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Chris Sale Tommy John Q&A Heezy 1323 It has been reported that Chris Sale of the Boston Red Sox will undergo UCL reconstruction surgery, also known as Tommy John surgery. Sale has not pitched in a live game since August 13, 2019. He then went on the Injured List on August 17 and did not return for the remainder of the 2019 campaign. He was reportedly seen at that time by several of the best-known US surgeons who care for pitchers and a decision was made to hold off on surgery, and instead try a platelet rich plasma (PRP) injection. He finished the 2019 season with a 6-11 record and ERA north of 4.00, significantly below the standard he had established throughout his excellent career. This is on top of the fact that Sale has yet to even begin his 5-year, $145 million contract extension. Sale will now miss whatever portion of the MLB season is played this year, as well as potentially some part of the 2021 season. A number of questions can often surround a decision such as this, so let’s cover a few things that readers may find helpful. (Disclaimer: As per the usual, I am not an MLB team physician. I have not examined Sale or seen his imaging studies. I am not speaking on behalf of the Red Sox or any other team. This article is for educational purposes only for those who might want to know more about this injury/surgery or about how these types of decisions get made.) Question 1: What is this injury? How does it occur? The ulnar collateral ligament (or UCL) is a strong band of tissue that connects the inner (medial) part of the elbow joint. (Figure 1) Though it is relatively small (about the size of a small paper clip), it is strong. The native UCL is able to withstand around 35 Nm (or about 25 foot pounds) of force. However, by available calculations the force placed on the elbow when throwing a 90mph fastball exceeds this, at around 64 Nm. How, then, does the UCL not tear with each pitch? Fortunately, there are other additional structures around the elbow that are able to ‘share’ this load and allow the UCL to continue to function normally (in most cases). The flexor/pronator muscles in the forearm are the most significant contributor. The geometry of the bones of the elbow also help. In many cases, the UCL is not injured all at once (acutely), but rather by a gradual accumulation of smaller injuries which lead to deterioration and eventual failure of this ligament. When the ligament is injured, it obviously does not function at 100% of its normal capacity- in which case the other structures around the elbow are required to ‘pick up the slack’ in order to continue throwing at the same speed. This is why when a pitcher reports a ‘flexor strain’, there is concern that the UCL is not functioning properly – the muscles of the forearm are being forced to work overtime to compensate for a damaged UCL. There are also cases where the ligament does fail suddenly. These are often accompanied by a ‘pop’ and immediate significant pain. Question 2: What do players report as the problem when their UCL is injured? Most commonly, players report pain with throwing at the inner part of the elbow as the most pronounced symptom. However, other symptoms can also be present including loss of throwing control/accuracy, inability to fully move the elbow, swelling, numbness or tingling of the hand and more. Symptoms can be significant almost immediately, or they can begin very subtly and slowly increase over time. Once they have reached higher levels of baseball, most players are aware of this type of injury (thanks to efforts toward education for coaches, athletic trainers and others) and are able to recognize symptoms and report them to the appropriate personnel. Question 3: Once the player is concerned about an injury to the UCL, what happens next? Most commonly the player will be examined by an athletic trainer or team physician to assess the injury and direct further treatment. Often, xrays will be performed of the elbow to assess the bones of the elbow joint for any abnormalities. There can sometimes be bone spurs, small fractures, bone fragments or other findings on these xrays. However, much of the time the xrays are normal and an MRI may be performed to further assess the situation. An MRI allows us to see the soft tissues around the elbow in addition to the bones. Specifically, we are able to look more closely at the actual UCL itself, the surrounding muscles as well as get a closer look at the nearby bone. (Figure 2) The MRI helps the treatment team get a sense of the integrity of the ligament, which allows for the next step in the process: deciding how to treat the injury. Question 4: How are UCL injuries treated? This is where the challenges often really begin. Much of the time, the UCL will appear abnormal on MRI. There are a handful of grading systems that are used to classify these injuries (one of which, incidentally, I helped create), though there isn’t one that is universally used or agreed upon. Generally speaking, they try to separate injuries into those that are partial tears or complete tears and also try to identify the specific location of the damage. The damage can occur at the upper end of the ligament (called the humeral end), the middle (called midsubstance) or at the lower end of the ligament (called the ulnar end). In those cases where there is a complete tear of the ligament (meaning that the ligament is no longer in continuity and attached at both ends), there is near universal agreement that surgery is typically necessary to allow that athlete to return to competitive throwing activities. The problem, however, is that most MRI’s show a partial injury to the UCL. These injuries can be extremely difficult to predict how they are going to respond to a chosen treatment. In addition, athlete A can have an MRI that looks much more abnormal than athlete B, yet the symptoms of athlete B are substantially worse. This is the basic cause of the uncertainty as it pertains to treatment for this injury. There has been tremendous research performed attempting to quickly identify ways to reliably separate those throwers that are going to need surgery from those that will not. Indeed, with pitchers such as Sale, there can be tens or even a hundred million dollars plus at stake. However, to date there is not a perfected method that can be used for every athlete to make this surgery vs. no surgery decision. Question 5: What non-surgical options are available? There are primarily two non-surgery options available to these athletes, and I’ll attempt to briefly cover them here. A) Physical therapy- the commonly used ‘rest and rehab’ method. This is probably the most important component of any treatment plan, and a good therapist who has specialized training in the care of overhead athletes is critical. Often, the athlete is prescribed rest from throwing in order to allow the UCL an opportunity to ‘settle down’ any inflammation and perhaps perform some healing of the injured tissue. In addition, as we discussed above, the muscles of the forearm contribute to stability of the elbow joint. Strengthening these muscles (along with a number of other muscles throughout the body) contributes to ‘protecting’ the UCL from further injury. As the recovery progresses, a return to throwing program is initiated, usually starting with a small number of throws from a short distance and gradually progressing to longer throws with greater effort and eventually throwing from the mound (for pitchers). This hopefully results in a more well-balanced and mechanically sound athlete who is more evenly distributing the forces of throwing across the various anatomic structures involved. B ) Platelet rich plasm (PRP)- This is a product that is obtained from the athlete’s own blood which is drawn and then spun in a centrifuge to separate the blood into its components. The portion of the blood which contains the platelets is then taken and injected at the site of injury to the UCL. This injection includes a number of chemical signals (called cytokines) that regulate healing and inflammation (along with many other things). The injections are thought to help with healing of these partial UCL injuries. The available data on this is mixed, with some studies showing improved results with PRP and others showing no difference. In the linked study, the rate of ‘successful’ non-surgical treatment was 54% (including both PRP and non-PRP athletes). Question 6: How is the decision to proceed with surgery made? This is probably the most challenging part of the evaluation process of UCL injuries. There are a tremendous number of factors which play a role in this decision. These include the specific characteristics of the athlete (such as age, position, role, contract status, stage of career, desire to continue playing and several others); exam and imaging findings (understanding that these are frequently ambiguous); as well as response to previous non-surgery treatment (to name a few). Often more than one expert opinion is sought, particularly when it is a big name/big contract player. Usually, surgeons will speak with a number of people when considering options including the athlete and family, team doctors and staff, team officials, and other experts (who may or may not have seen the patient themselves). In my experience in these situations, the vast majority of the time there is a consensus amongst those involved how best to proceed. Occasionally there will be differing opinions, in which case the athlete often has to make a choice on how to proceed. Question 7: Why didn’t Sale just go ahead with surgery last fall? I suspect that this is a question that many Red Sox fans are wondering about right now. As discussed above, these decisions are typically difficult and have many contributing factors. While it may seem as though ‘rest and rehab’ never works and everyone should just go ahead and have Tommy John surgery at the first sign of trouble, that is not really borne out in the data. There is some variance depending on the definition of ‘successful return to play’ used in any particular study, but for the most part the rate of success of Tommy John surgery in pitchers is around 80-85%. That means about 1 in 5 never make it back to pitch. This may not seem like bad odds, but I submit that your opinion might change if it was your elbow (and livelihood/contract) at risk. As they say, hindsight is always 20/20. In the case of Sale, I suspect that the season being shortened by the unusual circumstances of coronavirus this year likely also played a role. Once it became clear that a full season would not be played, the decision may have been easier. I think I’ll stop there for now (if anyone has continued to read this far…). If people are interested in technical aspects of how the surgery is performed, please let me know in the comments an I’d be happy to do another post about it. I have spare time currently, as you might imagine. Stay safe everyone, and please listen to the medical professionals who are trying to help us combat this virus. It is a serious threat to our way of life, and we need to treat it as such in order to minimize the damage. Thanks for reading.

In November, the Minnesota Twins added five players to their 40-man roster. One of those players was right-handed pitcher Dakota Chalmers. This past weekend at Target Field, we caught up with the hard-throwing 23-year-old about the whirlwind of his career since joining the Twins in August 2018.Dakota Chalmers was drafted in the third round of the 2015 draft by the Oakland A’s. A highly-touted prep pitcher from Georgia, he signed a seven-figure signing bonus, more than twice the slot number for the 97th overall pick. Immensely talented and strong-armed, Chalmers recorded a lot of strikeouts and a lot of walks. He missed time due to injury. When he returned to Beloit in 2018, he made two appearances and walked eight and struck out ten batters in five innings. He was pitching hurt. Soon after, he had Tommy John surgery. Back home in Georgia, what happened next was completely unexpected. In late August, he was traded to the Twins in exchange for veteran reliever Fernando Rodney. “It wasn’t remotely on my mind at all. I was out sweeping leaves off my back porch when they called me.” Chalmers continued, “It didn’t really settle in until I had all that handled and I was in Ft. Myers rehabbing. And then it was such a smooth transition. Fortunately I was so busy, I didn't have time to think about anything.” There were some difficult logistical changes following the trade. He didn’t know anyone in the Twins organization. He got to Fort Myers to continue his rehabilitation from surgery. Fortunately (or unfortunately, however you chose to look at it), there were several Twins minor leaguers there rehabbing from elbow surgery. “It helps to have guys who have had it already. It’s nice to know you can help and encourage your teammates. It’s such an up and down process. I think it’s good to have players around each other. For me, it’s nice to have guys go through things with you, as much as it sucks. It’s something that’s part of our game, you deal with it and get back as soon as possible.” But for the most part, everything went well throughout his rehab process. He said that there weren’t any physical setbacks in his rehab. Sure, the schedule would have had him throwing for the first time during the holidays, but it was just pushed back as there was no rush. Just before the Florida State League All-Star break, he was added to the Miracle roster and began his rehab with the GCL Twins. On July 2nd, he went 1 1/3 innings. He faced ten batters and gave up six runs (five earned) on two hits, a walk and two hit batters. All four outs were strikeouts. The results didn’t matter at all. He was back on the mound. He made three more starts in the GCL and gave up just one run on six hits over 12 innings. On July 30th, he was added back to Miracle roster and made his first official start in about 15 months. Of course, even that couldn’t be easy. “My first real game, there was lightning everywhere. Everywhere. Every lightning bolt, we thought it would get cancelled. It was a little distracting. Obviously I was a little nervous just getting back into the swing of things. It was a mess. It got cancelled after one inning. It was crazy, but I settled in and had a strong finish to the year.” He went four innings in his next start and then threw at least five innings in his final three starts of the year. In those starts, he gave up three runs (two earned) on nine hits in 16 1/3 innings. He walked seven, but he also struck out 23 batters. And with his stuff and those final starts, he earned a promotion to Double-A Pensacola Blue Wahoos and he made one playoff start. He threw three no-hit innings. “It was certainly fun pitching in that environment.” He had worked a total of 34 2/3 innings, so the Twins sent him to the Arizona Fall League. Along with just accumulating innings, Chalmers had some goals in mind, including finding more consistency. “Historically in my career, I’ve had ups and downs in starts. I would have a good start, bad start. I had about three or four good, not great,but quality starts to end the year with the Miracle. So I was really just trying to not focus on making any adjustments, just trying to ride out my first season, stay healthy and see how many good ones I could stack on top of each other.” He continued, “Then we ran into some troubles late in the Fall League and those were mechanical problems that we knew that we had to fix. The Fall League was about pitching more innings, and the offseason was for fixing those issues.” Chalmers started the championship game for the Salt River Rafters, helping the team to the Arizona Fall League title. At the end of November, Chalmers received the call that he had been added to the Twins 40-man roster. It hadn’t been something that he had thought about throughout the season and in the rehab process. “I wouldn’t say that I really even thought of it. I was more focused on getting back on the field healthy. I knew it was going to be a short year coming off of Tommy John. I had an inclination that I might go to the Fall League at the beginning of the year. My goal was to finish the Fall League healthy and get a good start on spring training. The 40-man was more of a timing thing. It was out of my control. I pitched as well as I could, had some ups and downs, and that’s what they chose to do.” Chalmers has big-time stuff. He is certainly one to watch especially as his first-full season is set to begin with big-league spring training in a couple of weeks. Chalmers has a big arm. His fastball gets good movement and he throws it anywhere from 92 to 97 mph. He has a curveball that can be sharp.Some days, his best pitch is a changeup with good fade and drop. He spent his offseason back home in Georgia. He worked on adding a cutter. He also worked on throwing strikes.He spent time in the weight room too. “Trying to strengthen my core and lower half so I could stabilize my delivery. Keep my head online and throw my strikes.” He was invited to Twins Fest and enjoyed the opportunity.”It’s cool seeing some faces that you only have seen on the TV, and that’s always cool. Any time you can expand your baseball community, and the baseball world is such a small world. Any time you can add another name to that list it’s good, to have somebody on your side. ” After all the ups and downs, in about two weeks, he will head to Ft. Myers and report to his first big-league spring training. ------------------------------------------------ Get to know more about Dakota Chalmers and about 170 other Twins prospects in the 2020 Minnesota Twins Prospect Handbook. It is available in paperback or PDF(for immediate download). Order your copies today! 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As the Twins get ready to finish up the four game series against the Blue Jays, Michael Pineda will take the mound for what will be his 4th start of the season. The early returns of his two-year contract have looked good so far as he was another cheap, low-risk signing by the Twins new management during the 2018 offseason. As we’ve seen how shaky our bullpen can be, much of the Twins success this year will rely on their starters and specifically could depend on what version of Pineda they get. Pineda exploded on the scene in 2011 with the Mariners as an All-Star and finished 5th in Rookie of the Year voting. Unfortunately, that success was short lived as he spent all of the 2012 and 2013 seasons recovering and rehabbing from a shoulder injury, which can be a career ending or altering injury for a pitcher. Prior to this injury he featured fastball that sat at 95 miles per hour, used an above average slider as his out pitch, and mixed in a circle change-up about 6-percent of the time. Brooks Baseball did count 23 “sinkers” in 2011 (and 36 for his career), but that’s not enough data to glean anything meaningful from and is likely a misinterpretation of the pitch that was actually thrown. After two lost seasons and a trade to the New York Yankees, Pineda finally returned to the mound for 509 innings from 2014 to 2017 before a partially torn ulnar collateral ligament required Tommy John Surgery and miss a season and half. In his time with the Yankees, his velocity never completely rebounded sitting at about 94 miles per hour and his slider didn’t have quite the same bite. Despite this his K-BB percentage held steady and converted in to a ground ball pitcher, although the added ground balls hurt his ERA a little bit which is evident by his xFIP being almost a full run better than his ERA. Velocity and movement are the two things that make a pitcher effective, but can also be less effective after a pitcher returns from an arm injury which has help us set some “norms” for what we we’re looking for from Pineda. To give it to you straight, the small sample we have on Pineda in 2019 looks good up front but the peripherals should leave you a little tentative. First thing that sticks out is that his fastball is sitting at 92 miles per hour, which isn’t too surprising as he is still getting back into things after recovering from Tommy John, but is something to definitely keep an eye on if he starts to get hit. As far as his other pitches go, his slider has much less movement than in years past but his circle change has the same velocity and movement as usual. Consequently, he has reverted back to a flyball pitcher which has flipped his ERA and xFIP by about half of a run. On the other hand, his K-BB rate is the best of his career and he’s been having success because hitters are making contact on pitches outside of the zone significantly more than usual (71.8 percent in 2019 versus 57.1 percent for his career) which leads to less walks and weaker contact. It’s way too early to jump to any conclusions on these figures, but it something to keep an eye as he gets back into the swing of things after a year and a half hiatus. Over his next few starts, the two big things to look at are his fastball velocity and how much “help” he’s getting from the opposing hitters. These tendencies should give you an idea on how the rest of the season will look for Pineda.

Twins Daily Roundtable is a weekly series. As part of this series, a question will be posed to the site’s writers and they will respond in 200 words or less (Some writers don’t like to stick to this limit). This will give readers an opportunity to see multiple points of view and then add their own point of view in the comments section. There has been plenty of discussion in Twins Territory about Minnesota’s decision to not call-up Byron Buxton for the end of September. In doing so, the Twins are going to gain an extra year of team control. Some feel this is unfair to the player. Some feel it is the team utilizing the rules to their advantage. This week’s question is: “Do MLB and the Player’s Union need to revisit the service time rules as part of the next collective bargaining agreement? Why or why not?”John Bonnes I like linking free agency to service time as a professional player instead of service time as a major league player. I'm cautious because it could conceivably be a radical change, encouraging teams to move players through the minors at a rushed pace, but that might be a positive development. Both sides could embrace that change because it will result in players making it to the majors more quickly (and thus getting paid more) but teams could get more years of control at the major league level. I would think there would be three areas to negotiate: Different tenures of service time based on how a player signs, so 16-year-old international prospects have a higher threshold than amateur draftees, which are higher than college draftees. Something like 12 years/10 years/8 years. This is important for teams.An escalating level of compensation once a player is in the majors that leaves them close to their actual free agent value by the end of their service time, similar to arbitration, but with required changes. This is important for players.Perhaps modifying the service time based on the quality of the player? So exceptional players can make it to free agency a year earlier? I'm not as sure about this aspect, but I expect this would be important for agents.Tom FroemmingYes, the player's union needs to find a way to counteract the adjustment modern front offices have made. Teams know that even the very best players are rarely wise investments once they've surpassed 30. Accordingly, they've stopped throwing out big, long-term contracts to most free agents. At the same time, the system has been set up to suppress the earning potential of younger players and front offices are getting, let's say more creative, in the ways they're finding to delay a player reaching arbitration/free agency. Basically, the owners are winning on both ends of a player's career. Maybe the solution is something as simple as dramatically increasing the league minimum, which was $545,000 this season, or maybe they can find a way for players to reach arbitration/free agency earlier by updating the service time rules. The big issue in the short term seems to be that the current Collective Bargaining Agreement, which just went into effect last season, is in effect through 2021. With that being the case, it's difficult to see the owners to have any urgency to concede anything, unless there's (gulp) a strike. Jeremy Nygaard Absolutely it's time for the rules to be revisited. The problem is that there isn't a great solution. Do you change it from six years of service time to something like six seasons of control after a player's debut? Or five seasons? Can it be only based on a player's age? Or some other counting stat? It's going to be difficult to find a way that a club can't continue to manipulate... but it definitely has to happen. Cody Christie Service time rules will change as part of the next Collective Bargaining Agreement. There was one simple solution I saw during the entire Buxton-saga. After a team drafts a player, they get: High school player= 10 years of team control, 6 years of arbitrationCollege player= 8 years of team control, 6 years of arbitrationEven if a player hasn’t made the MLB level, he would still qualify for arbitration. Some hiccups in this rule would come from international signees. Would teams get 12 years of team control with the final six years being part of the arbitration process? Injuries also present an interesting predicament. If a player misses an entire year because of Tommy John surgery, what would be the options for a team? Could teams get something like a “red-shirt” year where they get an extra year of control because of a season-long injury? Changes are coming but the owners aren’t going to give up too much team control. Steve Lein I definitely think it will be a big part of the discussion on the next CBA. There are always going to be problems (including plenty that could be pointed out with my thoughts below), but there are a couple things I dislike about what is done now: 1. Time on the disabled list counts toward service time. 2. A year of service equates to a full-calendar MLB season. There aren’t many players who play all 162 games in a season, but to get a full year a player is required to be active the entire time. I would look to have only active MLB roster days count, and a full year of service be a number like 120 days. A pitcher needing Tommy John surgery may have only pitched 2 games but earns a full year of service, while another guy who plays 130 games in the field doesn’t. The math is off to me. I don’t like to penalize injuries to a player, but that’s another wrinkle for the player’s union to tackle. This way, teams have a much harder decision to make about keeping players in the minors to “gain” an extra year. Instead of a couple weeks and still getting a guy like Kris Bryant into 151 games during the season (how was that NOT a “full season”?!), it’s a couple of months and maybe 100 games. Something that can really affect a team’s aspirations for the season if that player could be a big part of it. Most of all, I will never understand a rule that keeps potential superstar players, and other deserving ones, off an opening day roster. That is what is beyond stupid to me with the current rules. Ted Schwerzler When looking at the current CBA, how it’s interpreted, and how it’s exploited, I think it’s absolutely fair to question the validity of the current situation. In the case of Byron Buxton, Minnesota is well within their means, but it’s a situation that looks unethical and reflects poorly on the team. When comparing millionaire players and billionaire owners, fans should always side with the product on the field. At the end of the day, there needs to be a better representation when it comes to the Player’s Association and the ideals that are fought over. Common ground can be found here, but there’s opportunity for it to land in more of a middle ground than it currently does. Seth Stohs Does it need to be changed? Probably. Am I smart enough to know what the best system would be? Nope. Will teams try to find the loopholes and ways around whatever a new system might be? Absolutely. SD Buhr I have to imagine that service time is a part of virtually every CBA negotiation and I’m sure that will be the case on the next one, too. I don’t think anyone should expect major adjustments to the current system, though. There almost has to be a line drawn somewhere and wherever it’s drawn, owners are going to do what they can to preserve as much control over a talented player’s salary as possible. Any change that works more to the union/player advantage will come with a cost, of course. The players’ side will need to give up something and I’m not sure this issue has affected enough players to a significant degree that the other 98% of the union membership will be willing to give much to get better terms. I do think the next CBA negotiation is going to be far more challenging than the past couple have been. Draft slotting, international pay limits and almost every issue affecting payroll have all been tilted heavily toward ownership lately and I sense that players are going to negotiate much harder on any number of issues. I could see the owners giving a bit on service time in order to avoid get what they want in other areas of greater priority. If you missed any of the most recent roundtable discussions, here are the links: The Looming Mauer Decision Grading the Front Office Grading Molitor Closing Time Prospect Promotions Click here to view the article