Chris Sale Will Have Tommy John Surgery After All

A day after the Boston Globe reported that Chris Sale had resumed throwing following a shutdown, and two weeks after he was diagnosed with a flexor tendon strain but no new damage to his ulnar collateral ligament, the Red Sox have announced that he’ll undergo Tommy John surgery. The going-on-31-year-old lefty joins the Yankees’ Luis Severino on the short list of star pitchers who will miss all of the 2020 season — however long it may be — following UCL reconstruction, and the Astros’ Justin Verlander among players whose decisions to undergo surgery make more sense in light of the delayed opening to the season.

As I detailed three weeks ago, Sale made just 25 starts amid an uneven season last year; he was fantastic in May and June (2.78 ERA, 1.98 FIP in 71.1 innings) but bad or worse on either side of that stretch before being shut down on August 13 due to elbow inflammation. Though he set career worsts in ERA (4.40) and home run rate (1.47 per nine) — both more than double his 2018 rates — his strikeout rate still ranked second in the majors among pitchers with at least 140 innings, his 29.6% K-BB% fourth, and his 75 FIP- 14th. His 3.6 WAR, despite being his lowest mark since 2011, was more than respectable. That said, Statcast data showed that he had the largest year-to-year dropoff in four-seam fastball velocity of any pitcher from 2018 to ’19, 1.8 mph (from 95.2 mph to 93.4), and the second-largest increase in exit velocity, 3.4 mph (from 84.7 to 87.0).

While Sale paid a visit to Dr. James Andrews for a second opinion last August, he avoided surgery, though he did receive a platelet-rich plasma injection. Although many within the industry have been predicting that the wiry lefty would someday blow out his elbow given his violent delivery — you can find armchair pitching coaches calling him “a ticking time bomb” as far back as 2012, if not earlier — there was no public indication at the time that his injection or his injury were related to his ulnar collateral ligament. This spring, the Red Sox continued to give reassurances that his elbow was fine, even as Sale began spring training behind schedule due to a bout of pneumonia.

Sale felt renewed discomfort after throwing a simulated game on March 1, and underwent an MRI the next day. He received not only a second opinion from Dr. Andrews but a third from Dr. Neal ElAttrache, yet another heavy hitter in the world of orthopedic surgery. The conclusion was that he’d suffered a strained flexor tendon, and while he received anti-inflammatory medication and was shut down for a couple of weeks, neither doctor recommended surgery. But with continued discomfort after he resumed throwing this past weekend, the calculus apparently changed. Sources told ESPN’s Jeff Passan that Sale’s concern about missing significant time next year as well as this one factored to his decision, though already, the team’s estimate is that he’ll be out 14 to 15 months, pushing his return to June 2021. Quite understandably, so did his level of pain. Per MLB.com’s Ian Browne:

“He experienced enough pain that we had to put a stop to it,” [Chief baseball officer Chaim] Bloom said. “He huddled with us, from folks that were on site and on the phone, where we put our heads together and made this determination. We knew obviously when he had the setback at the beginning of the month that this was a possibility. When we let the flexor calm down and ramped him up again, he didn’t respond as we had hoped and that’s where we are today.”

As to the ambiguities about whether Sale’s UCL was damaged enough to merit the surgery, here’s Bloom via NBCSports Boston’s John Tomase:

“Imaging is not a perfect solution to every arm problem,” Bloom said. “The various structures there, obviously the ligament and flexor are very close to each other. An image is only going to show so much, and you also have to go off the symptoms that you experience, and given the history of the symptoms that he’d experienced, even though there was a consensus among the doctors at the beginning of the month that this wasn’t something that warranted surgery, even that he had had this history, it was also agreed upon that if we gave the flexor a chance to calm down and then ramped back up again, experienced pain, surgery would be the next option.”

Just as the Red Sox have played Sale’s condition close to the vest, likewise with the timing of his surgery. Citing “confidentiality factors,” Bloom would not reveal the surgeon, though the Boston Globe’s Pete Abraham noted that Dr. Andrews has been his go-to for injuries over the past three seasons. Nor did Bloom announce the scheduled date, that at a time when elective surgeries are being canceled or at least discouraged as hospitals focus their resources on dealing with the COVID-19 pandemic. That said, Tommy John surgery is generally an outpatient procedure that lasts 60 to 90 minutes, and doesn’t require an overnight stay in a hospital. Again via MLB.com, Bloom indicated sensitivity to such concerns:

“Obviously it’s something we’re mindful of, No. 1, the difficulty generally surrounding elective surgeries with what our country is going through and also making sure that we’re doing this in a way that doesn’t put any extra burden on the public health system,” Bloom said. “Those are definitely considerations as we work to get this set up and get this done. We’re going to make sure that we do it in a way that doesn’t place any undue burden on everybody who is suffering as a result of the outbreak.”

The loss of Sale is another blow for a Red Sox team that already faced diminished expectations after trading Mookie Betts and David Price to the Dodgers in early February. To add insult to injury, the surgery will wipe out the first year of the ace southpaw’s five-year, $145 million extension, one of the major commitments — along with Xander Bogaerts‘ extension and J.D. Martinez’s choice not to opt out this past winter — that led the Sox to conclude they couldn’t afford Betts in the first place. Even so, our playoff odds estimated the Sox to have a 34% chance at the playoffs over the course of a 162-game season with Sale, while Dan Szymborski’s separately-calculated ZiPS odds showed those chances climbing from 32% to 40% as the schedule reduced from 162 games to 81. Those numbers were before the loss of Sale, however. Via our Depth Charts, their rotation as a whole now ranks 23rd in the majors in projected WAR, and from among their likely starting five to begin the year (Eduardo Rodriguez, Nathan Eovaldi, Martín Pérez, Ryan Weber, and Brian Johnson, with the last two names floated by interim manager Ron Roenicke as the leading candidates thus far) only Rodriguez projects to provide at least 2.0 WAR.

Via Jon Roegele’s Tommy John Surgery Database, Sale is the third major league pitcher to require UCL reconstruction this spring after Severino (February 27) and Giants righty Tyler Beede (March 20). Over at The Athletic, old friend Eno Sarris wrote about the possibility that this year could feature a spike in such surgeries due to the interrupted spring training, the lack of workload monitoring due to the closure of camps, and the sheer uncertainty everyone is facing as far as how long the shutdown will be. Eno’s whole article is worth reading, but a few paragraphs caught my eye:

“With no games, the question is can pitchers get the needed workload to build up before the season starts,” said Casey Mulholland, founder of KineticPro Performance in Tampa, a facility that trains many major leaguers in normal times. “The repercussions of this time off could greatly alter any future season, but if not managed properly, could alter the careers of many of the game’s top athletes.”

Mulholland predicted that we will see a spike in Tommy John surgeries this year, particularly if the downtime — and the return to action — isn’t managed with a sense of care and a knowledge of the existing research. If this sounds like saber-rattling from outside the league, most of my sources within baseball agreed with him. The only asterisk was that one source wondered if a reduced season would obscure the rise in operations, since there would be fewer chances for pitchers to injure themselves. But that seems almost a technicality.

…“Players are going to have major issues staying compliant with maintenance programs due to lack of facilities, personnel, and likely being quarantined,” said one front-office member who focuses on pitching. “A good maintenance plan needs to account for a shutdown period to build players back up. If players bank on staying game-ready through this indefinite postponement, they won’t have a program in place if that’s not a possibility. MLB should consider this when asking players to get ready for the season.”

…“If the season is to start in two months, pitchers could ramp down (de-load) by 50 percent and build up safely,” Mulholland said. “If the season were to start in one month pitchers could ramp down approximately 25 percent and build up safely. The issue, though, is it has been noted that many pitchers have begun to reduce throwing and/or stop completely as there is complete uncertainty as to when they will start the season.”

All of this, and the TJs of Severino and Sale, threaten to wipe out whatever glints of optimism the recent trend of Tommy John surgeries may offer, both at the major league level and throughout the professional ranks:

Last year, just 16 major league pitchers underwent the surgery, the lowest total since 2011 according to Roegele’s data. Likewise, the combined total of 72 in the majors and minors was the lowest since 2013. That second “since” comes with a caveat; in 2018, Travis Sawchik noted that Roegele’s minor league data is less complete prior to 2015 than after.

Regardless of the trend, the loss of Sale is a bummer that resonates beyond the Red Sox. It’s bad enough that we have to endure time without baseball, but knowing that another perennial Cy Young candidate will be out at least a year is yet another gut punch.