Under The Knife 9/25/24

50 x 1100

50 years ago today, early in the morning and a few miles south of Dodgers Stadium, Dr. Frank Jobe looked down at an elbow. He had cut it open, then stepped back. He had his normal nurses, anesthesiologists, and another doctor - a hand surgeon named Herbert Stark, who had previously worked on Sandy Koufax - with him at the clinic that bore his name. Jobe moved the elbow a couple ways and settled on a position. Pausing again, he consulted with Stark and asked if he thought the palmaris tendon would be robust enough to hold up if transplanted now that he saw the damage. Stark regularly used the palmaris to reconstruct the UCL of the thumb, further proximal the same arm. Stark leaned in and looked at the ligament, mentioning that the damage didn’t look acute, but that he thought if Jobe looped the tendon on itself, it would be strong enough.

It was.

On the table, Tommy John didn’t have much to do with the operation that’s more famous than his career, which should be in the Hall of Fame twice over, alongside Dr. Jobe. Instead, it was his ability to pitch through pain that he said he’d had since age-13. John didn’t blame MLB for his injury, but the move from Little League fields to the “big field.” John is 81 today, in good health, and his elbow remains intact. He never had issue with it after the operation, aside from a nerve issue that had to be corrected a few months after, which is why it took longer for him to return. John thought it would be three months before he was back on the mound.

I detailed all of this in a Bleacher Report special feature - remember those big enterprise pieces? - detailing how the operation came to be and its impact on the game. In the 11 years since I wrote it, even more have undergone the operation. We have details of over 1,100 pro pitchers, but the real growth - epidemic? - has been in the lower end. The actual number isn’t knowable, nor is the impact. Countless careers have been saved. Imagine MLB today without Kerry Wood, Stephen Strasburg, or Adam Wainwright. Imagine if Dr. Jobe’s Dodgers just lost Emmet Sheehan and River Ryan forever rather than just being lost for a year or so.

Look at this quote:

The two injuries—one a sudden breakdown of the left elbow, the other a "gradual erosion" of the right shoulder—are not as unrelated as they seem. Both fall under the umbrella classification of "sore arm," and both have the same primary cause—too much throwing. Any such injury, according to Dr. Jobe, "is a prime example of the end result of long-term stress on the arm. We call it the Overuse Syndrome. If a person throws very hard for a long period of time, the body responds with an inflammatory reaction. This can cause a scar, calcification, degeneration and rupture of the ligaments. The difference between throwing a ball hard enough to get a major league hitter out and hurting the arm is infinitesimal."

That’s from this Sports Illustrated article from 1978. And almost nothing has changed, save Jobe’s surgery and the ability to remake elbows, which is now so standard that teams simply take it for granted. They don’t fear it at all. And they haven’t changed.

What’s interesting to me is that the operation is still largely the same. More use the hamstring tendon than the palmaris. Some move the nerve, some don’t. Some use a docking technique, some don’t. InternalBrace has changed things, but not as much as many hoped.

In the fifty years, there’s really only a handful of surgeons that have done the vast majority of MLB Tommy Johns. Frank Jobe, Lew Yocum, Neal ElAttrache on the west coast. James Andrews, Keith Meister, Jeff Dugas in the south. Dave Altchek on the East. Tim Kremchek in the Midwest. That’s probably 90 percent of all surgeries performed. A few of those have passed, all are getting older, and I’ll be honest, I’m not sure who’s next or even what’s next. Ok, I have some ideas, but I’m less sure of who than the what.

Man, dig that crazy 70’s red shirt on Dr. Jobe!

Doctor Jobe would be 99 this year. His operation is 50. His impact will never pass. In honor of Dr. Jobe, Dr. Stark (who deserves more credit than he’s given), and of Tommy John, let’s get to the injuries:

YORDAN ALVAREZ, DH HOU (sprained knee)

Yordan Alvarez was diagnosed with a right knee sprain after imaging on Monday. The Astros didn’t detail which ligament, but the timeline is very short. There’s some other clues, such as Joe Espada talking about Alvarez’s body weight coming down on the knee. Given the video and how his knee was placed, and gravity, the ligament that would be most likely stressed is the LCL, on the outside (lateral) aspect of the knee. If this is a Grade I LCL sprain, a quick return seems reasonable.

The question is stability, especially when it comes to rotation. Alvarez generates a lot of force with his swing, but most of the rotational force is unidirectional. Watch his right knee on this big swing:

Alvarez is moving clockwise, so the forces on his right knee at foot plant are largely taking the center of the knee joint laterally. That stresses the MCL more than the LCL, while the reverse is true for the back leg. This should mean that Alvarez won’t put as much stress on the damaged ligament as the one that is presumably healthy. It’s not zero stress on the LCL, but the Astros will know quickly how he his knee will react and likely already do.

This is normally where the paywall would go, but for the 50th anniversary, let’s make this one free! Please consider subscribing to read and support all of my work.

DAULTON VARSHO, OF TOR (strained cuff)

Daulton Varsho had rotator cuff surgery and while there’s not a lot of detail here, cuff surgery still is one of the tougher injuries to come back from. Varsho’s a unique profile as well, complicating things a bit. The Jays have basically abandoned him as a catcher, which helps, but his career path is defined by Craig Biggio and that’s about it.

Varsho hasn’t hit well this season, but we don’t know exactly when the strain occurred. His OPS is actually up this season, so saying this is long term doesn’t seem instructive. We often see players take almost a year to fully come back, and there’s often setbacks. The biggest issue isn’t throwing as most would expect, but the effect on the swing takes a good amount of adjustment. Varsho doesn’t have much room for error with his production as is.

My guess is they pulled the trigger on this now because they wanted him back during spring training next year. If Varsho has to shift out of center or DH at the start of the season, that impacts how the roster gets put together. Varsho is hardly the toughest decision the Jays braintrust has to make - that would be Vlad Guerrero’s status - but getting some certainty ahead of the Winter Meetings likely factors into this.

FRANCISCO LINDOR, SS NYM (inflamed back)

The Mets think Francisco Lindor could be in the lineup as soon as Wednesday. A source is very confident Lindor will be “close to normal” for a playoff run, which is a good thing. One thing the team is worried about is Lindor’s confidence, which is why they want to get him in the lineup ahead of the playoffs. “It’s less about getting to the playoffs for him and more about making sure he’s ready. We don’t get far without him,” said one team source.

Lindor’s back remains a bit of a mystery, a management rather than a cure. That’s not uncommon and hardly unusual, especially at this point in the season. The Mets know a lot more about the condition and the plan than they’re telling us, but even in the worst case scenarios, Lindor in the short term is likely to play pretty normally. My expectation is that he’ll return this week - late word is it could be as early as Wednesday - and that he’ll get a couple days off as well.

A couple readers asked if the set off-days of the playoffs will help Lindor. I don’t think it makes much difference either way as they’ll have to manage him. The up-down of baseball is often as tough as playing, as the back cycles through activities, sitting and standing, and quick movements. They seldom show it on TV, but I’m curious to see if they keep Lindor moving some between innings, perhaps even sending him back into the training room.

KENLEY JANSEN, RP BOS (inflamed shoulder)

Kenley Jansen finishes his 2024 on the shelf with shoulder irritation. He’s fought through the pain and inflammation for the last month and at this stage, the Sox decided to shut him down and go with what they have. Jansen’s situation isn’t considered serious, but there’s no need to fight it. They’ll let him rest and try to clear things up more passively for a bit.

Jansen will be a free agent and the Sox have options in-house, including the expected return of Liam Hendriks, which might make Jansen expendable. Remember, teams are on the hook for injuries on their watch, even when a player is a free agent. Until he passes a physical and is accepted by another team, the Sox “own” Jansen’s shoulder injury. That’s why exit physicals are taken so seriously by so many teams. Think of it as an inventory.

At age-36 now, Jansen’s had an extraordinary career, especially if you consider how he started, as a catcher convert. He’s fourth on the saves list at 447, about one more good season behind Lee Smith (478). I’m curious what team will give him that shot. Call me crazy, but he’d fit nicely with Baltimore.

MAX KEPLER, OF MIN (inflamed knee/inflamed hip)

Max Kepler could come back this season, but the rest of the Twins roster is going to have to extend the season to make it happen. Out a month with patellar tendinitis and having had an injection for a hip issue during that rehab, Kepler hasn’t shut things down. He’ll have to basically come back into the game cold, though the team could send him to the Florida complex or trust in the medical staff and Trajekt to get him ready.

That last part is the key. The ability of teams to use these advanced pitching machines to both model specific pitchers and to simulate multiple pitchers makes something like this possible and the rehab assignment increasingly antiquated. One rehab coordinator told me earlier in the season that he demonstrated what he could do to key members of his front office in April. “I keyed in the three pitchers from the previous days Triple-A game, where they wanted to send [the player]. In ten minutes, he had three at bats, like he would have, but without the travel and with all of the control. We could replicate it over and over, so he could have ten games of at bats in a day, against any pitchers they wanted. Does he need a soft warm up? We have programs of some of our own lower level guys from the spring. We have everyone from Triple-A up. No one needs to leave.”

So if Kepler comes back “cold”, he won’t really be cold. What’s the next revolution? It’s not just teams that will have them. My guess is we’ll see top college programs get them, or for training facilities to rent them out in blocks.

ESTEURY RUIZ, OF OAK (strained wrist/inflamed knee)

A nasty knee issue isn’t good for anyone, but for a speed player like Esteury Ruiz, it’s worse. Ruiz was on the IL for his wrist issue, but had a patellar tendon debridement, indicating there was damaged, perhaps dying tissue. That only occurs with advanced cases and is a particularly brutal surgery. I know some subscribers are squeamish, so I won’t include even a link to a video, but let’s just say it involves a lot of cutting and scraping.

Ruiz was expected to have another big steals season, but he made it just 29 games, largely due to the wrist. The hope is the knee cleanup will have him ready for spring and Sacramento, or wherever it is the A’s end up. He’ll be an appealing late target for steals in fantasy drafts, but he’s going to come with a lot of risks due to the knee issues. Even with the surgery, those tend to linger and at just age-25, this is very early for such a drastic fix to be needed.

Hmm, I’m wondering if this is the last time I type “OAK” on a player in UTK.

Quick Cuts:

Austin Riley had a CT scan on his hand and the healing pace won’t get him back before the end of the season … Clayton Kershaw (toe) won’t face hitters this week, but is not being shut down. He’s very much in play for the playoffs, just not yet. Expect the Dodgers to be very active with swapping up their roster between rounds, even though they have a bye … Gavin Stone (shoulder) was shifted to the 60-day, making him unavailable for the playoffs. It wasn’t happening anyway, so they used the roster spot on Edgardo Henriquez … Nestor Cortes heads for an MRI on his elbow rather than starting on Wednesday as planned. Cortes has been solid recently, so this could force Marcus Stroman back to the rotation … Gabriel Moreno is having more issues with his strained groin, but he was back in the lineup on Tuesday. They’ll try to clinch and get him a couple days off ahead of the playoffs, but Atlanta is just a game back of Arizona and New York …. Chas McCormick (hand) has begun hitting and could be activated as soon as Friday … Jonathan India is in the concussion protocol, but not the concussion IL yet, after taking a nasty hit to the head in Tuesday’s game … James McArthur has been shut down. His UCL sprain isn’t responding to treatment and decisions will be made on next steps, which could include surgery … Dodgers prospect Carlos Duran was shifted off the active roster at Triple-A. He’s coming back from Tommy John surgery and could be a candidate for next year’s rotation, so this is barely a setback … DALL-E isn’t perfect, but Cooperstown should make a real one of these soon. I have no idea why it insisted Dr. Jobe needed a mustache and glasses.