Armed and Dangerous: Elbow versus Shoulder Surgery in MLB Players

It happens all the time to professional baseball players. There’s no discrimination in terms of ability; elbow and shoulder injuries affect the little-known setup guy as much as they affect the ace pitcher. And given the odds of recovery, it’s no wonder that fans cringe in horror any time they see their team’s pitcher wiggling their arm after a pitch. But depending on what area the pitcher is grabbing when he is wincing could determine the likelihood of his full recovery.

First, let’s just acknowledge the obvious; normal wear and tear on pitchers’ arms is bound to happen when their jobs are to throw a baseball at high speeds and in different arm motions. You aren’t going to see the same amount of arm injuries in, say, the plumbing profession as you do in Major League Baseball. There’s a reason that pitchers make the big bucks, and along with those exorbitant paychecks comes a great amount of risk for those paying the bills. These risks take the form of injury reports like “needs rotator cuff repair,” “has a torn labrum,” and “requires ulnar collateral ligament surgery (UCL; perhaps better known as “Tommy John surgery”). But there remains a distinct difference in the percentage of players who are able to bounce back from elbow versus shoulder injuries.

As ESPN’s Jerry Crasnick mentions in his latest submission, “if 2010 is the ‘Year of the Pitcher,’ it's also the year of the pitching injury.” He goes on to produce an extensive list of 2010 arm injuries, with perhaps the most notable being young phenom fireballer Stephen Strasburg, who will require the ever-popular Tommy John surgery this month. But there seems to be a silver lining for Strasburg and others who have required UCL surgery. Crasnick’s colleague Stephania Bell, ESPN’s own injury expert, recently pointed to some encouraging data on pitchers who have undergone Tommy John surgery. The American Journal of Sports Medicine (AJSM) in 2007 completed a study “that looked specifically at return to play for major league pitchers following UCL reconstruction, [and found that] 82 percent successfully returned at an average of 18.5 months after surgery.” Obviously, as Bell points out, the subjective term here is “successfully returned,” and for the purposes of this study, AJSM followed those pitchers who returned to the big leagues and “demonstrated no significant change in mean ERA [earned run average] or WHIP [walks hits/innings pitched] when compared to their pre-injury numbers.”

It’s clear that the road to elbow surgery recovery includes some dedication and a stringent rehab schedule, and in most cases, just requires a whole lot of time. However, sometimes that time can actually benefit a player in that he comes back ever stronger than he was before the surgery. If anyone would know about that it would be the Atlanta Braves’ Tim Hudson, who required Tommy John surgery in 2008 and returned to spectacular form upon his return. Crasnick spoke to Hudon’s teammate, catcher Brian McCann, who told him that, since Hudson has made his return, “his sinker's sinking harder. His cutter is cutting harder. Everything has that extra gear to it.” Hudson doesn’t disagree. In fact, he told Crasnick that “If you're in your 30s and you have a major surgery, you're obviously concerned. But for an older guy going through Tommy John, you have a year to let your body kind of recharge and get stronger. It's almost like you take a pit stop for a year. You can get your elbow redone and get everything else good to go.” So, while having Tommy John surgery isn’t exactly the preferred method of ensuring a one-year rehabilitative sabbatical, it could be worse for pitchers—they could have a shoulder injury.

Tommy John: a famous pitcher who helped define an infamous procedure.

Shoulder injuries seem to be a different kind of beast, and the numbers behind the studies that have been recorded on MLB pitchers are far less encouraging than the data captured regarding elbow injuries. In fact, studies have indicated that only 35-50% of throwing athletes return to their previous level of performance following shoulder surgery. It’s a stark contrast to the 82% success rate of players with elbow injuries. But why such a huge difference in recovery rates?

It all begins with the basic anatomy and biomechanics of the two joints. The elbow is a hinge joint and allows for bending and straightening. The shoulder is more complex and allows for movement in three planes. As Bell states, the human shoulder is so mobile that we can almost make a 360-degree circle with the arm. Bell is also quick to mention that the mobility comes at a price. “Increased range of motion translates to less stability in the joint, which is why shoulders are one of the most easily dislocated joints in the body… consequently, any disruption of those surrounding tissues can not only cause pain, it can also spell trouble for shoulder stability.”

This makes shoulder surgery much more complex than elbow surgery, at least in terms of these typical MLB pitcher injuries. Whereas a surgeon who is performing Tommy John surgery only has to replace one tendon, the surgeon cleaning up the shoulder is left to deal with multiple structures. Because of the complexity, it’s usually left up to the discretion of the doctor when it comes to just how much needs to be done once operating on the shoulder. Doctors aim to do enough to address the damage and pain that the athlete is suffering without overdoing it.

Los Angeles Dodgers medical director Stan Conte also makes a good point about the disparity in recovery rates between athletes who have undergone shoulder surgery versus elbow surgery. He mentioned to Bell in an interview that there have been extensive, large scale studies on Tommy John surgery, but there seems to be a major lack of those same types of studies when it comes to shoulder surgeries. Apparently, the MLB agrees, as they are working on producing such large-scale studies to promote research on shoulder surgeries in MLB players. Perhaps one day these studies will close the gap between the successful returns of players who have injured their elbow versus their shoulder. In the meantime, players, coaches, and fans will hope that if they ever see one of their pitchers grimacing after a pitch, that they go for their elbow and leave the shoulder alone.