How could the Red Sox sign someone with an elbow that wasn't in perfect condition? What is this medical staff thinking? How irresponsible can you get? These are questions that keep popping up with John Lackey going under the knife for Tommy John surgery to repair his elbow, ending his 2012 season before it begins, and while it's fair to question why a team would knowingly assume that risk, it's not as uncommon as it might sound like.
There are many pitchers out there who are damaged goods. Ticking time bombs, waiting for the right moment where a ligament tears, or an elbow pops, or a shoulder comes unhinged -- the act of pitching is unnatural, and it causes damage for each and every pitcher. How a pitcher heals is what separates them from the rest of the pack, as even proper mechanics (Mark Prior), or careful handling (Stephen Strasburg) don't necessarily save you from the operating room.
For something like Tommy John, specifically, the reasons it needs to be performed vary. It all involves the ulnar collateral ligament, but they don't go out the same way. Sometimes, there can be no pain at all, as there was with Daisuke Matsuzaka, whose already inconsistent nature was magnified by his elbow trouble when, even though he didn't feel off, his body wasn't responding the way he wanted it to, or needed it to, in order to succeed on the mound. Other times, you get the Rich Hill variety, where it's pretty obvious something inside his elbow exploded based on his reaction.
John Lackey is somewhere in between, where his elbow was causing him discomfort, but a cortisone shot was able to reduce the swelling and bring him back to competence. At least, until the swelling returned with the cortisone shot wearing off -- then things went off the rails for Lackey once again, prompting this week's visit to Dr. Lewis Yocum.
Ben Cherington discussed Lackey's elbow yesterday, on his first day on the job as the Red Sox' general manager:
Cherington said an MRI exam "didn't show a tone of change compared to the one we did when he signed" in January 2010. As a result, the Red Sox decided to take a "conservative approach" by placing him on the disabled list and allowing him to rest his elbow and go through a rehab process. Lackey allowed three earned runs or less in six of 10 starts from June 5 through July 27, a brief stretch that left both he and the team hopeful that the last resort of surgery had been avoided. But Cherington said Lackey's elbow flared again later in the season, noting that he even changed his pitching style during a Sept. 25 start in New York and prompting the recent examination by Dr. Lewis Yocum in Los Angeles. "Based on the combination of the symptoms, the physical exam of Yocum and the new MRI, Yocum felt like it was probably time to consider surgery," Cherington said. "And John agreed. Over the course of the season it deteriorated a little bit more. It kind of reached a point at the end of the season where he felt he couldn't be the guy he wants to be."
As something was wrong with his elbow at the time of the second MRI, and it was similar to the first, it's safe to say something was amiss when Lackey signed. But before you get too upset about that, remember, the Red Sox built a provision into the contract just in case something like this occurred. Lackey's deal has a sixth year in it that triggers when he misses significant time due to a pre-existing elbow condition -- missing a year qualifies as "significant time," so the Sox will likely have Lackey under contract in 2015 for the league minimum, taking some of the sting off of his average annual salary (as well as wiggle room under the luxury tax), and giving them a potentially productive year they wouldn't have got out of them had he avoided surgery.
Pitchers can still pitch -- and well -- with a damaged UCL. Adam Wainwright, who had Tommy John surgery before the season started, had a tear in his UCL that occurred in 2004, but scar tissue that formed over it allowed him to pitch with the injury, as Corey Dawkins and I discussed at Baseball Prospectus back in February:
In pitchers, the UCL often very slowly tears from the inside out, starting with the deepest layers of the ligament. The majority of the fibers could still be intact and there might be very slight looseness, but it can still be stable. By strengthening the muscles surrounding the joint -- specifically the flexor pronator mass that lies directly over the UCL -- forces that were once transferred directly to the ligament can be decreased as they are absorbed through other structures. This can be done with very small tears, often with positive results for many years.
That seemed to be what happened back in 2004, when Wainwright suffered a partial tear of his ligament. It is likely that it partially tore on the undersurface, but it wasn't loose to the point of causing further injury to either the ligament or other structures in his elbow, and thus was deemed stable. It was this combination of scarring, strengthening, and proper mechanics explained above that allowed him to return to pitching at a very high level-as mentioned Wednesday, Wainwright threw nearly 900 innings after suffering this small tear.
It's not the best idea to bet on someone with a busted UCL pitching well, but it does happen, and the Red Sox provided themselves with a provision to protect themselves. The unexpected bit that hurt them was that Lackey landed somewhere in between "too hurt to pitch" and "just healthy enough to take the mound" in 2011: the result was not just a sub-par Lackey campaign, but the worst season for a starter in Red Sox history. Following that, there was no choice but to forego trying to pitch through it, and attempt to get his elbow fixed.