You're Not Alone: On Rest & Rehab Vs. Tommy John Surgery

Denis Poroy

We've grown frustrated over the past couple years over the Twins' medical staff and their inability to correctly diagnose injuries, or to prescribe "rest and rehab" to pitchers with torn elbow ligaments only to see them require Tommy John surgery. I look at the latter and see how various players have tackled their response to damaging their elbows, and find that virtually everyone comes to the same conclusion.

When I ask for your opinion of the Twins' medical staff, what comes to mind? For me, it's the timetables for injuries that were underestimated, like Alexi Casilla's hamstring and Jason Kubel's foot. It's the misdiagnoses, like Pat Neshek's hand. And of course, the rest and rehab for torn elbow ligaments when Tommy John surgery is the inevitable fix.

These errors became so egregious that finally the Twins made a change when they fired head trainer Rick McWane last offseason. Whether this move was truly due to incompetence by McWane or just the organization's way of feeding the hungry wolves satisfying angry fans, we're not fully sure. For whatever it's worth, we have seen similar errors in judgment with Darin Mastroianni's foot and Josh Willingham's knee this year, so perhaps the issues were not alleviated with McWane's departure.

However, I'm not arguing about Mastroianni or Willingham here. Instead, I'm taking a step back and compare two younger players in the organization that recently had Tommy John surgery in the past few years. Those two players are Kyle Gibson and Alex Wimmers.

I will first start with Wimmers. He was a 2010 1st round draft pick for the Twins out of college and was viewed as a pitcher that could climb the organizational ladder rapidly. He did battle control problems in 2011 but finished the year on a good note with a 7-inning no-hitter in his final start. However, his 2012 year started horribly as he complained of elbow pain in just his first start of 2012.

In early May, Wimmers was diagnosed with a partially torn UCL in his right elbow. It was at this point that the Twins chose to shut him down from pitching. A week later, it was announced that he was going to rehab his injury. After rehabbing for about 2 months, Wimmers made his return in rookie ball on July 23rd, but lasted only 2/3 innings before leaving with more elbow pain. It took another week before Wimmers was re-evaluated by the Twins medical staff, and GM Terry Ryan expressed his frustration over getting down to the bottom of Wimmers' injury. Finally, on August 2nd, Wimmers had Tommy John surgery on his elbow, a little over 3 months after he was first injured. With that half-season delay, Wimmers lost a good chance of being able to pitch in 2013, whereas he theoretically could have pitched for half of this season had the Twins scheduled his surgery back in early May instead of August. This could have meant that he'd have been a preseason rotation candidate or a midseason call-up for the Twins in 2014. Instead, he will likely debut late next season.

Now on to Gibson. The 2009 1st round draft pick was pitching for the Rochester Red Wings in 2011 when he suddenly began to struggle. For 8 starts over June and July, Gibson had a 6.47 ERA. While the exact time when he hurt his elbow is unknown, it certainly seems that this 8-game stretch was probably when it started. He was eventually placed on the disabled list on August 3rd, and then was diagnosed with a partially torn UCL nearly a week later. Despite the diagnosis, he was encouraged to rehab his elbow. But, less than a month later, he was scheduled for Tommy John surgery. Since the time of the original injury is unknown, we can't be sure if Gibson took as long as Wimmers to have his surgery completed, but it might be a safe bet that Gibson's timeline actually proceeded faster than Wimmers'.

Still, there was great frustration in both cases among Twins fans. Whether because two of the Twins' top pitching prospects were hurt with an injury that would take about a year to heal or because the medical staff indeed mishandled the two players, many of us were upset with the outcomes.

However, I'm not fully sure that we have perspective as to what normally happens when a player requires TJ surgery. What I've done was some quick research on a bunch of players that needed TJ within the past year or so, and looked at when the player first hurt his elbow to when the TJ surgery finally took place. The first list here has players that required Tommy John surgery after being prescribed some sort of rehab first.

- Chad Billingsley (first hurt in mid-July 2012, platelet-rich injections in August and September, underwent TJ in April 2013)

- Dylan Bundy (hurt in March, was actually given the OK by famous TJ surgeon James Andrews in late-April, followed with platelet-rich injections, then had TJ in late June)

- Rafael Furcal (hurt late August, re-evaluated in October and rehab was still recommended, offseason exams showed elbow was healing, pain returned with baseball activities in March, and had TJ in mid-March)

- Mike Adams (technically a shoulder injury that occurred in mid-June, chose to rehab and receive platelet-rich injections, then was reported that he's likely headed to surgery late last week)

And here are those that had more reasonable timelines with their elbow injuries.

- Jason Motte (hurt in mid-March, TJ recommended in early May)

- Randy Wolf (hurt in late September 2012, underwent TJ in late October 2012)

- Jonny Venters (hurt in late March, TJ surgery in mid-May)

- Daniel Hudson (re-tore ligament in early June, TJ surgery just 2 weeks later)

Now these lists are hardly anywhere near being complete, as I pretty much just Google searched "Tommy John" and dug up as many players as I could find. After all, I know I've omitted Kyuji Fujikawa and Joel Hanrahan (I'm pretty sure both were hurt early, came back, then hurt their arms even worse) and certainly there are more players that have had Tommy John surgery within the past 12 months. We also can't forget Ramon Ortiz who tore ligaments in his elbow in early June, although there's been no news as to his next step in recovery.

Nevertheless, there are still some things we can take away from these incomplete lists. First, it seems like the fast timeline of TJ surgery involves going under the knife within 1-2 months of the diagnosed injury. Daniel Hudson is certainly an outlier here, but I think we can attribute that to this injury being his second TJ in the past 18 months, so he probably knew exactly what that pop in the elbow was when it occurred in June. Second, we see that a couple teams attempted to avoid Tommy John surgery just like the Twins. In Dylan Bundy's case, his timeline is pretty similar to Alex Wimmers', except Bundy was actually told his elbow ligaments were not torn. Also, even with the mistake of rest and rehab, Bundy only used up an extra month to get TJ than Venters, Wolf, and Motte, guys that did not dedicate their return to baseball by rehabbing their injuries.

Billingsley and Furcal were two players that really screwed up with rehab, but I get the feeling that having an entire offseason to rest probably contributed to their longer timelines. It's possible that the extra time off probably gave them a false sense of security that their arms were indeed healing, or perhaps were strong enough to resume playing at 100%.

Another thing we can take away from this research is in the second Bundy article. In that, author Cliff Corcoran focused specifically on platelet-rich injections and how its success rate has been poor when used as a method to avoid serious surgeries. Corcoran mentions that anecdotally, only Takashi Saito in 2008 successfully used platelet-rich injections to avoid TJ surgery. However, we should not forget that Bartolo Colon did the same in 2011, though I suppose we could probably say his connections to the Biogenesis clinic may have contributed as well.

What I've seen in doing this research is that many players/teams opt for the rest and rehab route even though surgery is likely inevitable. Perhaps it's that Lloyd Christmas "You mean there's still a chance?" idea that no matter how slim, the 3-month timeline of rehab with the risk of surgery later is still preferable to the operation now. Some, like Rafael Furcal and Chad Billingsley, fight it to the end before finally giving up. Others, like Wimmers, Bundy, and Adams, give it some time before acknowledging that their arms aren't getting any better. And finally, there's Daniel Hudson, who knew immediately and wasted no time in getting his ligament repaired.

The next time we see a Twins player injure his elbow, I think we should at least allow him and the Twins a couple months to sort out their plans. With the exception of Hudson, it seems like all players with damaged elbow ligaments use 1-2 months to figure out the best plan of action and debate whether rehab or surgery is the best course. If rehab is prescribed, then we can argue that it's very likely pointless, but expect up to 3 months before the surgery is scheduled. But if the player rehabs for over that 3 month period, well damn it, he probably should have just gone for the operation in the first place.

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