Pitch 22

This story appears in ESPN The Magazine's May 25 Pitchers Issue. Subscribe today! And make sure to watch Outside the Lines Sunday at 9 am on ESPN, which will detail the rise of pitchers having Tommy John's for the second time.

1 It's everything the scouts want. It's a 94 mph fastball, a changeup with tail and a slow curveball with a 1-to-7 shape. It's command to both sides of the plate. It's a tall body, a pitcher's body. It's the deception out of the left hand, obscured by a rock 'n' roll delivery and a soft, closed stride. It's any pitch at any count. It's the best amateur pitcher in the world, 17-year-old Brady Aiken, on a high school field in San Diego, months before baseball's 2014 draft, a future big leaguer dominating future estate lawyers and future math teachers and future landscapers. It's potential, and it's as beautiful and fragile a thing as baseball can create.

2 When we throw overhand, it puts what's called valgus stress on the arm, which is a fancy way of saying the elbow is trying to bend in an unnatural direction. And when somebody throws 95 mph, it creates so much valgus stress that the forearm essentially wants to detach from the body; if it could, it would simply fly into space. But one 2-inch ligament in the elbow holds two bones together and keeps the forearm in place. It is a pretty important screw.

But ligament is not muscle; it can't be strengthened through exercise as well as muscle can be. It is also not bone, which will adapt to the stress placed upon it. Ligament is just fibrous tissue, and an elite pitcher's ligaments are pretty much the same as yours and mine for one reason: There is little he can do to make his better.

Rick Peterson, the Orioles' director of pitching development, recalls a physicist who approached him after a conference. The physicist had done some calculations. The force exerted on the elbow ligament in the 0.03 of a second of acceleration during a pitch? If a human were exposed to that for 60 seconds, the physicist said, he'd die. So the ligament is pretty tough. It's just not getting any tougher.

3 This is the story of baseball's Tommy John epidemic, which is so complex and confounding that that simple phrase isn't even correct: The name conflates the cause (ulnar collateral ligament damage) with the cure; the word "epidemic" implies something contagious (it is not) and suggests we know more than we do. There's so much we don't know.

Certainly, Tommy John surgeries have become widespread as pitchers fall to elbow pain at a record pace. Last year The Hardball Times writer Jon Roegele recorded 101 professionals, including 31 major leaguers, who went under the knife for TJ -- about 50 percent more than in 2013. The pace is comparable this year and includes Rangers ace Yu Darvish and Mets rising star Zack Wheeler. What we don't know is what this all means: Are more pitchers actually hurting their elbows, or are the sport's doctors just getting better at diagnosing injuries, or are pitchers just more open about admitting their injuries, or are teams just more liberal about prescribing the surgeries? As for the hurt itself -- forget it. We don't know what broke Wheeler this spring, and we don't really know when he broke. The ligament tear might have begun when Wheeler was a teenager.

4 But we do know a lot about human beings, the greatest species of idiot geniuses who have ever lived, the cause of and solution to all of life's problems. We know we have to start there, because we did this. There are no villains in this story, just incentives.

5 The world that the baseball gods created was not this cruel. Pitchers threw underhand by rule; it was a straight-arm action. "The term 'pitching' was ... apt," Peter Morris writes in A Game of Inches, "because the motion was akin to pitching a horseshoe." But the serpent told the pitchers they should bend their arms and throw harder, or snap their wrists and thus achieve spin.

New restrictions were imposed, and pitchers found ways to avoid them. They were allowed to throw from the hip, "but the liberalized rule only encouraged many of them to try to get away with still higher release points." Then the waist; they hiked their pants up, their belts "deceptively high." Eventually, all major leagues conceded and allowed pitchers to throw overhand -- though it was thought, even then, that this would cause pitchers to get hurt. "It was found useless trying to contend against the advances of the pitcher," wrote the Detroit Free Press in 1895.

6 In 1987, a surgeon named James Andrews hired a biomechanics expert named Glenn Fleisig to work at his American Sports Medicine Institute. Sports biomechanics was a nascent field focused mostly on improving performance, but Fleisig and Andrews flipped the paradigm. Injuries were like crimes to them, and they wanted to fight crime from the ground up, through science and data and public awareness. They thought of biomechanics as first a way to understand how athletes' motions led to injuries, and then to fix the problems. "Glenn," Andrews told Fleisig, "I'll do the surgeries. Your job is to put me out of business."

Twenty-seven years later, Andrews performed, according to Jon Roegele, three Tommy John surgeries on professional players in one day: one on Yankees veteran Ivan Nova, one on Brewers rookie Johnny Hellweg and one on a Giants prospect named Mac Williamson. Clearly, something has gone wrong, and according to Andrews and Fleisig, that something starts well before we've heard of these pitchers. The problem, he and Fleisig say, starts in the teenage years with players who throw harder than ever and don't ever take a month off.

7 There is plenty that isn't known about arm health, but a consensus seems to be emerging. ASMI, the group founded by Andrews, has represented that consensus in a series of research-based recommendations and warnings. Among them, for youth pitchers:

Pitching in offseason industry showcase events, instead of resting, is risky.

Pitching year-round on travel ball teams is risky.

Throwing too many innings in a year is risky.


Throwing hard is risky.

Now those same warnings but rephrased:

Being good, so that you're asked to pitch at industry showcases, is risky.

Being good, so that you're asked to pitch for travel ball teams, is risky.

Being good, so that you're asked to pitch a lot of innings, is risky.

Being good, by having the ability to throw hard, is risky.

The problem is obvious. The sport has put a time bomb in every pitcher's body, a time bomb that starts ticking when they get good -- because they get good.

8 Brady Aiken got good. As a junior, he emerged as the ace at Cathedral Catholic High in San Diego. He then pitched well on the summer showcase circuit in 2013 and for a U.S. 18-and-under squad in the fall. Riding comparisons to another surfing left-hander from the San Diego area, Cole Hamels, he projected as a first-rounder the following June.

He knew about baseball's time bomb. His coach at Cathedral, Gary Remiker, and his dad, Jim, agreed on a plan to keep him healthy his senior year: He would take the winter off, as doctors recommend. When he finally took the mound, he would ramp up slowly, with 50- and 60-pitch limits, even as 30 teams' scouts crammed onto the school's two bleachers. He would avoid between-start appearances out of the bullpen, and when his pitch count got high he'd leave the game -- even when it was 2-1 against a top rival. If these decisions cost him money in the draft, so be it: He had a scholarship to UCLA as a fallback.

9 In late January 2014, Remiker got a call. MLB's scouting bureau was organizing a showcase in Compton, two hours north of San Diego, and it wanted Aiken there. Nearly 50 top prep players would attend, and every major league team would send scouts. All Aiken needed to do, Remiker was told, was throw an inning with radar guns on him. That it came during Aiken's winter of inactivity, that his arm strength wasn't built up, that he would be asked to flash top-velocity fastballs for dozens of radar guns with millions of dollars on the line -- all of it was clearly concerning, but the bureau wanted Aiken there.

Remiker hated the request. "All it was going to do was hurt Brady," he says.

10 MLB teams all know what Fleisig and Andrews recommend. Fleisig's research and guidance are everywhere on MLB's Pitch Smart, a gorgeous webpage with "a series of practical, age-appropriate guidelines to help parents, players and coaches avoid overuse injuries and foster long, healthy careers for youth pitchers." Bud Selig, before he retired as commissioner, promised the league's medical director "whatever you need" to research and improve pitcher health. So the league gets it.

But the competition among teams undercuts this work. They were asking pitchers like Aiken to ignore Fleisig's recommendations. Says Murray Cook, a longtime GM who now scouts for the Tigers, "We're guilty of encouraging these kids, whether it be subliminally or actually, to play all year round."

11 What makes an elite athlete now is the willingness to accept injury -- sports in the Survivor age. In the recently published book The Fall Line: How American Ski Racers Conquered a Sport on the Edge, Nathaniel Vinton writes that skiers travel at twice the speeds they did a century ago, at tremendous risk. Even the surface is more merciless: "The snow -- injected with water, sometimes treated with chemicals -- got faster. In order to make firmer guarantees to buyers of broadcast television rights, the sport's overseers hardened the snow, making it icier and slicker." Researchers have noted what they call an "epidemic" of ACL injuries among competitive skiers.

The same mentality -- get as close to the edge as possible and hope to get lucky -- is evident across youth sports. At the University of Kentucky's department of orthopedic surgery, Dr. Mary Lloyd Ireland sees rapid rises in injuries for youth softball pitchers, especially those playing year-round. The throwing motion puts very little stress on softball pitchers' elbows -- elbow injuries are rare. So instead they're hurting their knees, back, shoulders. ACL injuries are "epidemic" in girls basketball and soccer, according to a Loyola University research paper. Shoulder injuries for elite swimmers are "approaching epidemic proportions," according to Swimming World. "The 21st century athlete of any age or sport must throw faster, play harder, earn the scholarship, and don't tell anybody you're hurt," Ireland says. They do this even in sports without financial incentives -- athletes pursuing scholarships, not $6 million signing bonuses. Modern athletics are no longer just a test of who is best. They're a test of who can stay healthy when their sports are trying to break them.

12 Few clubs hold it against a young pitcher if he has thrown more than the recommended 100 innings in a year, or has done so in warned-against overlapping seasons, or has failed to get the suggested months of rest in between those seasons. Most clubs don't even know how many innings their high school draftees have pitched; it's too hard to collect the data from scattered leagues, tournaments and showcases. Innings don't tell the whole story anyway: Most pitchers will throw only an inning or two at a showcase, but they'll need to be in pitching shape to do so, which rules out resting in the weeks leading up to it.

So the pitchers keep pitching, trying to get noticed, trying for a signing bonus. "The industry rewards the prospects who have been the best performers on the biggest stages for the longest periods of time," says one National League scouting official. "We do acknowledge that some players have been ridden harder than others ... but I wouldn't say we systematically dock those players because of it. MLB scouting practices [and spending constraints] do not incentivize ASMI's suggestions." "You take the best arm," says another NL exec. "If Player A is better than Player B, you take Player A. You don't worry about what they did at 13 or whatever. And maybe you should. But it doesn't happen."

Baseball America editor-in-chief John Manuel has considered boycotting some showcases that come in the late fall or winter, when pitchers should, according to Fleisig and Andrews, be resting. Some scouts privately agree. "It'd be nice if we did boycott," one scout says, then looks off in the distance and laughs. "Not going to happen."

So the ASMI's recommendations are a hard sell. "We advise it [to players] all the time," says sports agent Alan Nero, who has represented first-round picks, "but nobody does it."

13 Before Darvish and Wheeler and Matt Harvey and Jose Fernandez, there was Sam Peltzman, an economist at the University of Chicago. In a seminal 1975 study, he argued that national safety regulations involving seat belt laws hadn't led to fewer automobile deaths because people just drove more recklessly when they felt safe. This became known as the Peltzman Effect: Steps to make something safer sometimes lead to offsetting behavior and, perversely, just as many accidents. The Peltzman Effect has been observed in mountain climbing, bicycling, skydiving. Economists at West Virginia University found it in NASCAR, where safety regulations preceded an increase in accidents and caution laps.

Jeremy Bruce, a surgeon who worked with Andrews, wonders whether Tommy John surgery has led to the very behaviors that cause it -- especially because surveys show that the public believes the procedure is far safer, more effective and easier to return from than it really is. Though 80 percent of big league pitchers who have the surgery throw again in the majors, only 67 percent of them appear in 10 games or more in a single season, according to one 2014 study. Last year, of the pitchers who needed Tommy John, 35 percent of them were having it for the second time.

"The improvements in the surgery have actually hurt our injury prevention," Bruce says. "It's hard -- no one wants to show off their bad results. But it's almost what we have to do, to put the fear into people."

14 Pitch counts took hold as a safety precaution around 1999, a quarter-century after the first Tommy John surgery. Far from solving the problem of elbow injuries, they coincided with further increases, perhaps because pitchers who are no longer expected to work deep into games are more likely to throw with maximum effort on every pitch. Shorter starts, meanwhile, mean more relief appearances -- and relievers (who throw even harder and have less rest between outings) are even more likely than starters to have the surgery. It was found useless to contend against the advances of the pitcher.

15 Other experts hypothesize that the Tommy John epidemic is the direct result of the ending of the shoulder-injury epidemic of a few years ago. The energy of pitching, the hypothesis goes, travels through the body until it finds the weakest link. For a while, that had been the shoulder, but strength and conditioning (along with biomechanics insights) have dramatically cut the number of shoulder injuries -- from 7,000 days lost to the DL in 2008 to 3,000 last year, according to research by The Hardball Times' Jeff Zimmerman. What's the new weakest link? That 2-inch ligament. Days spent on the DL for elbow injuries have, in the same six years, jumped from 5,000 to 8,000.

16 But optimists find reason for optimism, and as always, it comes down to incentives. Says Dodgers medical director Stan Conte, "Last year MLB spent $665 million on players who were on the DL. At some point the money is going to count." The league has moved beyond issuing grants to running its own research, some of it of unprecedented scale. This spring, the league began a longitudinal study of hundreds of healthy minor league pitchers that will last five years; rather than asking pitchers who are broken what might have caused it, this study will collect the data and observations in real time and see what sets the survivors and the injured apart.

17 More important, some clubs' behavior is changing. Conte now tells his scouts to pay attention to, and be wary of, the number of showcases the pitchers have gone to; his medical staff scours news reports looking for hidden injury risks. And the Yankees, burned by a run of injuries to top draft picks, hired a medical coordinator last year to help prepare for the draft full time, year-round. The coordinator, who is in the draft room when the club makes its picks, charts a variety of variables -- how much a pitcher has pitched, how hard he throws and how clean his biomechanics are -- with green, yellow or red flags. He says his assessments will get more specific as biomechanical analysis gets easier and more exact, and if the Yankees succeed in getting honest tallies of amateur pitchers' innings. But the message is clear: A high school pitcher who protects his arm will have at least one team willing to pay extra for him. Scott Lovekamp, a minor league pitching analyst for the Yankees, estimated that the difference in worth between a red and a green flag for a high draft pick would be as much as $1 million.

"If there's one thing clubs are good at it's innovating and finding the next competitive edge," says Chris Marinak, the league's senior director of labor economics. "They'll find a way to do it."

18 Perhaps most encouraging is the story of Brady Aiken's senior year. Pressured to pitch in that Compton showcase during his rest month, he said no. "It was an immediate and resounding 'No and hell no,'" Remiker, his coach, recalls.

From there, Aiken stayed on the schedule that he, his coach and his dad agreed on. A scout remembers seeing him cruising in a close game, against a huge rival, when suddenly, 85 pitches in, Aiken was pulled in the sixth inning. This was unthinkable even a few years earlier. (Perversely, Remiker had to send emails to scouts alerting them to the pitch counts. Otherwise they might have thought Aiken was hurt or lacked stamina. An imagined grimace could turn into a narrative.) He was throwing 95 now, not 91. And even without that showcase appearance, the world's scouts found him. By April, he was a candidate to go first overall in the draft, bumping his expected payday from around $2.5 million to something in the neighborhood of $6 million to $7 million.

Last June, the Astros made it official, picking him first overall. They cited, in the news conference afterward, that his workload had been monitored closely. GM Jeff Luhnow explained: "That's obviously a hot topic these days. It's another reason we liked him." The incentives, it seemed, were finally aligning.

19 And then, because this world is cruel and arbitrary, it was all undone. The Astros lowered their signing bonus offer after Aiken's physical, reportedly because his elbow ligament was abnormal -- small, though not damaged. He went unsigned, and this spring, while waiting for a different team to draft him in June, Aiken's elbow actually did give out. He had Tommy John surgery. The pitcher who had done everything right, and the club that cared more than most about responsible usage, each ended up with nothing. A reminder that we aren't any closer to solving this damn thing.

20 Aiken will get drafted again this June -- not first overall but likely in the first round, a reminder too that Tommy John surgery is, first and foremost, a miracle of modern medicine that has saved hundreds of careers. Some club will bet on Aiken's post-surgery upside, on a good surgeon, and live with the chance that he's the 1-in-5 kid who never comes back. Risk, reward. That's the business.

21 Innovation within that business is certain. Progress is not. Take pitch counts: Intuitive but blunt, with no strong correlation to injuries, they nonetheless served as the best proxy for fatigue. But now teams have the mThrow, a wearable sensor that tracks biomechanical markers and offers specific, real-time measures of how much stress each pitch has put on the pitcher's arm. A year ago, the mThrow was nothing but a prototype, set to be tested on a handful of Little League fields. Now it's in use by 27 major league teams, worn by hundreds of major and minor league pitchers for bullpen or long-toss sessions. Odds are it will be approved for use in major league games before long.

The mThrow will prevent some injuries. Same goes for other innovations: scalable biomechanics instruction (like that offered by Rick Peterson's fledgling 3P Sports); new ways of organizing pitching staffs (like the tandem rotation Houston has beta-tested in the upper minors, assigning each game to two "starters" who each have more manageable workloads than one alone would); and, perhaps, new ways of scouting young pitchers. Same goes for the futuristic solutions -- stem cell therapy to help speed rehabilitation and recovery, or, further down the road, even synthetic ligaments.

22 We hail each advancement, but none will stop injuries, and none will probably even make a dent.

The only thing that could is stopping players from wanting to win. To remove the incentive for them to do whatever they can to succeed.

But what sort of future is that?