when Norris will be shut down for the season. De Jong and Gonzales will likely come in right around the mid 40s in IP.
So, the above data really doesn't emphatically prove the Year After Effect beyond Hutchison's injury, but it's still a very good guideline to follow. A major weakness, of course, is the fact that it doesn't really factor in pitch counts; 30 extra innings can be quite different for a groundball pitcher than they could be for a power pitcher.
Why do These Injuries Happen?
Shoulder and elbow injuries, as we have noted, tend to be brought on be a combination of fatigue and bad mechanics. The injuries tend to be more prevalent in younger, growing pitchers - Silver and Carroll identifed 23 as the age in which the risk for the average pitcher tends to decrease, while Verducci puts it at 25. To be sure, :
As an athlete matures, his bones calcify and harden, his growth plates close, and his ligaments reach full strength. Since no athlete matures on the same schedule as another, it is important to note that chronological age does not always directly correlate to physical age.
-Silver and Carroll
And with the rise of travel teams and continent-wide showcases and young players playing a lot of ball at a young , Robert Dvorchak, in the Pittsburgh Post-Gazette describes a scene at the office of Dr James Andrews - the famous Tommy John doc:
When the parents of a young pitcher with a damaged arm visit his clinic, Andrews has them write on a chalkboard when the child started pitching, how many teams he's played for, what baseball camps he attended, how much extra throwing he does in the back yard and other items pertinent to his pitching background. In extreme cases, he found that youngsters are taking off only two weeks a year -- Thanksgiving and Christmas – while concentrating exclusively on baseball.
"I point to that blackboard and tell them why their child is seeing me for surgery. That's when the light goes on for them," Andrews said. "No 13-year-old should have that kind of wear and tear on his arm."
So, for some young pitchers, the damage may have already started before they even enter pro ball. Even with proper mechanics, if they have faced excessive workloads, and haven't had adequate recovery time, the risk becomes higher. Many clubs, like the Jays, will limit their draftees' first pro season in order to overhaul their mechanics. Osuna was criticized by some scouts for having a high elbow during the early cocking phase of his delivery, then throwing across his body in order to complete it:
Osuna was pitching in the Mexican League at 16 (when he threw 19 innings), so he may have developed wear and tear issues this season as a result of throwing a lot of pitches year round from an early age. The UCL tends to occur as a series of small progressive tears over time, and then it finally lets go, as it did in Osuna's case. So, he was under the 30 innings increase limit, but much of the damage may have already been done. The good news is that he's not even of draft age until next year, so there is lots of time for rehab and recovery, if surgery is ultimately necessary.
Are These Injuries Preventable ?
As far as the research we've done is concerned, the answer is yes. And no.
You can teach proper mechanics and monitor pitch counts and innings closely, but there are no guarantees, especially for American pitchers, many of whom have had a heavy workload since they were about 11 or 12.
The website thecompletepitcher.com offers the following guidelines for youth pitchers:
1. No youth pitcher should be throwing the curveball before 14 years old.
2. No sliders before 18 years old.
3. The change-up is not considered any more stressful than the fastball and should be utilized in
place of the curve or slider. .
4. Monitor pitch counts.
4. Monitor pitch counts.
The Cubs organization, apparently, takes a further step of limiting their minor league pitchers' activity between appearances. Their general rule of thumb is:
If a pitcher throws 25 pitches in an outing, he has to wait 24 hours before throwing again.
For 35 pitches, 48 hours, 72 hours for 60 pitches, and four days for pitch counts above 75.
Starters are on a 5-day rotation, and no pitcher throws more than 100-125 pitches in a game.
The Jays employed a "piggybacking" system to protect three of their top pitchers (Sanchez, and the departed Syndergaard and Nicolino) at Low A Lansing for part of a season last year. One of the three would start, and would be relieved by one of the other two after he reached his pitch/inning count, and the reliever would, in turn, be relieved by the third. The trio took turns with their roles, so they learned to come into games in higher leverage situations with runners on base. The system worked well to build up arm strength for all three, until the piggybacking was ended in July that year, and each worked as starters.
Syndergaard and Nicolino are enjoying success in High A this year, as was Sanchez, until he was sidelined in early May by shoulder issues. Reports are that he is ready to return to action soon.
No franchise better understands how to identify, develop and maintain quality pitchers than the Rays. They are to pitching what Google is to algorithms, and—under owner Stuart Sternberg, president Matt Silverman and general manager Andrew Friedman, all of whom came to baseball from the investment banking world—nearly as protective of their proprietary knowledge.
Tom Verducci, "The Rays Way," Sports Illustrated, April 1, 2013
Verducci penned an excellent article about the Rays' methodology and philosophy of developing pitchers. The Rays prefer their pitchers to be tall, lean, and athletic. The drills they use promote balance and a repeatable delivery. They preach the value of the changeup, and focusing not on the first pitch to a hitter in trying to get ahead in the count, but the the first three. As far as maintenance goes, they have a 30-minute daily regimen using dumbbells, resistance bands, and weigthed balls, somewhat similar to the Jays' Steve Delabar's heavy ball program that pitchers like Brett Cecil and Dustin McGowan have credited with their turnarounds. The Rays put their first year pitchers on strict pitch/inning restrictions: no throwing a cutter (they are allowed once they have reached Double A), pitching in a six-man rotation, and limited to three inings per outing in the first month, four innings in his second, and five innings (but no more than 75 pitches) in the third month. As a result, the Rays have a league-leading five man homegrown rotation, and haven't used a starter over 30 from another organization over the past five years.
Granted, David Price was shut down last month with a strained triceps muscle, and just received permission to throw off of a mound this week, but it's very hard to argue with the Rays' results. They are one of the best organizations in baseball as far as selecting, developing, and keeping young pitchers healthy. There are no guarantees, but their model should serve as a template for other teams.
We've covered a fair amount of ground, but admittedly, this is a complex topic.
If we were in running a major league organization, we would recommend a multi-faceted approach:
We would instruct scouts to look for the body types that the Rays seem to have mastered the talent for identifying; pitchers that are long, lean, and athletic. The first two are important for developing a downward plane on their pitches, the third is crucial for coming up with the ability to repeat an effective delivery that minimizes stress on their arms.
We would also be wary of young pitchers who have been, for lack of a better word, misused since a young age (not difficult during this day and age of showcase tournaments across America): pitchers who have accumulated a lot of innings since their youth, and/or have been allowed to throw a curve and slider.
We would put in place the strictest of pitch and innings limits for first year pitchers (with some flexibility built in for college pitchers) . Some would argue that pitch counts don't allow for a young pitcher to learn how to get out of trouble. We would counter that if you take the long term view of development, there is plenty of time for that as the pitcher progresses through the system.
We would instruct all clubs in the organization to teach their pitchers to pay as much attention to their in-between outings routines as they do to the days they pitch. Enforce mandatory rest times after each outing, depending on the number of pitches. Convince the pitchers it is in their best interests to pay attention to strength, cardio, and flexibility training on a year-round basis.
The above, of course, is no guarantee against injury. Most clubs, we're sure, are using this approach. Obviously, there is a huge variance in the extent to which they're employing it. Selecting the right pitchers in the first place would be the biggest challenge.