Shoulder Complications Make Recovery Difficult
Tommy John surgery has revolutionized elbows, shoulder injuries give players a much cloudier future
By John Manuel
March 31, 2004
TEMPE, Ariz.--When you're a pitcher, you throw. That's what Joe Saunders always had done.
Then he came to spring training last year, his first after the Angels took him in the first round of the 2002 draft, and hurt his shoulder.
For the first time that he could remember, Joe Saunders couldn't pitch anymore.
"I came in a bit out of shape. It was my first offseason, and I was a little slack about it," Saunders says. "I mean, I'd been throwing since January, when practice starts for college, then a full season, then Rookie ball and Class A. I think I had three weeks off the whole time. I just needed a little time off.
"So I didn't really work out like I should have, and came in out of shape and hurt myself. I took pitching for granted. I won't make that mistake twice."
Saunders partially tore his rotator cuff and detached the labrum in his left shoulder. He'd heard of those injuries, but didn't know exactly what they really were. He knows all too well now . . . sort of.
"The rotator cuff is a muscle," he says during a lunch break at the Angels' Gene Autry Sports Complex. "The labrum, I'm pretty sure, is a ligament that keeps the bone in the socket in your shoulder."
Saunders was close. The rotator cuff, which was the chic pitching injury of the 1970s and '80s (see Mark Fidrych, Rick Reuschel and 1982 Cy Young Award winner Pete Vuckovich), is a grouping of four muscles in the shoulder. The labrum is actually cartilage that helps hold the humerus (the bone in the upper arm) in the shoulder joint.
Don't be too hard on Saunders, though. The shoulder is perhaps the most complicated joint in the body along with the hip. Plus, he didn't have surgery on his shoulder. He instead pursued an aggressive rehabilitation course to strengthen both the muscles in his shoulder and to increase his flexibility.
Mariners righthander Jeff Heaverlo got the quiz right, but he also has had surgery to repair a torn labrum. The 1999 supplemental first-round pick tore his labrum in big league camp in 2002, causing him to miss the entire season.
"I had surgery Feb. 28, 2002. I won't forget it," Heaverlo says. "I got to know the parts of my shoulder real well. I could tell you about my teres major (a muscle) and my scapula (a bone a.k.a. the shoulder blade). Having had surgery, I felt I had to know about those, so I could make it easier on the training staff to help me when I have pain.
"I can go into the trainer's room and tell Mickey, 'I think my teres major is a little sore,' or I can let him know if it's just the subscapular muscles."
Trainer Mickey Clarizio has worked for the Mariners for 10 years and is now their minor league trainer and rehabilitation coordinator. Clarizio has seen too many shoulder injuries lately. Three players the Mariners drafted in the first round--Heaverlo, lefthander Ryan Anderson (1997) and catcher Ryan Christensen ('99)--have had surgeries to repair torn labrums.
Clarizio shakes his head as he hears the list of players read back to him. Like most doctors and trainers, he prefers not to talk about specific cases. But he can talk about specific injuries. And the news with shoulder injuries isn't good.
"The shoulder is so complicated because it's a multidirectional joint, and the more doctors and trainers get into the shoulder, more is learned," he says. "You have the elbow, which is a hinge joint, and now we have a procedure like Tommy John surgery that has a good case history going. With the shoulder, the surgical techniques are great, but we're not seeing the returns we'd hope to see. We don't have a Tommy John procedure for the shoulder.
"If you're having surgery, in essence your career is over. You're having surgery to be able to throw again. And just because you're having it does not mean you will come back. You're only having it because your goal is to pitch in the major leagues, and if your shoulder is hurt, you can't get anyone out.
"So I wouldn't recommend it."
Labrum tears pop up throughout any survey of top pitching prospects. Righthander Angel Guzman, the Cubs' top prospect, was throwing well in spring training after having arthroscopic procedure to repair a slight labrum tear last summer. Tigers righthander Kenny Baugh, a 2001 first-round pick, is a season removed from labrum surgery. Brewers righthander Nick Neugebauer--a teammate of Christensen's at Arlington High in Riverside, Calif.--is on the road back to recovery from two years of labrum and rotator cuff operations.
Christensen notwithstanding, labrum tears are generally pitcher's injuries, as the throwing motion creates wear and tear on the joint. Clarizio says trainers aren't sure that it's simply a case of the more wear, the greater the tear. Trauma, such as a collision, may cause labrum tears as much as gradual use.
The recent rise in labrum surgeries isn't the result of a new wave of injuries. Until recently, the equipment to diagnose labrum tears didn't exist.
"With the MRI and the improvements in technology, things like an arthrogram, we have found these labrum tears," Clarizio says. "Twenty years ago, we had never heard of these injuries. Now we've just recognized this condition. Like 25 years ago, we said guys had 'water on the knee.' Now we know that's an anterior cruciate ligament tear."
Diagnosing the injury, though, isn't the same as fixing it. Clarizio says surgery isn't a cure-all for labrum tears, because no two tears are alike. Heaverlo had the surgery and says his stuff just wasn't the same last year, when he went 5-12, 5.39 at Triple-A Tacoma. In 2001, he led the Double-A Texas League in strikeouts with 173 in 179 innings. Last year, he fanned just 75 in 124 innings.
"I didn't feel like myself last year," Heaverlo says. "Essentially, I had to get my body to re-learn how to pitch. My mechanics weren't right. I wasn't getting full extension on my slider, I was cutting it off. I think sometimes I was compromising to protect my arm, and that can just lead to hurting it again because you have to have proper mechanics.
"I'm throwing hard. In fact, I might be throwing harder than I used to. I've had to learn proper mechanics, and I'm stronger and in better shape because of all the rehab I've done."
Saunders says he's not throwing harder than he used to, but agrees the rehab helped get him in better shape. Dr. James Andrews prescribed a program of stretches and exercises to bring his arm back. They're known as Jobe exercises in honor of Dr. Frank Jobe, the Dodgers team doctor who also pioneered Tommy John surgery.
Saunders' rehab also included regular visits to team doctors, trainers and strength/conditioning coaches. Improving core strength--legs and torso--also is a must after a labrum injury.
He won't discontinue his strength program just because he's throwing without pain in intersquad games this spring. Saunders' lifestyle has changed because it had to if he wanted to pitch again and avoid surgery. He'll continue his stretch program and Jobe exercises as long as he wants to pitch pain-free.
The Angels are confident that a pain-free Saunders will be an effective pitcher, whether or not he regains pre-injury velocity on a fastball that topped out at 94 mph. The organization is more concerned with keeping him healthy and giving him the time to regain his command of his fastball, plus changeup and curveball.
"Pitchers have tears and still pitch," Angels farm director Tony Reagins says. "We just want to be cautious with our guys who are rehabbing. We have to trust our medical staff, just like I think all clubs have to. We're fortunate in that Dr. Lewis Yocum is our team doctor, and he's one of the leading orthopedists in the country.
"We need our doctors to know our players, and the players have to know themselves, to tell us when they're hurt. Joe's a pretty cerebral guy, but he's learning that pro ball is a little bit different. He's going to have to make the adjustment."
The rare hitter who has a labrum tear also has to adjust. Just as the Mariners pitching prospects have had more than their share of that injury, so too have the organization's position players.
The Mariners hope that infielder Jeff Flaig, one of the more promising hitters in the 2003 draft, can make his pro debut, likely as a DH, by July or August. A two-way star in high school, Flaig tore his labrum and rotator cuff in 2002. After signing for $710,000 last August as a second-round pick, he had further shoulder problems in instructional league and required more labrum surgery in November.
Christensen missed most of last year after losing two months in 2002 with a broken left foot. His shoulder injury robbed him of arm strength, an obvious key for a catcher, and led to the point where it hurt to do anything on a field.
Since having surgery last spring, Christensen has played just four games in the Rookie-level Arizona League. His return has been slow, and he hopes to DH and eventually do some catching and play first base this year.
"I just hope to have 500 at-bats," he says. "Last year was wasted. It's just important for me to get healthy and have a full, healthy season. I'd consider that a success. I can't have any success on the field if I'm not on the field."
The same can be said of organizations. It's difficult for them to have success if they can't keep their players on the field.
Clubs continue to adapt to advances in injury treatment themselves. Mariners farm director Frank Mattox, who served as their scouting director for the last six drafts, remembers 1999, when three pitchers who already had undergone Tommy John surgery (Kurt Ainsworth, Colby Lewis, Nick Stocks) were selected in the first 38 picks. Organizations don't have the same kind of confidence in pitchers who have had shoulder injuries.
"We have had bad luck with shoulders lately, and we don't take it lightly," Mattox says. "We have guys who had shoulder surgery back there in the trainer's room, and I make sure to talk to them every day, to let them know we still care about them and we're trying to help them get back on the field. Keeping a positive attitude, that's a huge part of the recovery process.
"But from what I've read, labrums are a lot tougher to come back from than Tommy John. I wouldn't wish shoulder surgery on anybody."