Weighing the effects of Tommy John surgery on fantasy pitchers

By David Young, Special to SI.com

Tim Hudson, one of many pitchers to undergo Tommy John surgery, is expected to make his return to the bigs this season. AP

One of the biggest disappointments of the fantasy year has been the mediocre pitching of Minnesota's Francisco Liriano. In 2006, he was the heir apparent to Johan Santana and in contention for both the AL Cy Young and Rookie of the Year awards. But elbow pain landed him on the DL and later that year he had Tommy John surgery. He returned in '08 and went 6-4, but his strikeouts were down while his WHIP and ERA were up. This season, he's been even worse with a 5-12 record and an ERA of 5.80. Could his '09 numbers have anything to do with trying to come back from the surgery too quickly?

Every year pitchers go under the knife to have their Ulnar Collateral Ligament (UCL) replaced, which starts the clock on the rehab process to regain velocity and form. The original rehab time to return to pre-surgery pitching efficiency after this procedure is 18 months. But in recent years a team's desire to get its multi-million dollar investment back on the mound combined with the athlete's natural need to compete have driven the rehab time down to 12 months. This shortened rehab schedule has produced mixed results.

This article will look at the results of certain pitchers who have come back from the surgery. Based on what is discussed below, here's the protocol you should follow when evaluating any pitcher that has the procedure done:

1. Start watching for updates about their rehab efforts about 11 months from the date of their surgery.

2. Barring a setback, expect the pitcher to return at the one-year anniversary. But also expect the pitcher to be less effective then his pre-surgery numbers indicate.

3. While not foolproof, have more faith in the return to form of starters that are allowed to work out of the bullpen that first season back.

4. While the pitcher will be healthier than at the time of the injury, do not expect him to exceed the talent he showed before the injury.

5. Again, not foolproof, but in a best case scenario, beware a fall off after six or seven seasons of post TJS play.

Tommy John surgery

UCL surgery involves replacement of a damaged elbow ligament using one from another part of the body -- typically the hand, wrist, forearm or hamstring -- which is then wrapped in a figure-eight pattern through holes drilled in the arm's humerus and ulna bones. The procedure is more commonly known as Tommy John surgery after the Dodgers' starter who received the procedure in 1974 and came back to have a prolific career into the '89 season.

Prior to John's successful comeback, a torn UCL meant a pitcher's career path was headed towards coaching or broadcasting. However, after returning during the '76 season, John was able to add 2544.2 IP to the 2165.2 he had already thrown, and logged more than half of his 288 career wins after his surgery. Even by today's standards pitching an additional 14 post-surgery seasons was a remarkable feat, and John's results are the medical equivalent of Cy Young's 511 career wins: It's foolish to even discuss whether someone will come close to matching it.

Dr. Frank Jobe, the surgeon who performed John's surgery, was a former Dodgers team physician and argues that Sandy Koufax could have extended his career with it (he claims Koufax's career-ending arthritis was caused by a stretched UCL). Regardless, the surgery has become routine -- taking about one hour to complete -- and is available to pitchers at any level that tear their UCLs. Dr. James Andrews, among the handful of top TJS surgeons in the country, claims the surgery sees a success rate of 85%, up from 60% about 15 years ago.

The myth of post-TJS performance improvement

Pitchers have reported a post-surgery increase in velocity. Former closer Billy Koch claimed to have hit 108 mph on a radar gun after rehabbing. Others, like Kerry Wood, agree that they too have seen higher velocity numbers thanks to the surgery. However, this is likely a case of pro hoc, ergo propter hoc ("after this, because of this"), the argument that blames rain on a just-washed car. The surgery and the higher velocity are related, but not directly. And not all pitchers experience this increase.

Doctors postulate there are other reasons a pitcher might see increased velocity post-surgery. The pitcher likely pitched with a torn UCL prior to the surgery, so he had not been pitching at peak performance. Replacing the UCL allowed the pitcher to get back to where he would have been before the ligament damage, but not necessarily to a point of improvement. Also, the rehab process works to build up the shoulder and elbow, which means the pitcher is probably in the best shape of his life, concentrating on health, nutrition and fitness for a full year. And sometimes, the pitcher matures physically during the resting period. Any one of these reasons -- or any combination -- could lead to increased velocity.

The downside to TJS success stories

Koch (yes, him again) once said, "[My arm] felt so good when I came back, I said I recommended it to everybody ... regardless what your ligament looks like." Sure he was being facetious, but since we're talking about potential multi-million dollar careers, many didn't take his comments that way. There has been talk of prophylactic TJS on healthy ligaments, but that would run south of anybody's interpretation of the Hippocratic Oath.

What is more disturbing is the increase in surgeries among younger pitchers. Dr. James Andrews estimates that 20% of his TJS patients are major leaguers, another 20-25% are minor leaguers, and the remaining 55-60% are college or high school athletes. The late Nick Adenhart had the procedure done when he was 18 and former MLB pitcher Dewon Brazelton got it when he was 15. Doctors have quoted lower success rates in high school pitchers mainly because the commitment to rehab is likely harder for the youngster who may decide the work is not worth it, as opposed to the major leaguer who knows the seven or eight-figure cost of not returning to form.

TJS rehabilitation

The initial rehabilitation time between Tommy John's UCL surgery and his return to the majors was 18 months, or basically the end of the '74 season to the beginning of the '76 season (technically, from 9/25/74 to 4/16/76). In his first season back John -- a sinker curveball pitcher -- made 31 starts (207.0 IP) with a 3.09 ERA and pitched six complete games. While his 10-10 record was mediocre by his standards, his underlying statistics were not far off his pre-surgery numbers and he was voted the NL's Comeback Player of the Year.

Since John's UCL surgery, post-TJS rehabilitation has become better defined. The arm is initially immobilized for a week then put in an adjustable brace. The patient is engaged in range-of-motion exercises working up toward swinging a golf club by the 12th week. By the 16th week the pitcher starts throwing on flat ground and then throws from a mound at six months. By the end of 12 months the pitcher has thrown breaking balls and can pitch batting practice. It is at this point the pitcher may return to competitive pitching. However, that's just from a muscular and joint point of view. The pitcher still has to mentally trust the arm (something some say Liriano is yet to do) and get back his mechanics, and it often takes another season before he can be considered back to full effectiveness.

Differences in physiology, surgery effectiveness, and environment can affect the length of the rehab. Also, the pitcher has to make sure to work on his shoulder while rehabbing his elbow, or risk a DL stint with shoulder problems because they allowed the muscles to weaken during times of limited arm movement.

The Morris-Smoltz bullpen model for post-TJS MLB return

With the established time to return to effectiveness being 18 months but the time that a pitcher can return to competition being 12 months, the more patient teams have used the compromise of having the starting pitcher return by way of the bullpen. The plusses are obvious as the pitcher, who may not still be back to physical and mental game shape by the end of the 12 months, need not be stretched back to pitch 100 pitches in an outing. Also, giving him one-inning outings allows him to get the feel of his pitches back with less damage to the team, and the manager can be more selective on when the pitcher enters a game.

Perhaps an argument in favor of going to the bullpen is the high-profile closers and relievers that have been able to perform well at the major-league level post-TJS. Danys Baez, Rod Beck, Manny Delcarmen, Octavio Dotel, Frank Francisco, Eric Gagne, Tom Gordon, Hong-Chih Kuo (twice), Jose Mesa, Rafael Soriano and Bob Wickman were all able to pitch competitively after receiving TJS. And just to set the record straight, Mariano Rivera did have TJS, but once the doctors opened up his elbow they found the UCL was fine and only needed to be moved. Therefore, technically Rivera had the surgery, but did not have the procedure done to his arm.

Perhaps the highest-profile example of going the post-rehab bullpen route is future Hall of Famer John Smoltz, who had surgery just prior to the 2000 season. When he returned in mid-May of '01, he started five games before determining he wasn't cutting it as a starter. The Braves needed a closer and Smoltz needed less innings, so he eased into that role and recorded 10 saves that year with a total of 59.0 IP (25 as a starter, 34 as a reliever). The next three years he amassed 144 saves, including an NL record 55 in '02, before returning to the rotation in '05. He then had three straight 200-IP seasons as a starter. Despite his injury-filled and disappointing '08 and '09 seasons, pitching for seven full seasons at an All Star level following the surgery make Smoltz a success story.

The blueprints for Smoltz's move to the bullpen in '01 may have been drawn by the Cardinals in the previous season. Starter Matt Morris had TJS at the beginning of the 1999 season and returned at the end of May in 2000. The Cards sent him to the pen for the season where he pitched 53 innings. The next season they put him back in the rotation, and he made over 30 starts in five of his next six seasons, including two All Star appearances (he likely should have been an All Star in '05 as well). His eight seasons of post-surgery competitive baseball along with Smoltz's seven seasons are strong arguments for the Morris-Smoltz Bullpen Model for recovering TJS patients.