The Cleveland Indians and Tommy John surgery

Editor's note: You all know Andrew as BritDawg. Today he joins the LGT writing team.

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Trivia question: Who was the last Indians player to undergo Tommy John surgery?

According to Jon Roegele's excellent (but probably not yet fully comprehensive) TJ spreadsheet, 26 Tribe players have undergone TJ surgery over the years, all but three of whom were pitchers. The most recent of these were Frank Herrmann (Mar 2013), Josh Tomlin (Aug 2012), CC Lee (Jan 2012) and Carlos Carrasco (Sep 2011), with Danny Salazar one of four Tribe TJ surgeries in 2010. [Edit - I subsequently discovered that some time in either late 2013 or early 2014 Akron pitcher Jeff Johnson also underwent TJ surgery, and after I notified Jon Roegele of this, he subsequently confirmed that this does indeed appear to be the case.]

And yet, in the two years since Herrmann's surgery, more than 150 professional players have been operated on, that's an average of over five per team! We are in the midst of what renowned orthopedic surgeon Dr James Andrews has called an "epidemic" of TJ surgeries, but (touch wood) the Tribe hasn't been infected recently. Is this just blind luck or can it partly attributed to pitcher management - something that Tito Francona and pitching coach Mickey Callaway should take some credit for? And what is the prognosis for the 2015 season?

In the 2015 Hardball Times Baseball Annual, former MLB team consultant Craig Wright contributed an article entitled "The Explosion in UCL Injuries", in which he attempts to explain the current proliferation in TJ surgery, which affected around 30 MLB pitchers last year. Partly this increase is the consequence of more accurate diagnosis methods and more players opting for surgery instead of taking the Masahiro Tanaka "rest and rehab" route, but there have also simply been more UCL injuries across the league. Why?

Wright believes that pitch selection probably plays at most just a small role. The slider is usually regarded as the most likely culprit when it comes to elbow injuries, especially for younger pitchers, but Wright states that slider usage has remained more or less constant in the MLB. Hence this can't be the whole story when attempting to explain UCL injuries, a conclusion that is supported by other writers. Jon Roegele does suggest that 'the average pitcher headed toward Tommy John surgery tended to throw slightly more fastballs and sliders than his league average peer, at the expense of slightly less curveballs and changeups. In effect, for every 100 pitches thrown, one extra fastball and one extra slider are tossed instead of one curveball and one changeup.' But although that's a measurable difference, it's obviously not a huge one.

So, who on the Tribe's roster made extensive use of the slider last year and hence might possibly carry a slightly higher risk factor? According to Fangraphs, it was relievers Mark Rzepczynski (43.1%), CC Lee (37.5%), Kyle Crockett (28.5%) and Bryan Shaw (a career-high 27.3%), whereas Corey Kluber, Josh Tomlin, Cody Allen and Scott Atchison didn't throw any sliders at all.

So what about fastballs? Is the never-ending quest for increased velocity perhaps to blame? Wright suggests that if a pitcher's increase in velocity is the product of poor mechanics then that can put tremendous stress on the UCL. He cites the examples of two Tigers pitchers, Joel Zumaya and Bruce Rondon, both of whom suffered UCL injuries at a young age, in his view because of 'dangerous mechanics that juice velocity'. The Tribe doesn't really have any out-and-out 99MPH flamethrowers like Zumaya and Rondon, although of course Carrasco, Salazar, Bauer, Allen, Hagadone and Adams all possess well above average velocity.

It has been shown in studies that "pitching when fatigued"is a big risk indicator for youth pitchers, not just in terms of throwing too many pitches in games, but also playing all year without a proper break. ASMI (American Sports Medicine Institute) Research Director, Dr Glenn Fleisig has stated that "The professional injuries today are, in fact, occurring to the first generation of players who grew up playing baseball year-round." Perhaps in many cases the seeds of an MLB player's UCL injury were planted many years before?

Nowadays all MLB managers and pitching coaches do closely monitor their pitchers' workloads. They possess the experience to spot early signs of fatigue and, almost always with other bullpen options at their disposal, can avoid placing undue stress on any one pitcher's arm. Besides, not all players are the same - some players can handle bigger workloads than others. "Ultimately, the best computer for assessing injury risk is the pitcher’s brain," says Fleisig, "...The truth is, listening to one’s body can be the best injury preventative measure."

Wright's proposed solution to the UCL explosion is drastic. To reduce the emphasis on throwing harder and harder, he suggests cutting down on the number of pitchers allowed on the roster: to 11, then 10 and then 9. Furthermore, he would like to see a ban on using pitchers for one inning or fewer (in the process, removing the traditional 'closer' role).  However, whilst these changes might discourage pitchers from coming in all guns blazing at maximum velocity, it seems to me that they could well prove counter-productive. A much smaller bullpen and a ban on the "one inning or fewer" pitcher would surely lead to more fatigue among pitchers, potentially actually increasing injury risk rather than reducing it.

Given that in the past couple of years Tito has increasingly relied on an 8-man bullpen, featuring extensive use of one-out and two-out relievers, the Indians are very much the antithesis of Wright's solution - and yet to date they haven't been afflicted by TJ surgeries like many other teams. Is it possible some relievers might be less prone to injury if they are given regular, shorter outings rather than less frequent, longer outings? Every pitcher is different - some might be suited to a different regimen than others.

Finally, renowned sabermetrician Russell Carleton has shown that "the biggest risk factor for injury is previous injury". Players who have suffered, say, an elbow injury in the last two years are the most likely to suffer a future elbow injury. As far as I am aware, with the exception of recent signing Gavin Floyd, none of the pitchers on the 40-man missed time due to elbow (or for that matter, shoulder) injuries last season, which is encouraging. However, the fact that Carrasco, Salazar, Tomlin, Floyd and CC Lee have all undergone TJ surgery in the past does place them in a slightly higher risk bracket, since repeat UCL injuries are not uncommon.

Can we draw any Indians-related conclusions from all this? It's still hard to escape the impression that the Tribe appears to have been extraordinary lucky with UCL injuries in the recent past. But looking at the make-up of the pitching roster, there don't appear to be any reasons to be unduly alarmed. The general pitching health profile is fine. Some players are probably more at risk than others, especially if, like Bryan Shaw, they are asked to carry a heavy workload and may occasionally be pitching when fatigued, but overall there aren't too many red flags.

And what if by some miracle the Tribe somehow manages to survive another season without a TJ surgery? If that happens then perhaps we really should all start believing in Mickey Callaway magic™.