It used to be that if you were a pitcher and you blew out your ulnar collateral ligament — the ligament that holds your elbow together — you were done.
Goodbye, playing days.
That was the verdict that Tommy John, then a pitcher for the Los Angeles Dodgers, was handed down when his elbow went pop. But he was dogged and lucky and just happened to be under the care of a doctor, Frank Jobe, with a novel idea about how you might take a piece of healthy tendon in the wrist and use it to tie the elbow back together. The body would do the rest, he thought, plastically transforming the tendon, at the cellular level, until it really became a new ligament. If the surgery were to work — what a feat of imagination to believe that it might really work! — you'd have a new elbow.
Start the clock back again and launch a new career.
Well, it did work, and Tommy John did launch a new career. Despite having been declared DOA, he was able to go on to pitch 13 more years and, indeed, to do so at the very top level.
Since John first underwent replacement surgery, the operation has been performed more than 10,000 times. Draw up a short list of today's pitching superstars. You'll be astounded how many of them have had Tommy John (as the surgery is universally known): Stephen Strasburg, Matt Harvey, Yu Darvish, Jacob DeGrom, Jose Fernandez, Chris Carpenter, Adam Wainwright, and on and on.
What's going on here?
The null hypothesis is that pitchers have always been blowing out their elbows. In the olden days (before 1974), that would have been that. Never to be heard from again. Now, they just need to get their elbows refurbished and they're good to go.
But that can't be right. The thing about Strasburg and Harvey and DeGrom and Fernandez and so many of the others is that these guys didn't go under the knife the way John himself did to extend an otherwise mature career. They had their elbows rebuilt at the very start of their careers; they did it to have a career.
And there's another piece of the puzzle: Although at the time they blew out their elbows these pitchers had only just begun to prove themselves at the major league level, they were one and all hugely hyped and widely regarded, already, as superstars.
Jeff Passan's superb new book, The Arm: Inside the Billion Dollar Mystery of the Most Valuable Commodity in Sports, takes a penetrating look at what, in the words of Hall of Fame pitcher John Smoltz — himself a beneficiary of Tommy John, and the first member of the Baseball Hall of Fame to sport the scar — is really an epidemic not only of elbow injury but also of surgery to remedy the affliction.
Passan makes a powerful case the problem's roots lie in youth baseball. Or rather, in a complex set of changes and developments that have changed not only youth baseball but, in a way, childhood itself and have created new "moral hazards" that parents, coaches and the sport at all its levels are only beginning to fathom.
Passan quotes Smoltz, who felt called upon to address this topic in his speech at his Hall of Fame induction in 2015:
"It's an epidemic. ... It's something that is affecting our game. It's something that I thought would cost me my career, but thanks to Dr. James Andrews and all those who came before him, performing surgery with such precision has caused it to be almost a false read, like a Band-Aid you put on your arm.
"I want to encourage the families and parents that are out there to understand that this is not normal to have surgery at 14 and 15 years old. That you have time. That baseball is not a year-round sport. That you have an opportunity to be athletic and play other sports ..."
What's going on here? It's a complicated story; Passan tells it well. It goes something like this:
Kids who love baseball love baseball, and they want to play. They dream of the big leagues. It used to be that when Little League was over, that was it. You played basketball or football. It also used to be that parents left kids more or less to their own devices while they attended to work, home and hearth.
Well, that's changed. Parents are keener than ever to get involved with helping their children live out their dreams — or maybe it is the deferred dreams of their parents? — and in recent years there is a growing bounty of new opportunities, afforded by for-profit companies, for the most part, that will enable parents to do this. In a sense, these are vanity leagues — you pay to travel with other boys whose parents can also afford to participate in tournaments put on by organizations that keep track of how you're doing, build up rankings, talent evaluations, and create a whole hugely expensive and hugely profitable baseball resort culture. What starts out as pay-to-play recreation, not all that different from traditional, community-based Little League, begins to assume the guise of the only way forward if you're serious about baseball. Indeed, if you are serious about a scholarship and a career in baseball. Real MLB scouts actually attend the tournaments. Poor kids get left out. Ambitious parents can give their sons a leg up on a dream of a successful life in professional baseball. It's a vicious circle.
Of course it isn't all bad. What is better than organizations established to help kids who love baseball get a chance to develop their talents and cultivate themselves for a chance at success?
But the downside is obvious. Pre-pubescent boys are pseudo-professionalized at way too young an age; the things of childhood are made objects of stress and unhealthy competition. Boys are made to play too much baseball. They are asked to throw too much and, more and more, thanks in part to the ubiquity of the radar gun as a gauge of precocious talent, to throw harder, and for longer, than ever before. A good thing goes awry: Children overuse and abuse their young bodies.
And we know the consequences. An epidemic of arm surgery on young men in the late teens and early 20s.
Who's at fault here? Not the kids, obviously. The parents? The coaches? Why aren't they protecting their kids?
There's no simple answer here, either.
For one thing, it's hard to recognize the contours of an epidemic if you're an individual inside it.
For another, how can you tell when your boy — who seems, after all, to be made of rubber and pure energy — is hurting himself? We like to pretend that there are experts that we can call on to make these judgments. But in a way there are no experts.
I wrote Passan and asked him about this. Here's what he said:
"I've struggled with this. What is 'proper' conditioning? Is it cardiovascular? (Bartolo Colon and CC Sabathia say no.) Is it core? Lower-body strength? Flexibility? I don't know the right answer, and accordingly I have trouble adjudicating this one. I mean, it's something of a cop out to say: Depends on the guy. But I really do believe that's true. Jose Fernandez blew out a few months after he became a hardcore cyclist. Was that causative? Possibly. Or maybe it was his delivery. Or his genetics. All of this is still such a mystery. It makes the pursuit of knowledge simultaneously invigorating and frustrating."
Passan hits the nail on the head. How do you protect yourself when you are deep inside the tunnel of your own ambition? We need knowledge. But, really, we need wisdom. There are unlikely to be any one-size-fits all recipes.
There is an additional moral cost that Passan does not focus on in The Arm. As a society, we seem to have a totally disorganized and incoherent set of values regarding the place of medicine and technology in the cultivation of athletic talent. We categorically prohibit the use of strength-building and injury-protecting PEDs, yet we allow surgical interventions like Tommy John to become increasingly business as usual, letting pitchers use their body well beyond biologically sanctioned safety and performance specs.
What's the principle that differentiates these? Maybe the biggest difference, as Passan suggested when I raised this issue to him in our correspondence, has more to do with "long-held stigmas than anything particularly rational."
Is it right to expect pitchers to undergo surgery to compete at the highest level? Is that any more acceptable than demanding that they should take steroids? Is it any safer?
Passan brings another piece of the puzzle.
It isn't only superstars who are getting Tommy John. It's players at every rank and level. And the personal costs — the risks of surgery, the hell of rehabilitation, the emotional risks of losing everything, a whole career, to injury — are enormous and very grim. The physical pain and scarring, the suffering, the insecurity, the stress.
Is this what it should cost to have a life in baseball?
Alva Noë is a philosopher at the University of California, Berkeley where he writes and teaches about perception, consciousness and art. He is the author of several books, including his latest, Strange Tools: Art and Human Nature (Farrar Straus and Giroux, 2015). You can keep up with more of what Alva is thinking on Facebook and on Twitter: @alvano
