The Arm (6 page)

Dr. James Andrews hears different versions of that same story almost every day, and he worries about the youth system's halfhearted effort to clean itself up. Tommy John surgery is not a panacea. It requires time to rehab kids don't have, training they may not be prepared to handle, and maturity they almost cer
tainly don't possess without parents and coaches emphasizing the importance of arm care.

“What twelve-year-old is going to say? ‘Excuse me, coach, I'm feeling a little soreness in my elbow. I think it would be most prudent if I stopped now,'” said Dr. Glenn Fleisig, the research director at ASMI. “We have a kid who's on a travel team and is a good pitcher. He enjoys being a good pitcher. His parents enjoy it. And they have nothing but the best intentions. Same with the coach. They all enjoy it. So here's this kid. He's pitching on a Saturday afternoon, and he's spent. And his mom and dad are rooting for him. And so is this girl. And they're winning four to two. So of course he's going to keep pitching.”

Doctors believe almost every UCL tear is an accumulation injury—a ligament worn down over time that finally relents. Kids play today more than ever, and while the correlation with the spike in UCL injuries is obvious, many in the sport see the relationship as causative, too. “There are so many misrepresentations of our game and how it should be taught and how kids should play it,” said Tony Clark, the executive director of the MLB Players Association. “I shudder at the thought of being told at thirteen years old to choose a sport because that would be my only chance to make it.”

If there's any good news, it's that the elbow's loss has been the shoulder's gain. Shoulder injuries used to be the bane of baseball, ending careers far more often than elbows and causing nearly seven thousand disabled-list days as recently as 2008, according to research by Jeff Zimmerman of the
Hardball Times
. By 2014, the number dipped to fewer than three thousand, thanks in large part to innovative exercise programs that strengthened shoulder muscles. Unfortunately, ligaments cannot be strengthened, which leaves the UCL to fend for itself against the onslaught of more throws and maximum-effort deliveries and pitches like the sinker, cutter, split-fingered fastball, and changeup that all call for some sort of hand manipulation.

“Medicine and science have come so far,” Washington Nationals pitching coach Mike Maddux said. “A hundred years ago, a couple guys in North Carolina said let's fly this thing called an airplane, and people said these guys are smoking some hashish, man. As far as we've come in science and medicine, we still haven't come to the human element of a pitcher's arm. No matter how smart we get, all the advancements we've made, nature always will take its course.”

I'm not sure that's true.

The arm is not a dead end. Obstructionism around baseball exists, and those in power need to take bold steps to fix a culture that has existed far too long for its own good. Over the three years I spent exploring the pitching arm's past, present, and future, I found brilliant people dedicating their life's work to saving it. They had ideas and technologies and strategies to help. Ingenuity still lives in the game. All it takes is one brilliant mind to change the culture. About forty years ago, baseball witnessed it firsthand.

T
HE PITCH WAS SUPPOSED TO
be a sinker, 82 or 83 miles per hour, effective in spite of its velocity and because of its dishonesty. In spin and look, it masqueraded as a fastball, only to dive to the dirt about ten feet in front of the plate. Hitters were aware of its charms and unable to resist them anyway. This particular sinker bore no such malice. It floated high and outside. Hal Breeden, who stood in the batter's box at Dodger Stadium in the third inning on July 17, 1974, took the last pitch Tommy John threw before he changed baseball forever.

Almost immediately, John ambled off the mound and toward the dugout. “Tommy John was a tough sumbitch,” Breeden said. “When he walks off like that, something's bad.” This wasn't pain; it was agony. John was thirty-one years old, a major leaguer for a dozen seasons already, and he knew soreness like every pitcher
knows soreness. This was more acute, concentrated in his left elbow joint, distressing enough that he scuttled right past future Hall of Fame manager Walter Alston and into the dugout, where his message for Los Angeles Dodgers trainer Bill Buhler was succinct: “Get Dr. Jobe.”

Frank Jobe left his box seat and wound his way to the trainer's room, a fifty-by-twenty-foot antechamber into which large men shoehorned themselves to receive treatment for sore muscles and other common ailments. Jobe, considered by many the best orthopedic surgeon in America, was also the Dodgers' team physician, on duty for a moment like this, when the pitcher with the fourth-best ERA in baseball winced and needed to know why his arm felt like someone had left it in a pizza oven.

Jobe steadied John's upper arm while moving his forearm, read his face for discomfort, and told him to head home, ice it, and visit the next afternoon. Medicine worked on a different timetable then, immediacy an impossibility, because the right technology didn't exist. It had been only five months since the United States issued its first patent on what would become the magnetic resonance imaging (MRI) machine. Jobe would rely on X-rays of John's elbow, and before he drew any conclusions, he wanted John to visit Dr. Herbert Stark, a hand surgeon whose patients included Sandy Koufax and Wilt Chamberlain. Stark manipulated John's arm in and out, same as Jobe. The meeting didn't last long.

“Boy, you sure did a job on it, didn't you?” Stark said.

“I guess,” John said.

“Go on back to Dr. Jobe,” Stark said.

By five o'clock, when John returned to Jobe's office, the X-rays were clear enough to confirm Jobe's fear: a torn ulnar collateral ligament. John didn't know what a UCL was. Few pitchers did. Players spent so much time dreading shoulder injuries that the elbow, such a simple, effective joint, not encumbered by sheaths of muscle braided together, was almost an afterthought. Elbow pain meant bone chips, or maybe a torn flexor-pronator mass,
which John knew well; Jobe had sliced open his forearm to reattach the forearm muscles following the 1972 season. The UCL was enough of a mystery that Jobe prescribed three or four weeks of rest to let it heal before trying to throw again. Twenty-six days later, before a game at Shea Stadium against the Mets, John tried to throw batting practice. After twenty pitches, his arm felt lifeless.

Without a working left arm, he tried to jerry-rig one. John asked Buhler, the trainer, to treat his elbow as he would a sprained ankle. Buhler mummified the arm in athletic tape, weaving a figure eight as John held his elbow at 90 degrees. Considering he couldn't straighten his arm, John threw rather respectably, though nowhere near well enough to get major league hitters out. His options were dwindling, his time fading, and on September 11, John called Jobe from San Francisco and lamented the lack of progress. Jobe told him to fly into Los Angeles the next morning, where he delivered a diagnosis: “It's not going to heal.”

Jobe was the kind of doctor who gave the bad news first, hoping the good news to follow would act as an analgesic. John didn't need surgery. He would live a totally normal life without a UCL. His first child, a girl, was due in two weeks, and he would walk her down the aisle just fine. He could do anything except pitch in the big leagues.

“We just told him to go home,” Jobe remembered. “He was through playing baseball.”

He could go to Terre Haute, Indiana, where he was born, and sell cars. Or partner up with a friend in San Francisco who owned a jewelry business. The name Tommy John meant something. He could've parlayed it into success outside baseball if he weren't so much like his father. Thomas Edward John had worked for Public Service Indiana as a power-line serviceman, tacking himself to utility poles, climbing, hanging only by a belt and the grace of God. He did this for decades, until he was sixty-three years old. Nobody would take him away from the lines.

John refused to accept that his baseball career had ended on a garbage sinker to Hal Breeden. He prodded Jobe, asking for an alternative. None existed. Jobe said that the only possibility was theoretical. For years, doctors had used a tendon in the wrist, the palmaris longus, to strengthen the ankles of polio patients at Rancho Los Amigos National Rehabilitation Center. Hand doctors rebuilt finger joints with it. The success of those surgeries emboldened Jobe to consider extrapolating the technique: he would use the palmaris longus to rebuild the elbow, something he told John might have a 1 percent chance of success. “Tommy likes to tell the story that he was a math major and knew that one in one hundred is better than zero in one hundred,” Jobe said. “But I thought it had a ninety percent chance to work.”

Jobe sandbagged so as not to give John false hope. He wanted to wait two weeks and assemble a strong support team to help with the experimental surgery. He didn't know whether the tendon would turn into a ligament or fail in the elbow joint and require more surgery. He worried about the sensitivity of the ulnar nerve, the lack of a concrete rehabilitation plan, the speculative nature of the entire operation.

“Tommy,” Jobe said, “I don't know what I'm doing.”

More than anything, those words convinced John this was exactly what he wanted. Before Todd Coffey—before Stephen Strasburg and Matt Harvey and José Fernández and minor leaguers you haven't heard of and college kids who never made it and high school kids suckered by delusions of majestic major league careers—there was only Tommy John the ballplayer, not the brand name of a surgical procedure. The greatest triumph in the history of sports medicine exists because Jobe and John shared a feeling to which neither was accustomed: vulnerability. “I knew he wasn't bullshitting me,” John said. “He's a friend first, a doctor second. But when a doctor admits he's not a god, a deity, and he can fuck up, that sold me.”

John stared at Jobe and said three words that forever would wed them: “Let's do it.”

Some doctor would have dreamt up the surgery at some point, but Jobe earned his reputation as the best. Take the procedure's name, because that more than anything captures his essence. Other doctors asked him what he wanted to call his new surgery. “The way you should say it,” Jobe told me almost forty years later, “is ‘reconstruction of the ulnar collateral ligament using the palmaris longus tendon.' It's not catchy enough.” The convention was for doctors to name the procedure after themselves. Every skin cancer patient knows Mohs surgery. Salk and Sabin both developed eponymous polio vaccines. Even body parts sometimes carried doctors' names; the transverse bundle of the UCL is also known as Cooper's ligament. “Jobe surgery” didn't sound right, not to Jobe's ears. He believed he was little more than a man with a scalpel, a drill, and an idea. The courage and gumption were Tommy John's. If this worked—if it actually became something that could save baseball players' careers—John deserved the recognition.

Jobe had learned quick thinking as a medic for the 101st Airborne. He braved the Battle of the Bulge, slept in the snow, dodged machine-gun fire, and sent letters to his mother back in North Carolina that no mother should have to read. “I consider myself the luckiest guy in the world,” Jobe said. “I've been lucky all my life. I was in World War II and didn't get killed.” When Jobe returned from the war, he left his family's fifteen-acre farm for California, where the GI Bill funded his undergraduate degree, and his battlefield experience made medical school a natural step. After getting his MD from Loma Linda University, Jobe ran a family practice for three years to pay off twenty thousand dollars in student loans. Debt-free, he landed an orthopedics residency and met the no-nonsense midwesterner Dr. Robert Kerlan, another sports-medicine pioneer, who took a shine to him and invited the genteel southerner to partner up.

Jobe's first patient was Johnny Podres, a Dodgers left-hander with a bone chip floating in his elbow. Even before the advent
of the arthroscope, removing bone chips was a relatively quick procedure, nothing like traversing the twenty-one muscles of the shoulder, which resemble a highway interchange. Digging deeper into the elbow wasn't an option, either, even though cursory research had shown the significance of the UCL.

In 1941, Dr. George Bennett, an orthopedist dubbed the “mender of immortals” by
Sports Illustrated
, studied arm injuries in pitchers. His resulting article in the
Journal of the American Medical Association
mentioned an elbow lesion “not seen in other occupations”—a torn UCL, though Bennett didn't call it by name. Five years later, a journal in Europe introduced UCL injuries through the prism of javelin throwers, whose technique is strikingly similar to pitchers' when viewed in slow motion. The stride, the external rotation of the shoulder, the deceleration during follow-through—everything was there, and javelin throwers blew out their arms frequently. For the next thirty years, the medical literature more or less ignored UCL tears, which Dr. James Andrews of the American Sports Medicine Institute later blamed on the difficulty of diagnosing the injury with X-rays.

Though far less frequently than today, torn UCLs did end pitchers' careers. Tired of telling pitchers the same sad two-word phrase—“You're done”—Jobe vowed to devise a work-around. Rather than get lost in fixing all three sides of the UCL, Jobe homed in on the anterior bundle, the most vital piece of the triangular ligament because it absorbs most of the energy that travels to the elbow. His choice of the palmaris longus was particularly intuitive, too, despite its success in other, unrelated surgeries. Its size was perfect, between 3.5 and 4.5 millimeters wide, almost an exact match of the anterior bundle. It was long enough to allow Jobe to drill tunnels in the humerus and ulna and wrap the tendon in a figure-eight pattern. The best part: the palmaris longus is altogether useless, anatomically inert, the appendix of the arm. Patients function no differently after its extraction than before. Doctors estimate 15 to 20 percent of people don't even have one. But when John touched his
thumb to his pinky and flexed his hand, a palmaris longus popped up in the middle of his wrist.

“God put it there,” Dodgers trainer Stan Conte said, “so Frank Jobe could do this surgery.”

I
N BETWEEN STARTS, WHEN HIS
elbow ballooned to cartoonish sizes because the damage in it invited fluid to congregate near the joint, Sandy Koufax would visit Dr. Robert Kerlan and brace himself. Relief came in the form of a needle that Kerlan jabbed into the swollen area. Red-tinged liquid oozed into an empty syringe. No matter how many visits to Kerlan it took, Koufax was not going to let his degenerative elbow stop him from throwing a baseball.

For the last three years of his career, Koufax, the Los Angeles Dodgers' ace, subjected himself to the treatment with regularity. His arm refused to cooperate otherwise. X-rays showed that three or four spurs hooked off the bones of his elbow. Nobody knew the full extent of the tumult inside, though the accumulation of fluid indicated that the body recognized trouble and was trying to protect it from further wreckage. On the day before, the day of, and the day after his starts, Koufax ate a white-and-orange capsule of Butazolidin, a brand of phenylbutazone, an anti-inflammatory originally intended for horses and today considered unsafe for human consumption. He eased the pain with a codeine-cut aspirin. Then, before Koufax pitched, the Dodgers' training staff snapped on rubber gloves, scooped a glob of Capsolin, a clear, pungent balm, and applied it to Koufax's elbow, shoulder, and back. Capsolin wasn't a salve so much as a declaration of war; it consisted of 3 percent pure capsaicin, the active ingredient in chili peppers, along with turpentine, camphor oil, and other elements that punished the body with heat. Nerve endings stood no match. They wilted and died from Capsolin overdoses. Koufax needed it to manage his misery.

Today, Koufax looks about two decades younger than his eighty years, fit and tan, a man who could star in a pharmaceutical commercial that features happy octogenarians taking a walk or tilling the garden. A half century after he walked away from baseball in his prime, Koufax remains one of the finest pitchers the game has ever seen. His friendship with Jobe blossomed in retirement, and Jobe has often said that if he'd conceived of UCL reconstruction a decade earlier it would be called Sandy Koufax surgery.

Koufax grants one-on-one interviews as frequently as a total solar eclipse. When I asked through an intermediary if he would talk about Jobe, Koufax was happy to make an exception, inviting me to Dodgers spring training to visit and reminisce.

“He was a very gentle man, but he was also very strong,” Koufax said. “Great bedside manner, but wouldn't take any crap.” Jobe never treated Koufax during his Hall of Fame career, probably because it ended almost as quickly as it began. When the pain in his elbow first materialized in April 1964, Koufax was twenty-eight years old. He couldn't straighten his arm. Injuries shelved him for one-third of his scheduled starts. Kerlan diagnosed him with traumatic arthritis, declared there was no cure, and suggested he pitch once a week. During spring training in 1965, Koufax woke up one morning to find the majority of his left arm black and blue. Undeterred, he pitched every fourth day, twirled a perfect game, and won the National League Cy Young Award. In the offseason, Kerlan suggested he quit. Koufax wanted one more year, needles and drugs and fear of permanent disability be damned.