Elkhorn lefty Patrick Johnson on the mound at Haymarket Park in the 2008 Class B State Tournament.  The Antlers went on to win the inaugural Class B state championship after being crowned the Class A state champs the year before.  Johnson is six weeks into recovery from labrum surgery on his throwing shoulder.

[See related article: Baseball Mojo:  "An Arm is a Terrible Thing to Waste"]

 

The prognosis is mixed for two of the top returning senior pitchers in the Metro area for the 2009 season following recent shoulder surgeries on their throwing arms.   Patrick Johnson, who earned back-to-back State Champion medals while throwing for the reigning Class B State Champion Elkhorn Antlers, underwent labrum surgery on October 24, 2008.  Patrick's father, Bryan Johnson, noted that the prognosis is guardedly optimistic for the highly regarded 6'2", 210 pound lefty.  According to Mr. Johnson, Patrick's orthopedic surgeon has penciled in a five-to-six month rehabilitation schedule that would allow  Patrick to play first base and hit from the outset of the season and even return to the mound by mid-to-late spring. 

 

The outlook for playing in 2009 appears to be much less optimistic for Bellevue East's Danny Pierce who underwent labrum surgery two weeks ago according to his head coach, Don Kiviniemi III.  Pierce, a three-year varsity starter who, along with classmate Matt Tew, was expected to give the Chieftains one of the best pitching tandems in the state, may be out of baseball entirely for the 2009 spring and summer seasons due to an anticipated lengthy rehabilitation, according to Coach Kiviniemi. 

 

Elbow surgery in September also dealt a setback to Omaha Skutt's Brett Swain, a junior who was beginning to garner considerable interest from college recruiters, according to Skutt varsity assistant Shawn Exner.  Swain, who saw light duty on the mound for Exner's Oakview Construction senior legion team after transferring to Skutt at the end of the spring from Creighton Prep, underwent "Tommy John" reconstructive surgery in September after suffering an injury at a University of Kansas showcase earlier in the month.  Swain, a 6'3", 200 pound righty, will need approximately nine to fifteen months of rehabilitation before returning to the mound, according to Exner.  The lengthy rehab will likely cost Swain most, if not all, of his junior season. 

Danny Pierce of Bellevue East also recently underwent labrum surgery on his throwing shoulder.  Pierce is a three-year starter for the Chieftains.

 

The three injured hurlers join a growing list of Nebraska high school pitchers whose careers have been hampered by arm injuries that resulted in surgery in recent months.   That list includes two recent Skutt graduates -- Creighton recruit Austin Cole and Hastings College recruit Mike Chase -- as well as University of Nebraska-Omaha recruit Colby McCord of Papillion LaVista, Wayne State recruit Eric Schwieger of Class A state champion Grand Island, University of Nebraska walk-on Josh Raburn of Creighton Prep, Neosho County (KS) Community College recruit J.R. Rehmann of Millard North and three-sport standout Zach Ziemba of Lincoln North Star.  Ziemba is currently a senior while the others listed are all 2008 graduates.  Raburn and Schwieger underwent labrum surgery while the other five had "Tommy John" surgery. 

 

The above-listed players represent only those whose surgery has been brought to the attention of this publication.  Physical therapist Jerry Jacobi of Excel Physical Therapy in Omaha, who oversees the rehabilitation of many injured pitchers estimates that there were 25-30 elbow or shoulder surgeries affecting Nebraska high school pitchers in the past twelve months.  "Unfortunately, the trend is upward," commented Jacobi. 

 

The "Tommy John" procedure, named after the first pitcher ever to undergo what is technically known as as ulnar collateral ligament reconstruction (or UCL), a surgical procedure in which a ligament in the elbow is replaced with a tendon from elsewhere in the body such as the forearm, hamstring, knee, or foot of the patient.  Dr. Frank Jobe performed the pioneering surgery on the Dodgers' pitcher on September 25, 1974.  John went on to pitch for another 15 seasons and earned 164 of his 288 career victories after the surgery.  He remains the winningest pitcher in Major League Baseball history not to be elected into the Hall of Fame.

 

What was once considered a miraculous and revolutionary surgery has now become somewhat commonplace in professional and collegiate baseball, and use of the technique at the high school level has increased dramatically.  An article on the MLB.com website about high-profile orthopedic surgeon Dr. James Andrews notes that Andrews performed nineteen Tommy John surgeries on youth players during the period from 1996 through 1999, 86 from 2000 through 2003 and 146 between 2004 and 2007.  In the thirty-four years since the surgery was introduced, the prognosis for successful results has increased to the point now where Dr. Andrews now estimates that eighty-five percent of pitchers will make a full recovery -- with most actually experiencing improvements in velocity and performance after the surgery and rehabilitation. 

 

The prognosis following shoulder reconstructive surgery -- such as surgery to repair a torn labrum -- is much murkier.  In  a 2004 article respected baseball writer Will Carroll, author of Saving the Pitcher:  Preventing Pitching Injuries in Modern Baseball, observes that "[o]f the 36 major-league hurlers diagnosed with labrum tears in the last five years, only midlevel reliever Rocky Biddle has returned to his previous level."  Fortunately, Grand Island's Schwieger, a 6'8" lefty, beat those odds following labrum surgery in June 2007 and made a triumphant return to varsity action nine months later on April 5 with a 6-5 win over previously undefeated Papillion LaVista South, earning the victory with three quality innings in relief of starter Kash Kalkowski.  Schwieger, now at Wayne State, also went 5 1/3 innings to earn the Islanders' state championship game win over Millard West.

 

"If guys can develop the self-discipline to make these exercises a part of their regular routine, they can really help themselves stay healthy and be more effective on the mound.  The consequences of neglecting the exercises are pretty drastic -- possibly missing an entire season due to shoulder surgery.  It's entirely up to them.  No one can do it for them." -- Physical Therapist Jerry Jacobi on the need for pitchers to consistently follow a regimen designed to strengthen rotator cuff muscles.

According to local orthopedic surgeon Kirk Hutton of OrthoWest, P.C., who specializes in the treatment of shoulder injuries, the labrum ("LAY-brum") is ring of firm tissue surrounding the shoulder socket that helps keep the upper arm bone, the humerus, in place in the socket.  The rounded head of the humerus sits against the cupped surface of the labrum in the shoulder socket much like a golf ball rests on a tee, held in place by a group of four rotator cuff muscles and the bicep tendon.  The bicep tendon, which fits into a notch at the front of the humerus, wraps over the top of the humerus and then attaches to the labrum at the top of the shoulder (see illustration; for a more technical overview of the gleno-humeral joint (shoulder) see Gray's Anatomy).  Tearing or fraying of the labrum at the point where the bicep tendon attaches is often referred to as a "SLAP" tear or lesion (lesion referring to a "tissue abnormality").  The acronym "SLAP" stands for "Superior Labrum, Anterior to Posterior," meaning that the top (superior) of the labrum is injured or torn from back to front. The location where the SLAP tear occurs is under tremendous strain during the throwing motion and tends to be more vulnerable to injury than other portions of the labrum because it is an area that is poorly supplied by blood vessels, according to Dr. Hutton . 

 

SLAP lesions can occur in a number of ways, according to Dr. Hutton, such as receiving a direct hit to the shoulder, falling on an outstretched arm, falling on one's shoulder or lifting heavy objects repeatedly or too suddenly.  Engaging in repeated overhead activities, such as a throwing a baseball, can also lead to SLAP lesions.  For baseball pitchers such injuries can occur as a result of the tremendous forces generated during the throwing motion, according to author Will Carroll, who writes that "the kinetic forces required to throw a baseball -- a  major-league pitcher's arm moves at 23 rotations per second -- routinely rip apart the structures designed to keep the shoulder together."   After suffering a SLAP lesion, a pitcher may perceive a "catch" -- a slight click or pop in his normal overhand throwing motion, accompanied by shoulder pain or tenderness and a loss of velocity on his fastball, according to Carroll. 

 

Medical diagnosis of a SLAP lesion may involve some a combination of physical examination to determine which movements cause pain, X-rays, an MRI arthrogram (a type of magnetic resonance imaging scan prior to which which a special dye is injected into the shoulder), or arthroscopic surgery in which the surgeon makes small incisions in the shoulder and examines the joint by inserting a camera through a small tube.  During the arthroscopic examination, the surgeon might repair the lesion at the same time. 

According to Dr. Hutton, the severity and nature of the SLAP lesion will determine the treatment procedure and the length of rehabilitation prior to resumption of normal activities.  SLAP lesions are evaluated and identified as being either Type I, Type II, Type III or Type IV, depending an the amount of tissue affected and the severity of the injury.  Surgical repair of the SLAP lesion may involve reattaching the labrum to the cup-shaped outward edge of the shoulder blade, called the glenoid fossa using sutures with anchors.  

 

Rehabilitation following labrum surgery involves a strict regimen of exercises under the direction of a physical therapist, according to both Mr. Jacobi and Dr. Hutton.  The rehabilitation process was "pretty rough," according to Grand Island's Schwieger.  "It really wore on me -- the exercises and weightlifting and workouts.  But most of all the whole ordeal was like a huge reality check for me.  Baseball has been my whole life.  I kept thinking, 'what am I going to do now if this rehab doesn't work out?'  I had always relied on baseball.  I actually passed out in the doctor's office when they first told me that I needed shoulder surgery and might never pitch again.  All of a sudden I had to focus on what I wanted to do if I could no longer play.  The whole mental and emotional aspect of the injury was hard on me.  But the more I worked with the physical therapist, I decided that a career in physical therapy was something that really interested me.  So now, I'm majoring in physical therapy so I can help people who are in the same situation I was in."

 

Schwieger was able to get back to pitching effectively in nine months, but the timetable for returning to action on the mound varies with the severity of the labrum injury.  "It's possible to get back to throwing in games in six months," according to Dr. Hutton, "but nine months is more common."  Mr. Jacobi advises his patients to plan on it being a year after surgery before they feel 100% again.  "Guys will be able to pitch competitively earlier than that, but they won't be as effective as they were before.  They probably won't have the velocity and will tire earlier.  As time passes and the shoulder recovers, the patient will start feeling 100% again and with that comes the confidence -- which really makes all the difference in being an effective pitcher.  They might actually get to full recovery sooner than that, and if so, great.  But, don't be surprised if it takes pretty much a year to get back to top form."

 

In terms of preventing shoulder injuries, both Dr. Hutton and Mr. Jacobi strongly emphasized the importance of good mechanics and a regular workout regimen designed to strengthen the rotator cuff group of muscles that stabilize the shoulder and keep the humerus centered in the shoulder socket.  Poor throwing mechanics often result in too much of the throwing force being generated by the arm and shoulder rather than by the body core and the large muscles in the buttocks and legs, according to Dr. Hutton.  "Only about 15% of the throwing force should come from the shoulder," commented Dr. Hutton.   "Guys who try to use their arms and shoulders too much to generate velocity generally end up stressing the rotator cuff muscles and scapula (shoulder blade) stabilizers that hold the humerus in the shoulder socket.  When the muscles that are intended to stabilize the shoulder get stressed and fatigued, weakness in those muscles results, and eventually muscle atrophy can occur.  Weakened rotator cuff muscles allow the humerus to move around in the socket during the throwing motion, creating a condition known as shoulder instability, which can result in bicep tendonitis, impingement (a rubbing or pinching action) and labral lesions.   The keys to avoiding these problems are developing proper mechanics and making sure the strength of the rotator cuff muscles is maintained throughout the season with a regimen of specific exercises designed for this purpose.  Basically, as a preventative measure, we recommend something called "prehab" where healthy players are prescribed exercises that strengthen the rotator cuff muscles and the scapular stabilizers and a stretching technique called the "sleeper stretch" to help loosen the posterior capsule so that the upper arm can rotate freely.

 

Mr. Jacobi echoed those comments and offered the following observation to emphasize the importance of strengthening shoulder stability before pitchers begin their pre-season throwing activities.  "A lot of these injuries could be prevented if every baseball player were required to participate in an eight-week fitness and conditioning exercise program starting right after Thanksgiving that was specifically designed to strengthen the rotator cuff muscles.  That would give them six to eight weeks of strengthening exercises to really get those muscles in great shape before they start their pre-season throwing in January.  But, you can't just stop with it then -- you have to continue doing these exercises throughout the season to keep those muscles in good condition."  Jacobi also noted that even though we're already past Thanksgiving now, it's not too late to get started.  "Even four weeks of conditioning is better than nothing," he observed.  "The most important thing is that guys get into a routine to work these muscles and stick with it."

 

Mr. Jacobi's prescribed preseason arm and shoulder conditioning regimen takes only about 10-15 minutes three or four days per week.  "If guys can develop the self-discipline to make these exercises a part of their regular routine, they can really help themselves stay healthy and be more effective on the mound.  The consequences of neglecting the exercises are pretty drastic -- possibly missing an entire season due to shoulder surgery.  It's entirely up to them.  No one can do it for them," concluded Mr. Jacobi.

 

Skutt's Coach Exner has bought into the message of arm and shoulder conditioning and has instituted an exercise regimen for his players involving a conditioning system known as "Crossover Symmetry" (See www.crossoversymmetry.com and demonstration video)  "We're going to incorporate this five minute workout into our regular exercise and pre-game warm up every time we go out," commented Exner who is a sales representative for the line of products used in the system.  "We think this is really going to help reduce arm and shoulder problems for our kids if we build it in as part of our normal routine."  (Note:  Coach Exner can be contacted at 402-210-5134 or sgexner@cox.net for those interested in learning more about the Crossover Symmetry system.  Coach Exner adds that the Crossover Symmetry products make great Christmas gifts and is offering free shipping before Christmas.) 

 

Hopefully, more coaches will follow Coach Exner's lead and help their players develop good arm health habits so that the disturbing trend of ever-increasing elbow and shoulder surgeries can be reversed.  Both Dr. Hutton and Mr. Jacobi agree that they would much rather see their patients avoid problems than see them for surgery or rehabilitation.  They also agree that the way to do that is to strengthen the shoulder before the season begins and maintain its strength throughout the season with a brief, but targeted, exercise routine.