BASEBALL
Excess pitching fuels explosion of elbow injuries
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MATT MILLER/THE WORLD-HERALD
Throwing a baseball, with the arm raised up behind the head, is not a natural motion. Millard West High senior Mitch Ragan eventually developed elbow problems that led to his recent Tommy John surgery. The operation has become routine in baseball and has a success rate of 90 percent, so Ragan hopes to be back on the mound next season.
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Posted 8 hours ago
By Dirk Chatelain / World-Herald staff writer
Mitch Ragan walked into the doctor's office wearing his favorite sweats, his Red Sox hat and his Millard West letter jacket. Mom and dad were at his side, sharing words of encouragement.
Good news was coming.
Ragan was one month from the start of baseball season, a critical point for a junior who'd targeted college or pro ball since seventh grade. He couldn't wait to take the mound. At 6-foot-3, 250 pounds, he was pushing 90 mph on the radar gun. And his mechanics were better than ever. He just needed Doc to check his elbow.
Two weeks earlier, an early February night at an indoor Omaha baseball facility, Ragan winced during a bullpen session. He'd battled sporadic elbow pain for three years. This time, he felt a clicking sensation. His pitching instructor feared the worst.
Across the country, the most valuable elbows in professional baseball were breaking down,
casualties of an epidemic that experts couldn't solve. But those guys were in their 20s. Ragan was still 16.
Good news was coming.
The doctor, whom the Ragans had known for four years, entered the exam room and echoed the family's optimism. Probably another case of tendinitis. A few weeks of rest and Ragan would be fine.
Then Dr. Doug Tewes laid eyes on Ragan's MRI. He recognized the fluid around the ulnar collateral ligament, or UCL, signaling a detachment from the bone.
When Doc raised his hand to his chin, Mitch knew bad news was coming.
Rather than attracting recruiters and scouts, rather than competing with teammates for a state championship, rather than standing 60 feet, 6 inches from home plate and firing his fastball past hitters who could barely see it (let alone hit it), Ragan would spend 2014 in rehabilitation. Four months later, the farthest he's thrown a baseball is 5 feet.
Tewes turned the MRI toward the Ragans ? "See this ligament here?" ? and uttered a name that always gave Mitch goose bumps.
Tommy John.
***
Baseball has a strange way of recognizing its most gifted pitchers.
Stephen Strasburg was the No. 1 pick of the 2009 draft, the most exciting pitcher in the game ? until he missed 12 months of action during 2010-11 following ulnar collateral ligament reconstruction. Jose Fernandez, the 2013 Rookie of the Year, is out for the '14 season after his own elbow surgery. So are Matt Harvey and Matt Moore and Patrick Corbin and, well, elbows are beginning to resemble ticking time bombs.
Why? That's what Mitch Ragan wanted to know.
Tommy John surgeries, named after the first recipient of successful UCL reconstruction in 1974, have skyrocketed the past decade at all levels of baseball. Twenty-one major-league pitchers have undergone season-ending surgery, a record pace for one year.
But finding consensus among coaches, orthopedic surgeons, physical therapists and data analysts is like turning a quadruple play. Somehow devoting more time and resources to arm care has exacerbated the problem. Fingers point in every direction.
Is it higher velocities? Pitchers are training more intensely, thus, throwing harder. Maybe the elbow can't handle the torque associated with a 95-mph heater. What about mechanical inefficiencies? High-speed cameras allow experts to analyze the pitching motion like never before, revealing faults undetected by the naked eye.
Some say full-grown pitchers are being abused. Some say they're being coddled ? instead of obsessing over pitch counts, they should actually be throwing more in order to strengthen the arm. Some blame the one-size-fits-all method of training; if pitchers come in all shapes, sizes and physiologies, then why are coaches treating them the same?
There's no magic formula for arm care.
"You can name 20 things, and it's probably a part of all 20," said Omaha Westside coach Bob Greco, who won a Class A state championship in May.
There is, however, one factor on which all parties agree. It is the primary cause of pitching injuries, according to doctors. It is the one thing coaches would change immediately, if only they could.
The next generation of baseball players is playing far too much baseball.
***
Mitch Ragan lives in the same house he did when he first picked up a glove. At night he could look across Q Street and see the baseball field lights at Millard West.
"He used to dream about playing baseball there as a little kid," said his mother, Shelly.
Mitch joined his first team at 5 years old. His little Cincinnati Reds jersey is now part of a quilt he gave his mom for Christmas.
His kindergarten teacher called him the gentle giant. He was bigger than his friends. Threw the ball harder, too.
At 8 he joined his first select team and quickly became a pitching ace. Each baseball season started a little earlier, each coach asked for a little more time. Mitch's parents tried to find balance.
Throwing a baseball is not a natural motion ? "there's a reason we don't walk around with our arms over our heads," ESPN analyst and Omaha native Kyle Peterson says ? but Ragan's actions looked totally natural within the youth baseball culture, where parents assume coaches know what they're doing, where coaches feel an obligation to maximize parents' investment, where kids can't get enough.
When a coach asked Mitch how his arm felt after a long inning, he said "Fine," even if he felt pain. When his team reached the Sunday championship game of a select tournament, Mitch threw three or four innings, even though he'd pitched six Friday and played catcher all day Saturday.
"The bad part about being a big kid and growing faster than your peer group is you're going to dominate," said Ragan's pitching instructor, Jim Haller.
"And you're going to be expected to dominate. What does the dominant pitcher do? He throws more. He's cajoled, 'Man, you throw hard.' Right? So what does a kid want to do? Throw harder."
Ragan's older brother, also a pitcher, who's playing now at Wayne State, suffered a shoulder injury in high school. Mitch regularly felt shoulder pain, too, until seventh grade, when he tweaked his motion. He began reaching back farther. His shoulder ? and his velocity ? improved. But his elbow flared up.
Before high school, he visited Dr. Tewes in Lincoln. Tewes noticed a widening of the growth plate, indicating the arm had been stressed. Doctors called it "Little Leaguer's elbow."
He didn't need surgery, but as pitchers become teenagers and their growth plate closes, the stress shifts to the UCL. It stretches, bends, frays and, especially without the proper rest, eventually breaks.
"This is cumulative trauma," Tewes said.
Pain forced Ragan to take about a month off from pitching in eighth grade, at his mother's urging, then again as a freshman, then again as a sophomore. His parents were wary of pitch counts, often telling coaches, "Sorry." When he did pitch, Ragan demonstrated the tools to be one of Omaha's best prep pitchers.
Haller said Ragan has as much potential as any young pitcher he has tutored. He has a big frame; he started on Millard West's offensive and defensive line as a sophomore and junior. He has mental strength. He's willing to be coached.
When Tewes completed 90-minute Tommy John surgery on Mitch's elbow in February, Haller was in the waiting room with mom and dad.
"If his rehab goes well," Haller said, "I wouldn't hesitate calling any college coach in the country and saying 'You've got one here.' "
Haller has seen enough to know.
***
On the morning of Sept. 25, 1974, Jim Haller was scheduled for surgery in Los Angeles, the latest setback in a frustrating pro career.
At 6-foot-6, the Creighton Prep graduate possessed an explosive arm. When he struck out Dave Winfield in an American Legion tournament, scouts fawned over him. The Dodgers drafted Haller ninth overall in the 1970 draft. But poor mechanics contributed to elbow problems.
That morning in California, Dr. Frank Jobe performed an ulnar relocation on Haller's elbow. Routine operation. Then Jobe washed up, entered another operating room and executed "this bizarre Frankenstein surgery," Haller said, better known as the first UCL reconstruction in baseball history. The patient?
Tommy John.
Jobe made an incision on the inside of the elbow and replaced the torn UCL with a wrist tendon harvested from John's wrist. He wrapped the graft through two tunnels in the bones ? like a figure eight ? then sewed it to the old ligament, reinforcing the new tissue.
Creative? Yes. Effective? Nobody would've bet on it.
When Haller saw Tommy John at spring training six months later, John's pitching hand was "curled up like a stroke victim," Haller said. John opened his fingers with his off hand, put the baseball in it and threw it as far as he could ? about 15 feet.
"We were, like, 'Give it up, Tommy. It's not happening.' "
But in '76, John made it back. The lefty pitched till he was 46, winning more games after surgery (164) than he did before (124).
By the time John retired in 1989, UCL reconstruction had become routine in baseball. Now the success rate is so high ? 90 percent ? that doctors occasionally hear from pitchers and their parents who seek Tommy John surgery for minor pain, believing ? falsely, according to doctors ? that the scars eventually will lead to a stronger arm.
Jobe died at age 88 in March. Not before his Frankenstein surgery had become a medical monster.
***
James Andrews, the modern-day Jobe, has published a list of recommendations for young pitchers that reads like a little league version of the Ten Commandments. Among his points of emphasis:
» No overhead throwing of any kind for at least two to three months per year ? four months is preferred.
» No pitching more than 100 innings in games in any calendar year.
» Avoid using radar guns.
» A pitcher should not also be a catcher for his team.
» Follow limits for pitch counts and days rest.
Stop by a suburban sandlot this week ? hundreds of select teams from around the country have descended on Omaha ? and you'll find those rules routinely disregarded.
An 11-year-old USSSA tournament, for instance, consists of 46 teams.
Many will play seven games in 2½ days. A few are eligible to play eight. Eleven-year-olds will be permitted to throw as many as 10 innings. Even at 15 pitches per inning, which is efficient by youth standards, that's a heavy burden. You won't find a major-leaguer all season who throws 150 pitches in a 2½-day span.
Contrast this with Andrews' recommendation: Any pitcher under the age of 14 who throws 65-plus pitches should rest for four days.
It's not just Omaha. Tournaments across the country follow similar rules. Some don't track innings limits at all. According to Ragan's former coach Rich Bishop, Mitch's workload was relatively conservative. One opposing pitcher in eighth grade threw 11 innings in 24 hours.
Often kids play on two teams in the same season, pitching for both. The coaches face no consequence for abusing an arm because, as Bishop said, "you're not going to blow your ulnar collateral ligament when you're 11. So they just pass him on."
Haller, who grew up playing only 15 to 20 organized games a summer, watches youth baseball tournaments in which kids throw one inning the first game, two the next, four the next. He sees high school relievers warm up multiple times before they face a batter. He sees 12-year-olds throwing at radar guns.
"What the hell are we doing to these kids?" Haller said.
***
Mitch Ragan is in week 16 of rehab. He follows Dr. Tewes' instructions to the letter, determined to pitch again under the Millard West lights.
Harvesting the tendon from his wrist stripped away the blood flow, rendering it a dead piece of tissue. Even though it's part of his elbow now, Mitch has to wait for the body to make it alive again. It's a slow process, week after week, month after month, just as it was 40 years ago.
If all goes well, Ragan will start throwing this winter and return to the mound next spring, just in time to earn his college scholarship, maybe even get drafted.
He'll stare down his catcher and wait for the sign ? fastball. He'll coil his torso, kick his leg and reach back ? way back.
He'll whip his arm toward home plate, hoping the scars don't get in the way