Stephen Strasburg's Injury: Not A Nightmare, Just A Delay

This is a difficult day. Not just for Nationals fans. This is a difficult day for anyone who enjoys seeing extraordinary talent on display. Stephen Strasburg's Major League debut didn't only capture the attention of fans in DC and Pittsburgh - it captured the attention of the nation entire, as baseball fans and non-baseball fans alike tuned in to see if the most hyped young pitcher in the world was worthy of the praise. What Strasburg proved that afternoon was that he most certainly is. And so to know that that guy, with that ability, is probably going under the knife - it hurts. It finds the part of the brain that's loyal to the game more than a team, and pokes it with a stick.

Nobody is pleased with this most recent turn of events. Not even Rob Dibble. At the same time, it's critical to cut through the hopeless despair and widespread panic to take an objective look at what's gone on and what lies ahead, so stick with me. This is bad, but it isn't the end of the world.

WHAT HAPPENED?

Here's what we know: an MRI on Stephen Strasburg's elbow - his second - revealed a significant tear of his ulnar collateral ligament. The ulnar collateral ligament (UCL) serves to stabilize the elbow and help it to withstand the extreme stress caused by overhand pitching. When this ligament tears, surgical intervention is required in order for the pitcher to be able to keep on pitching.

HOW DID IT HAPPEN?

Nobody knows. The Nationals believe the injury was caused by a single traumatic pitch, and wasn't the result of gradual wear and tear. Strasburg was managed very carefully for the specific purpose of protecting his arm against said wear and tear, but the difference between throwing 90 and 110 pitches in a game isn't as great as the difference between throwing 90 and zero. Every time Strasburg threw a pitch, he was putting his body at risk.

Overhand pitching is a dangerous activity. Studies have shown that the average upper-level pitcher puts about 80 Newton-meters of torque on his elbow when throwing a fastball. Studies have also shown that the average UCL snaps when about 80 Newton-meters of torque is applied. Pitchers push their bodies right up against their physical limits, which is why so many of them end up hurt.

Of course, where Strasburg's individual limits lie is anyone's guess. He may not have an average UCL. His could be stronger, or it could be weaker. We don't know anything about the strength of Strasburg's UCL, and we don't know anything about how much torque Strasburg's been putting on his elbow. All we know is that something has torn. What this implies is that Strasburg exceeded his physical threshold.

It's worth noting that, while Strasburg routinely throws in the high 90s and touches triple digits, he didn't gain his superior velocity until his freshman or sophomore year of college, when he shot up about 8-10 miles per hour from where he was in high school. His body may not have been prepared for such an increase. However, that's total speculation on my part.

WHAT COMES NEXT?

Strasburg and the Nationals are going to get a second opinion on his elbow before proceeding to surgery. However, assuming the second opinion is a lot like the first, then Strasburg will be due for an operation that is commonly known as Tommy John surgery. This is what everybody's already talking about, and this has already been acknowledged as the overwhelming likelihood.

WHAT'S TOMMY JOHN SURGERY?

Tommy John surgery is named, appropriately enough, after pitcher Tommy John, the first to have the procedure at the hands of surgeon Frank Jobe. It's also known as ‘ligament replacement surgery,' because it involves replacing the damaged UCL with a ligament approximation from somewhere else. Artificial tissue hasn't advanced to the point at which it can adequately serve the purpose of a UCL, so the new ‘ligament' tends to be a tendon that comes from one of two locations in the pitcher's own body - the forearm or the lower leg, with the forearm most often supplying the new tissue.  

The forearm (and ankle) will retain full function after the target tendon is removed. After that, the elbow is opened up, the area muscles are moved out of the way, the torn UCL is identified and some damaged tissue may be removed, holes are drilled into the elbow bones, and the replacement tendon is inserted and looped through the holes.

The tendon will learn to become a ligament over time, through mysterious means.

If you want more details, check out this article from Thomas Gorman and Will Carroll.

THEN WHAT?

Following surgery comes the recovery and rehabilitation stage. It usually takes a couple months after the procedure before full range of motion returns, and from there, weight exercises are recommended before the pitcher thinks about picking up a ball and throwing it.

The timetable that's usually quoted for a real return from Tommy John surgery is 12-18 months, and to be sure, there are some pitchers who need all of this time, if not even more. But then you have guys like Edinson Volquez, who had the procedure done in August of 2009 and came back to make his first start for the 2010 Reds on July 17. Every pitcher is different, and every recovery is different. Coming back in a year is entirely possible, and it's not out of the question that Strasburg could come back even sooner. Not that the Nationals would want to rush him.

WILL STRASBURG BE OKAY?

This is definitely the big question here. And the good news is: probably, yes, he should be able to make a complete recovery. Though Tommy John surgery was experimental 35 years ago, it's become rather common of late, and it's become common precisely because it works so well. Success rates are usually quoted to be around 85-90%, and while one's success rate depends on how one defines success, Tommy John surgery is way preferable to, say, surgery to repair a torn labrum in the shoulder. If a pitcher has to suffer a major injury, you'd always rather it happen in the elbow than the shoulder, because shoulders are complicated, and injured shoulders can ruin careers.

For your perusal, following is an incomplete list of Tommy John success stories:

Grant Balfour
Chris Carpenter
A.J. Burnett
Frank Francisco
Jaime Garcia
Mike Hampton
Tim Hudson
Josh Johnson
Francisco Liriano
Carl Pavano
Arthur Rhodes
Kenny Rogers
Anibal Sanchez
John Smoltz
Joakim Soria
Rafael Soriano
Billy Wagner
Jake Westbrook
C.J. Wilson
Randy Wolf
Kerry Wood

It's worth noting that Jordan Zimmermann, a teammate of Strasburg's, made his 2010 Nationals debut just Thursday night, a year and a week after going under the knife for the same procedure.

This isn't me telling you to get cocky. That Strasburg will be able to recover is no guarantee. There are risks inherent with any surgical procedure, and it's possible that Strasburg may not come away the same guy he was before, if he comes away healthy at all. Chris Capuano, for example, has made just two Major League starts since undergoing the operation after 2007. Strasburg may not work out. It's possible that his body just isn't cut out to withstand the stress of throwing so hard.

However, while one must understand the risks, the probability is that Strasburg will be okay, and that we could even see him back in the Major Leagues next August or September. Tommy John surgery used to be something of a fright. Nowadays, it's more of a delay.

SO THIS IS BAD NEWS, BUT NOT TERRIBLE NEWS?

That's the way I'd describe it. Pitching is hard. It's dangerous. There are more pitchers who get hurt than pitchers who don't, and though it was never fair to characterize a Strasburg injury as an inevitability, the specter of trouble was always looming. Strasburg's a freak of nature, and sometimes freaks of nature come across speed bumps.

So he's hurt. He almost certainly needs surgery. There is no upside to this. There's just the silver lining that it could've been worse. If Strasburg needed shoulder surgery, we'd be talking about his career being in jeopardy. We don't really need to worry about that as is.

But the downside isn't huge, because what the downside boils down to is that - unlikely complications aside - we'll just have to wait another year before we get to watch Strasburg pitch again. For Nationals fans, that blows, since Strasburg's the big prize and by far the most compelling player on the team, but he could still come back in 2011 and it's not like next season is gearing up to be a big one in DC anyway. And for fans of other teams, as much as we've all enjoyed watching Strasburg go to work, there are enough other impressive young power arms that we'll be able to get by. Take this opportunity to watch Josh Johnson. Felix Hernandez. Mat Latos. Ubaldo Jimenez. Clay Buchholz. And on, and on. There may not be a lot of Strasburgian talent in the Majors right now, but there are plenty of approximations.

I get why, for Nationals fans, this is so depressing. As a Mariners fan, I don't know how I'd deal with a reality in which Felix has to go under the knife. As far as morale is concerned, this sort of news is nothing short of devastating, and it doesn't help that Strasburg's going to keep accumulating Major League service time while he's on the DL. Just take heart in the knowledge that, even with the injury, the odds are on Strasburg's side.

He should come back. He should come back just peaches. And perhaps his time away will allow fans to attain a new level of appreciation upon his return.