DR HQ: Is labrum surgery still a career-ender?

Every year, questions persist of whether one should avoid pitchers coming off labrum surgery. This edition of Dr. HQ will focus on explaining labrum injuries and the impact on pitching careers.

Anatomy

Welcome to Anatomy 101 of the human shoulder, with a focus on the labrum and its function in the movement of the pitching shoulder. Below is a description of the labrum and some of the issues involving its function and location and a basic illustration of the shoulder from the front.

“The shoulder labrum is a thin layer of cartilage that lies between the humerus (bone of the upper arm) and the glenoid cavity (the cavity in the shoulder), the small groove which the humerus fits into. It functions as a shock absorber and a part of the shoulder joint’s connective structure. Therefore, it cushions the joint when the humerus collides with the glenoid fossa in activities such as throwing a baseball—a violent action that rips at the tissues of the shoulder.

Types of Labrum Tears
(1) Sometimes this aggressive motion can cause the labrum to tear. The most common type of labral tear in baseball is a superior lesion anterior (front) to posterior (back) or “SLAP.” Like most other injuries, a SLAP tear (or lesion) is initially thought to be only minor pain and tenderness. In addition, it is quite difficult to diagnose without exploratory surgery due to its concealed location between two bones. Frequently, the tear goes unnoticed for weeks to months until the tenderness and ensuing loss of pitching quality add up. Thus, it is interesting to figure how many great pitchers of the past had their careers ended by the injury.”(Jonathan Koscso 2011)

(2) If a pitcher suffers a shoulder dislocation, the shoulder pops out of the joint and can tear the labrum. When this tear (in the front of the shoulder usually extending all the way to the bottom of the labrum) is called a Bankart tear. It is not as common in minor league and major leaguer pitchers, rather it occurs more often in younger pitchers.

(3) Another type of labrum injury is fraying. This is when the outer edge of the labrum starts to tear into very small sections. In some cases the vast majority of the labrum, including the part that is anchored in the glenoid cavity is intact and not damaged.

Surgical Repair
Depending on the type and severity of the damage, a surgeon can repair the damage in most cases. Whether it is just to ‘cleanup’ like minor fraying or to re-attaching the labrum in the glenoid cavity by using surgical screws, it can be complex surgery. Twenty-five plus years ago a tear of the labrum was a career ender. Sports medicine has made tremendous strides in correcting these types of injuries but so much work and improvement is still needed. When Tommy John had the first elbow reconstruction surgery, replacing the ulnar collateral ligament in his pitching elbow was a ground breaking moment in sports medicine. Today, Tommy John surgery recipients at the major league level have a roughly 85% chance of return to prior production or better. Pitchers who undergo labrum surgery have a much smaller rate of success but it is improving.

Rehabilitation
In a typical rehab program, the pitcher may be limited to restricted mobility with the surgically repaired shoulder for six weeks. Then he is slowly allowed to start passive movement. Once the surgeon is convinced that the labrum has healed into the proper position, he gives the go ahead for more aggressive physical therapy. It is a long and arduous process, even for some of the best of athletes.

A decade ago, the odds of a pitcher recovering from the surgery and returning to the major league level was almost nil. A decade of progress reportedly has the success rate somewhere between 33%-66% though there has not a definitive study on the current rate of recovery. Some examples from the past 13 or so years:
 

Casey Janssen
Labrum surgery date: March 2008
Age (at the time of surgery): 27
Reported R/C damage: No
Return date (to MLB): 14 Months
Post-surgical success: A talented righthander who is now is entering his fourth season since returning from his surgery. He was converted to relief and re-invented himself as a quality relief pitcher.

Jason Schmidt
Labrum surgery date: June 2007
Age (at the time of surgery): 34
Reported R/C damage: No
Return date (to MLB): 25 months
Post-surgical success: Schmidt gets an A for effort but at age 35 he was never able to return as even a mediocre major league starter.

Rich Harden
Labrum surgery date: May 2005
Age (at the time of surgery): 23
Reported R/C damage: No
Return date (to MLB): 11 months
Post-surgical success: One of the quicker returns, though that may be attributed to the fact his surgery wasn’t as severe as others on this list. Still, he’s spent more time in the training room than on the mound. He has recorded ten trips to the DL so far.

Kelvim Escobar
Labrum surgery date: July 2008
Age (at the time of surgery): 32
Reported R/C damage: Yes (capsule)
Return date (to MLB): None
Post-surgical success: Escobar managed only one game in 2009 and has been out of baseball since. He is attempting a comeback in 2013 at the age of 36.

Chris Carpenter
Labrum surgery date: Sept. 2002
Age (at the time of surgery): 27
Reported R/C damage: None
Return date (to MLB): 19 months
Post-surgical success: Carpenter is the poster boy for success after having surgery on his labrum. Won the Cy Young in 2005 and finished second in 2009 and third in 2006. Threw well over 1,000 innings after the surgery.

Ted Lilly
Labrum surgery date: Oct 1999 (very small tear); Sept 2012
Age (at the time of surgery): 33
Reported R/C damage: No
Return date (to MLB): Pending
Post-surgical success: He over came several injuries and surgeries to his rotator cuff in his career. Asking a 37-year-old to bounce back from a torn labrum is a lot.

Jeff Francis
Labrum surgery date: Feb. 2009
Age (at the time of surgery): 28
Reported R/C damage: No
Return date (to MLB): 16 months
Post-surgical success: The jury is still out. At times he has been effective and he managed to throw 180+ innings in 2011. Francis also has battled inflammation in his shoulder every year since. Working in his favor is his age (32) and the fact he can pitch effectively with a top-flight fastball.

Dustin McGowan
Labrum surgery date: July 2008
Age (at the time of surgery): 26
Reported R/C damage: Yes
Return date (to MLB): 3 years, 2 months.
Post-surgical success: He just can’t get his shoulder healthy and needed surgery to clean out his shoulder this past August. He’s now 30 years old and time is starting to run out.

Clayton Richard
Labrum surgery date: Sept 2011
Age (at the time of surgery): 28
Reported R/C damage: Yes
Return date (to MLB): 7 months
Post-surgical success: Richard had damage to his R/C, labrum and frayed biceps but the damage was not extensive. It’s amazing he threw 218 innings with the Padres last season. One has to wonder if that amount of workload will cause issues this season?

Wade Miller
Labrum surgery date: Sept 2005
Age (at the time of surgery): 28
Reported R/C damage: None
Return date (to MLB): 12 months
Post-surgical success: His problems started in 2004 with a torn rotator cuff which was compounded by the labral tear at the end of the 2005 season. Career as we knew it was over.

Kurt Ainsworth
Labrum surgery date: March 2005
Age (at the time of surgery): 25
Reported R/C damage: Yes
Return date (to MLB): None
Post-surgical success: This highly talented former first roundercould never overcome the damage to his rotator cuff and labrum and his career was over at 26.

Gil Meche
Labrum surgery date: Feb 2001
Age (at the time of surgery): 22
Reported R/C damage: No
Return date (to MLB): 26 months
Post-surgical success: he was able to carve out a few decent seasons where he led the American League in starts two years running in 2007-2008. He worked over 1000 innings after his surgery.

Troy Patton
Labrum surgery date: March 2008
Age (at the time of surgery): 22
Reported R/C damage: No
Return date (to MLB): 3 years 2 months
Post-surgical success: He stuck it out and worked his way back as a starter in the minors to build up his arm strength then provided the Orioles with some effective relief pitching in 2012. If you get hurt early enough in your career, you do have time to work your way back.

Scott Elarton
Labrum surgery date: March 2002 (labrum and capsule); Aug 2006 (labrum only)
Age (at the time of surgery): 26; 30
Reported R/C damage: Yes
Return date (to MLB): Yes
Post-surgical success: He made it back twice from the surgery but the second time Elarton had nothing left in the tank.

Anibal Sanchez
Labrum surgery date: June 2007
Age (at the time of surgery): 23
Reported R/C damage: No
Return date (to MLB): 13 months
Post-surgical success: Sanchez underwent Tommy John surgery in 2003 and labrum surgery four years later. Since the 2010, he has been consistent and remained healthy which is an accomplishment considering his slight frame. Working in his favor is his youth and the fact he has never has rotator cuff issues on top of the labrum problems.

Jose Valverde
Labrum surgery date: Sept 2004
Age (at the time of surgery): 26
Reported R/C damage: No
Return date (to MLB):  8 months
Post-surgical success: Its usually easier for relievers to bounce back from the surgery (though see Rob Nen below). He’s had an excellent career after the surgery and may not be over yet.

Rob Nen
Labrum surgery date: Nov 2002
Age (at the time of surgery): 32
Reported R/C damage: No
Return date (to MLB): None
Post-surgical success: None. He followed up his labrum surgery with a torn rotator cuff the following season and never pitched again. He pitched hurt for part of the 2002, gutting it out for the Giants and their post season run. He made it all the way to the World Series but it cost him his career.

Brandon Webb
Labrum surgery date: Aug 2009
Age (at the time of surgery): 30
Reported R/C damage: Yes
Return date (to MLB): None
Post-surgical success: From 2003-2008 Webb was one of the best in the National League. He was as consistent and reliable as a starter could be then it was all gone. He broke down physically during his first and only start in 2009 but 1300+ innings and a ton of pitches before the age of thirty burned him out. Note Webb had rotator cuff surgery in 2011 while attempting to come back.

Conclusion
There are so many variables to consider. What type of labral tear the pitcher has, the severity of the tear, the surgical procedure, which rehab protocol was prescribed, the experience and success rate of the surgery—on and on they go. And HIPPA has restricted the level of information available needed to do a detailed investigation. T

But a complete, fool-proof study is not the goal of this column. Rather, it is to give you a new way at looking pitchers who have had labrum surgery. In the past, I have strongly suggested you ignore pitchers coming off labrum surgery. To be successful fantasy owners we need to continue to update our analysis skills as old theoms evolve into new ones.

So, is a torn labrum the end of a pitchers career in 2013? The answer is no and the progress being made in sports medicine circles will continue to improve the odds. It may never reach the 85% success rate of Tommy John surgery, but it won’t be a career ender for so many professional pitchers. 

The above eighteen pitchers serve as examples of the larger group of pitchers who have undergone surgery to a repair the labrum in their pitching shoulder. Below is what I consider the new rules in dealing with pitchers coming off labrum surgery:

  • Pitchers that have surgery to repair both the labrum and rotator cuff (or another structure) in their shoulders should be avoided at all cost. That’s the strong percentage play.
  • Pitchers under going labrum surgery (with no R/C issues) at the age of 32 and above remain high-risk investment but could provide some value 18 months or more after their surgery. The best time to acquire them is via free agency or at the very end of your draft.
  • The biggest area of progress appears to be with younger starters. Those from the age 22 to 29 can recover from the surgery and be nearly as effective as they were before and post solid careers. If you are going to invest in a pitcher coming off labral surgery, this is the highest percentage group. Anibal Sanchez, Troy Patton, Gil Meche, Clayton Richard and Casey Janssen are success stories. The percentage play in this group may remain around 50% but they are proof that younger pitchers can now overcome the surgery and it is only going to get better with the advances in sports medicine rehab and orthopedic surgery.

 

In a future column, we will take a look at 2013 post-labrum surgery candidates.

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Kosco, Jonathan. 2011. “The SLAP Tear: A Modern Baseball Focus” A thesis by Jonathan Kosco.

Labral injury articles by Corey Dawkins of Baseball Prospectus and Will Carroll’s labrum article in Slate (2004) were used as a guide in research for this column.

The following pitchers were review in the research for this column. Kurt Ainsworth, Jose Ascanio, Grant Balfour, Erik Bedard, Joaquin Benoit, Kris Benson, Rocky Biddle, Travis Blackley, Boof Bonser, Bryan Bullington, Chris Carpenter, Roger Clemens, Matt Clement, Chad Cordero, Omar Daal, Scott Elarton, Kelvim Escobar, Casey Fossum, Jeff Francis, Freddy Garcia, Jon Garland, Mike Hampton, Rich Harden, Trevor Hoffman, Jason Isringhausen, Casey Janssen, Steve Karsay, Brian Lawrence, Curt Leskanic, Ted Lilly, Brandon Lyon, Pedro Martinez, Dustin McGowan, Gil Meche, Wade Miller, Peter Moylan, Mark Mulder, Rob Nen, Jim Parque, Troy Patton, Robert Person, Luke Prokopec, Aaron Rakers, Jon Rauch, Clayton Richard, Ricardo Rincon, Anibal Sanchez, Jason Schmidt, Bud Smith, Jose Valverde, John Van Benschoten, Brandon Webb, Paul Wilson, Kerry Wood


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  For more information about the terms used in this article, see our Glossary Primer.