Elbow Pain, Go Away, Don’t Come Again Another Day by Jason Martinez March 10, 2020 If you follow the baseball news cycle, you’ve undoubtedly discovered that baseball players get hurt quite often. By the time the first official pitch was thrown to mark the beginning of the 2018 season, 118 players had been placed on what was still being called the Disabled List. There were 129 players on the Injured List prior to Opening Day 2019. As of today, nine players have been placed on the 60-Day Injured List and 50 others are projected to begin the season on the IL; history tells us that this number will likely only grow as the season creeps closer. Injuries are a big part of the game and, thus, roster depth is integral to building a competitive team each offseason. But even our grim familiarity with injuries can’t lessen the frustration of a season-ending elbow injury, which can often interrupt parts of two seasons for a pitcher. When an elbow injury is undiagnosed or unresolved, or its severity misunderstood, a player risks having surgery and the subsequent recovery process delayed by 4-6 months. Instead of missing just one full season and reporting to the following year’s spring training approximately 16 months removed from Tommy John surgery – see Lance McCullers Jr. – a starting pitcher can end up missing one full season and at least a few months of another, and that’s the best-case scenario. Relief pitchers can return sooner, although it’s not uncommon for the wait to be just as long. Diagnostic delays contributed to Luis Severino’s suboptimal recovery timeline. The Yankees right-hander, who underwent Tommy John surgery on February 27, experienced forearm soreness during the 2019 playoffs after missing much of the year with a rotator cuff injury. While MRI and CT scans during the offseason did not reveal any issues, it wasn’t until he experienced renewed soreness in spring training that a dye contrast MRI revealed a partial ligament tear. (The explanation for not having the dye contrast MRI done earlier, despite a more accurate detection rate, was that it can sometimes cause joint inflammation.) The Yankees will now be lucky if Severino is back in action by next July. With so many players suffering from various elbow related aches and pains, I thought it would be useful to provide an update on the players whose 2020 seasons might be affected by this most crucial of joints. To begin, below is every player who has reported to Spring Training and either ended last season on the Injured List with an elbow or forearm injury described as a strain, sprain, discomfort, or inflammation, or, in a handful of other cases, experienced issues during the season and might not be out of the woods yet. Some of those players are starting pitchers who have seen their issues recur: Starters With Renewed Pain In Spring Training Name Team 2019 Injury Status Chris Sale BOS Elbow discomfort Diagnosed with strained flexor tendon; no timetable for return. Griffin Canning LAA Elbow inflammation MRI showed “normal wear and tear”; received “biological injections” on 3/6; no timetable for return. Luis Severino* NYY Forearm soreness Underwent Tommy John surgery on 2/27/20. Miles Mikolas* STL Flexor tendon soreness Received PRP injection on 2/18; will begin season on IL. Ryan Borucki TOR Elbow inflammation Renewed elbow soreness; MRI did not reveal structural damage; no timetable for return. *Ended the 2019 season on the Active Roster despite having issues during the season. Still others have managed to avoid re-injuring themselves, at least for now: No Issues (So Far) Name Position Team 2019 Injury Status Collin McHugh RP/SP BOS Elbow discomfort Cleared to begin throwing program in late February; expected to start season on IL. Austin Brice RP BOS Strained forearm Has made 4 appearances this spring (0 ER, 10 K). Cam Bedrosian RP LAA Strained forearm Has made 4 appearances this spring (7 ER, 5 BB). Scott Alexander RP LAD Forearm inflammation Has made 3 appearances this spring (1 ER). Drew Steckenrider RP MIA Elbow inflammation Has made 3 appearances this spring (5 ER, 3 BB). Blaine Hardy RP MIN Strained flexor tendon Has made 1 appearance this spring (0 ER). Adam Morgan RP PHI Strained flexor tendon Has made 3 appearances this spring (0 ER). Jay Bruce* OF/1B PHI Strained flexor tendon Did not play OF after returning from IL on 9/1. Started at 1B on 3/8, but has not played OF this spring. Seranthony Domínguez RP PHI Elbow inflammation Has made 2 appearance this spring (0 ER). Jose Castillo** RP SDP Strained flexor tendon/torn hand ligament Returned to action on 8/8 and suffered season-ending finger injury; has yet to make spring appearance. Franchy Cordero** OF SDP Sprained elbow/strained quad Has made 6 starts in the OF this spring. Tommy Pham* OF SDP Partially torn UCL Expected to make first OF start of the spring by as early as 3/11. Trevor Gott RP SFG Elbow inflammation Has made 5 appearances this spring (4 ER, 4 BB). Aaron Loup RP TBR Elbow inflammation Has made 4 appearances this spring (1 ER). José Alvarado RP TBR Elbow inflammation Has made 4 appearances this spring (3 ER). Ken Giles* RP TOR Elbow discomfort No issues. *Ended the 2019 season on the Active Roster despite having issues during the season. **Ended the 2019 season on the Injured List due to an unrelated injury. I tend to be pessimistic when it comes to elbow and forearm injuries. Sometimes that pessimism is proved right right away; sometimes it takes years for the other shoe to drop. When the White Sox moved Chris Sale to the bullpen in May 2012 only a month into his first season as a starting pitcher, partly due to a slightly tender elbow, there was no doubt in my mind that he would soon be headed for Tommy John. I am so glad to have been wrong; he moved back to the rotation after one bullpen appearance. But seven All-Star selections, seven top-six finishes in Cy Young voting, and a World Series championship later, it appears to have finally caught up to him. After Sale was shut down last August due to elbow discomfort, tests did not reveal any ligament damage. He was given a platelet-rich plasma injection and was set to be re-evaluated six weeks later. As a result, it was several months before he began ramping up his throwing program to a point where it became evident that the elbow problem wasn’t behind him. Multiple specialists have weighed in, and the current prognosis is that Sale has a strained flexor tendon and does not require Tommy John surgery, at least not yet. He’ll try to play catch next week and will be re-evaluated. If symptoms return, surgery is an option. For now, Sale is trapped in a kind of elbow purgatory — not healthy enough to pitch and apparently not damaged enough to undergo surgery. The big question is whether Sale, who is less than 100% and may not be able to finish the season, is more valuable to a Red Sox team that probably won’t challenge for the division in 2020, or would be better off having surgery now to increase the odds that he is back to full strength by the second half of 2021. While the latter is the seemingly obvious answer, it’s far from a simple decision. Just because the recovery rate from Tommy John surgery is very good doesn’t mean the rehabilitation process is easy, or that the decision to go under the knife and not play baseball for at least 12 months is to be taken lightly. But other players prove to be more fortunate. As you can see, most players from the tables above are doing just fine (so far), and it wouldn’t be a huge surprise if many went on to have productive, injury-free seasons. When Masahiro Tanaka was diagnosed with a partially torn elbow ligament after 18 terrific starts to begin his major league career in 2014, there was no doubt in my mind that he would soon be headed for Tommy John. When he opted for PRP therapy over surgery, I thought he was just delaying the inevitable. But I was wrong. Over the past five seasons, Tanaka has averaged 29 starts and 174 innings while posting solid numbers across the board. He’s never been as dominant as he seemed destined to be in those first 18 starts, but he’s been a very good pitcher in one of the best divisions in baseball. This doesn’t mean you shouldn’t be concerned when a pitcher on your favorite team is shut down with elbow discomfort or forearm tightness. It just means that not all arms are created equal, and it’s difficult to tell which pitchers can bounce back without undergoing surgery, or how long they can hold up to the normal wear and tear of throwing a baseball for a living. But, for the most part, it’s not nothing. On the bright side, there are several players — some of whom you might have forgotten even existed — who returned to action late last season after having Tommy John in 2018, and who have no restrictions for the upcoming season. Plenty of others are in line to return at some point in 2020, if not by Opening Day. Below are the players who returned from Tommy John in the final days of last season: Returned From Tommy John Surgery In Late 2019 Name Role Team Activation Date Projected Opening Day Roster Status Anthony Banda SP/RP TBR 8/23/19 Major League Bullpen Keynan Middleton RP LAA 8/28/19 Major League Bullpen Brent Suter RP MIL 9/1/19 Major League Bullpen Ben Heller RP NYY 9/10/19 Bullpen Candidate Johnny Cueto SP SFG 9/10/19 Major League Starting Rotation Jordan Montgomery SP NYY 9/15/19 Major League Starting Rotation Garrett Richards SP SDP 9/16/19 Major League Starting Rotation Taijuan Walker SP SEA 9/19/19 Major League Starting Rotation And here are the players who, while not fully ready to play, should return at some point this season: On Track To Return From Tommy John Surgery In 2020 Name Role Team TJ Surgery Date Projected Opening Day Roster Status Alex Reyes** SP/RP STL 2/16/17 Bullpen Candidate Brent Honeywell Jr.** SP TBR 2/27/18 Optioned Kendall Graveman SP SEA 7/30/18 MLB Starting Rotation Daniel Gossett SP OAK 8/1/18 Optioned Jose Mujica SP/RP COL 9/11/18 Bullpen Candidate Michael Kopech SP CHW 9/18/18 Projected IL Chad Kuhl SP PIT 9/19/18 Rotation/Bullpen Candidate Shohei Ohtani SP LAA 10/1/18 Projected IL (pitcher only) Edgar Santana RP PIT 10/4/18 Major League Bullpen Franklyn Kilomé SP/RP NYM 10/24/18 Optioned Lance McCullers Jr. SP HOU 11/6/18 Major League Starting Rotation Salvador Perez C KCR 3/6/19 Major League Lineup Drew Smith RP NYM 3/12/19 Bullpen Candidate Silvino Bracho RP ARZ 3/13/19 Projected IL Dane Dunning SP/RP CHW 3/18/19 Projected IL Michael Fulmer SP DET 3/27/19 Projected IL Corey Knebel RP MIL 4/3/19 Projected IL Carlos Rodón SP CHW 5/15/19 Projected IL Jimmy Lambert* SP CHW 6/25/19 Projected IL Jordan Hicks RP STL 6/26/19 Projected IL Corbin Martin* SP ARI 7/3/19 Projected IL Jameson Taillon* SP PIT 8/13/19 Projected IL David Robertson* RP PHI 8/15/19 Projected IL Pablo Sandoval 3B/1B SFG 9/4/19 Bench Candidate Aaron Hicks OF NYY 10/30/19 Projected IL *Questionable to return in 2020 **Ended the 2019 season on the Injured List due to an unrelated injury. An update like this can feel like a downer, but as the above shows, it isn’t all bad news. Dr. Frank Jobe performed the first Tommy John surgery in 1974, and the eponymous pitcher threw over 2500 innings and was chosen to the All-Star team three times post-surgery. Severino will likely be back at full strength at age 27. If Sale ends up having surgery, he’ll be just 32 when he returns, and is talented enough that he could still give the Red Sox good value over the last three years (2022-2024) of his $145 million contract. In the meantime, Shohei Ohtani should be back on the mound early in the season. The same can be said of top pitching prospect Michael Kopech. Brent Honeywell Jr. and Alex Reyes, each of whom had been regarded as one of the best pitching prospects in baseball prior to Tommy John surgery, could finally return after long recovery periods that were extended by injuries suffered during rehab. McCullers, and fellow former All-Stars Johnny Cueto and Salvador Perez are on track for Opening Day, which is somehow only 16 days away. You never want a player, especially a pitcher, to suffer an elbow injury. Some players don’t come back the same; for some, it can signal the end of the road. But for many others, it’s the middle part of their journey. Perhaps that’s optimistic on my part, but hope springs eternal, or at least until Opening Day.