An MRI might have cost a high-school pitcher millions of dollars last week.

Brady Aiken, a left-handed pitcher from San Diego, recently became only the third high school pitcher to be selected as the top overall pick in the Major League Baseball draft. He reportedly had agreed to a $6.5 million contract with the Houston Astros before the deal fell apart.

According to Ken Rosenthal of FOX Sports, the Astros became concerned about a “significant abnormality” in his elbow ligament, likely the ulnar collateral ligament reconstructed in what are now commonly known as Tommy John surgeries. Aiken’s agent claims that his client is not only pain free, but he reached 97 miles per hour in his final high school start. Aiken also saw several orthopaedic surgeons who claim he is not injured.

MLB teams concerned about pitchers at risk for elbow injury?

Tommy John surgery almost seems to be a normal event for pitchers today. In fact, Bleacher Report’s Will Carroll reported in 2013 that one of every three starting pitchers in Major League Baseball had undergone UCL reconstruction. Maybe Aiken’s situation reflects increasing nervousness among clubs investing huge amounts of money in kids likely to go under the knife sooner rather than later.

A study presented at the American Orthopaedic Society for Sports Medicine’s Annual Meeting earlier this month suggests that teams have reason to be concerned.

Also read:
What is causing the spike in Tommy John injuries?
Tommy John surgery offers pitchers long-term success

Tommy John surgery early in pitching careers

Robert A. Keller, M.D. and other researchers at Henry Ford Hospital in Detroit reviewed statistics on 168 pitchers who underwent UCL reconstruction during their MLB careers. Approximately 60% of them had surgery within the first five years of pitching in the majors. Players who entered Major League Baseball at a younger age had an increased risk of requiring elbow surgery.

The UCL is a small ligament that must stabilize the elbow against a large amount of stress over thousands of pitches each year. A healthy ligament doesn’t usually snap with one pitch. Instead, the ligament gradually fails with repeated stress, much like the fraying of a rope. If a ligament has a partial tear or some other abnormality, it could be more likely to fail than a healthy one.

Also read:
Ask Dr. Geier – Preventing youth pitching injuries
Ask Dr. Geier – Tommy John injuries

Pitching performance after surgery

Another recent study, performed by Yankees’ team physician Dr. Christopher Ahmad and others, offers a warning to all young throwers who dream of pitching one day in college or the big leagues. While athletes with reconstructed elbows often do return to the mound, their performance is likely to suffer.

The researchers analyzed all MLB pitchers who underwent UCL reconstruction between 1999 and 2011. They observed significant declines in pitching performance statistics after surgery, including earned run average, walks plus hits per inning pitched (WHIP), batting average against, percentage of pitches thrown in the strike zone, innings pitched, and average fastball velocity. Possibly more alarming was the fact that 57% of the pitchers later returned to the disabled list due to injuries in their throwing arms.

Also read:
The misperceptions of Tommy John surgery
Pitching too many innings could end your baseball career

Common misperception about Tommy John surgery

These results might fly in the face of a common misperception about Tommy John surgery. Sports medicine surgeons often hear kids claim that they can throw as hard as they want, as often and as long as they want. If they get hurt, they will just have surgery and come back better than ever.

This idea that the reconstructed elbow is stronger than before is likely based more on perception than reality. After surgery, the pitcher has a rested arm. He has had time to build muscle strength, especially in his core and lower body. He might have improved his mechanics. And he is comparing how his arm feels after surgery to what he remembers when the ligament started to fail, not when it was healthy.

It’s possible that a high school pitcher will not return better than before his elbow injury, and he might actually perform worse. Plus, that assumption takes for granted that he returns to pitch at all. High school pitchers who undergo UCL reconstruction have lower return-to-baseball rates than do MLB pitchers.

Also read:
4 risk factors for youth pitching injuries
7 tips to strike out youth pitching injuries
What Stephen Strasburg can teach young pitchers

Message to young pitchers: Protect your arms

Time will tell if Brady Aiken will one day sign a huge contract. We will see if he ever develops elbow problems. Regardless, even pitchers unlikely to sign million-dollar deals as top draft picks need to do everything possible to protect their arms.

Rest for three months every year. Don’t throw in showcase events. Don’t pitch through pain. Kids would be better served trying to stay healthy than rolling the dice on Tommy John surgery.

Note: A modified version of this post appears as my sports medicine column in the July 23, 2014 issue of The Post and Courier.

Also listen to these discussions from The Dr. David Geier Show:
Episode 134: What has Tommy John surgery meant for baseball? (starts at 4:34)
Episode 107: Is Tommy John surgery inevitable for pitchers? (starts at 4:28)
Episode 34: Why are Tommy John surgeries so common in baseball pitchers? (starts at 3:18)

References:
Keller RA, Steffes M, Zhuo D, Bey MJ, Moutzouros V. The Effects of Ulnar Collateral Reconstruction on Major League Pitching Performance. Presented at the American Orthopaedic Society for Sports Medicine’s Annual Meeting in Seattle, Washington July 10, 2014

Makhni EC, Lee RW, Morrow ZS, Gualtieri AP, Gorroochurn P, Ahmad CS. Performance, Return to Competition, and Reinjury After Tommy John Surgery in Major League Baseball Pitchers: A Review of 147 Cases. American Journal of Sports Medicine. June 2014. 1323-1332.