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Talkin’ with Tucker

Lanning Tucker, promoted this season to assistant athletic trainer and rehabilitation coordinator for the Minnesota Twins, has rehabbed 20-to-25 pitchers from the elbow ligament reconstruction surgery over the years.
Tucker, 47 and a San Antonio, Tex., native, earned his bachelor of science degree in health education, psychology and athletic training at Texas A&M University. He earned his Master’s Degree in Sports Medicine at the United States Sports Academy.
Tucker answered these questions with The News-Press:
Q: How does Tommy John rehab work?
Tucker: Players who have undergone ulnar collateral ligament reconstruction are rehabbed following the protocol that is established by the treating physician.
Q: What are the different benchmarks and milestones that you look for?
Tucker: The rehab progression is dictated by the treating surgeons rehab protocol. Typically, the player is braced initially and the rehab process starts with restoring appropriate range of motion. Once the appropriate range of motion is restored and following the players specific rehab protocol, the player’s strength is restored before beginning a return to throwing program.
Q: How different is the process from one pitcher to another? For example, does it become apparent that one patient will respond quicker to rehab than another? When that happens, how do you adjust?
Tucker: Several factors make the rehab process different with players who have undergone ulnar collateral ligament reconstruction. The player’s medical history, surgery outcome, and work ethics are factors that determine their outcome. Adjustments are made to their exercises and throwing progression as needed under the guidance of the treating surgeon and help from the Pitching Coaches.

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Imagine moving your forearm forward so fast it would spin, if the elbow were unhinged, 20 times in one second.

That’s the best example Dr. Luke Oh, a consulting physician to the Boston Red Sox from Massachusetts General Hospital in Boston, could give when describing the stress pitchers place on their elbows.

The stress stems from bringing the elbow to a sudden halt and can lead to problems with the ulnar collateral ligament, the rubber-band-like tissue that partially or completely can tear. Reconstructing the ligament with a tendon, often extracted from either a tendon in the forearm or the hamstring muscle in one’s leg, is called Tommy John surgery, named for the first pitcher to undergo it in 1974.

“The deceleration of the arm is quite a significant amount of stress to put on the elbow,” Oh said. “Not just the elbow, but the shoulder and the entire upper extremity.”

The Minnesota Twins and Boston Red Sox know about trying to prevent and care for pitchers when it comes to that injury. Each team has a starter projected to be held by pitchers who have L-shaped, Tommy John scars on the inside of their elbows.

Boston’s John Lackey and Minnesota’s Mike Pelfrey joined a rough list of 488 other professional pitchers to have had the surgery since 1974, a list compiled in November by Jon Roegele of SBNation.com.

Kyle Gibson, optioned to Triple-A Rochester on March 14, has the chance to join Minnesota’s big-league rotation sometime this season. He had the surgery Sept. 7, 2011. Twins minor league pitchers Jhon Garcia, Lester Oliveros, Adrian Salcedo and Alex Wimmers each had the surgery in 2012 and are in varying stages of their year-long rehabilitation programs.

Gibson said he experienced more anxiety about his professional future before knowing he would need the surgery than after deciding to have it. Between 94 and 95 percent of pitchers who have the surgery return to competition after it, Oh said.

“For a month and a half, I didn’t really know what was wrong,” Gibson said. “Once I was able to find out that I would have the surgery, there was more comfort where, OK, I’m going to get this taken care of. I knew what’s wrong. I knew why my arm’s hurting. I’m going to get it fixed. I’m going to rehab it. Then I’m going to get back to pitching.”

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The Twins organization had 18 players, or 3.7 percent, of the surgeries on the list compiled by Roegele, ranking in the middle of the pack among the 30 teams. The Boston Red Sox had the second-most in baseball with 26, or 5.3 percent.

“We’ve actually been fortunate to not have had many pitchers go through this,” Twins general manager Terry Ryan said. “Back in the ‘70s, there were hardly any Tommy John surgeries. They were few and far between. It didn’t become a prevalant surgery until the ‘90s. The rehab has changed over time, but we haven’t done anything much different over the past decade.

“It’s all about repetition and rest. Most of the guys we’ve had who have had that surgery have come back to health.”

The pitchers who have the surgery leave the realm of a 25-man roster and instead become part of a three-man team: pitcher, doctor and trainer.

Wimmers did not blame his injury on overuse. It just happened, he said. He turned to Gibson and other Twins who have had the surgery for advice.

“We’re all in this together,” said Wimmers, who pitched for the Fort Myers Miracle in 20010-11. “We all go through pretty much the same program. Everybody’s different. You don’t want to get hurt. But once you get hurt, you have to change your mindset. You have to get better.”

With Wimmers’ elbow, he tried to come back from a partial tear through rehabilitation. Not long after giving up three runs off four hits in two-thirds of an inning last April for a 40.50 ERA with the Gulf Coast League Twins, Wimmers opted for surgery.

With Gibson’s elbow, multiple doctors and trainers had stress tested it, unable to find a definitive tear. He had, in fact, a 70 percent tear discovered in August of 2011.

“If it’s a partial tear, usually we rehab it,” said Oh, who did not treat Gibson but performs the surgery 40 to 50 times per year. “If you fail rehab, then we do surgery. Some people just can’t handle pitching with a partial tear. Their velocity is down. Their control is off. Because the rehab is a year long, you have to be really sure that they’re not getting better with rehab.

(Page 3 of 6)

“At the major league level, if it’s a full tear, then you’re usually having the surgery.”

The pitchers

Lackey, 34, ranks fourth in wins (128), third in games started (294) and third in strikeouts (1,465) since 2002. He also ranks third in innings pitched (1,876) during that span despite missing all of 2012 while rehabilitating.

Lackey had his surgery Nov. 1, 2011, by Dr. Lewis Yocum in Los Angeles.

“You’ve got to be patient,” Lackey said. “There are only a certain amount of things you can do for your elbow a day before you start hurting it. You’re doing probably 70 percent shoulder work, trying to strengthen that to try and protect the elbow when you come back. Your elbow has a better chance. Having to pace yourself is the main thing, because it’s a long process.”

Gibson, 25 and a first-round draft pick out of the University of Missouri in 2009, had just 248 minor league innings on his resume leading to Sept. 7, 2011, when he had his surgery performed by Dr. David Altchek, a consulting physician with the New York Mets.

Gibson, who started seven games for the Class A Fort Myers Miracle in 2010, blamed his injury not on an increased workload but on flawed mechanics.

“Pitching is so mechanical, that if you’re not on, you can put yourself in danger,” Gibson said.

Pelfrey, 29, is tied with new teammate Kevin Correia for 11th place for most starts in the National League since 2008. Pelfrey has started 132 games over the previous five years despite missing most of last season.

That workload took its toll. Dr. James Andrews, a reknown orthopedic surgeon, took a tendon from the former Met’s hamstring muscle in his leg and then grafted it inside the 6-foot-7, 249-pound right-hander’s elbow on May 1 of last year.

Pelfrey, who became a free agent after last season, debated about having surgery. He called his agent, who told him: “If you alter your mechanics, and you end up hurting your shoulder, that’s a gray area. They can fix an elbow. But if you hurt your shoulders, I can’t get you specifics on coming back from that.”

(Page 4 of 6)

“So that backed me off, and I went and got the second opinion,” said Pelfrey, which led him to Andrews.

Lackey, Gibson and Pelfrey had different surgeons. They said a level of trust had to be established before putting their careers in someone else’s hands.

The doctor

Oh, 41, apprenticed under Andrews, learning the surgical techniques from him.

“He’s the best there is,” Oh said.

The lessons Oh said he learned from Andrews went beyond surgical techniques.

“It’s been a fantastic experience working with him for sure, just learning how to talk to people, work with people, what makes people tick,” Oh said. “I wanted to see how he communicates with athletes. It’s all part of the skill set. I learned how professional athletes think. You have to develop a certain level of trust. You have to develop a reputation for taking care of a whole athlete rather than just being a technician to fix an elbow.

“That’s part of the whole equation.”

When the pitcher wakes up from surgery, the doctor will brief him on how the procedure went. Then the doctor passes the baton to the athletic trainer.

The trainer

Pelfrey refused to accept the one-year recovery timetable.

“I went home and had the MLB package,” said Pelfrey, who was in the last year of his contract with the Mets at the time. “I was depressed. I was devastated not to be a part of the team. I didn’t know what to do with myself. After about a month or so, I came to the realization that I couldn’t help out the team right now. My next step was, I’ve got to get back.

“It showed me how much I appreciate the game and how much I love the game, to have it taken away from me. That was how I had it in my mind to get back.”

Pelfrey, a Wichita, Kan., native, enlisted the aid of Rob Manske, an associate professor of physical therapy at Wichita State and a physical therapist.

“From day one, he was such a super guy,” Manske, 46, said. “He did anything I asked him to do. He’s such a motivated guy, he hardly needed me to tell him to do anything.

“He’s had the right mentality from day one. If anything, I needed to slow him down. He wasn’t the kind of guy you had to push. He was going to do it. And if you told him to back off, he would. He was respectful of the process.”

(Page 5 of 6)

Throwing a baseball does not begin in most cases until the 16-week mark.

“I pushed it,” said Pelfrey, who signed a one-year, $4 million contract with the Twins Dec. 20. “I wasn’t going to have a job. My contract was over. My whole thing was, I needed to find a job. So I pushed it. I didn’t take any extra days off. And I felt good doing it. I wasn’t aching or anything like that. I felt great.”

Pelfrey said his hurry played a role in him choosing Dr. Andrews over Dr. Altchek.

“Dr. Altcheck’s protocol is a little slower than Dr. Andrews,” Manske said. “Mike talks about it like he was really pushing the envelope. And he really was. But he was still following Dr. Andrews’ protocol. It’s just a little faster. It’s not totally crazy. It’s just a different philosophy.”

MOVING FORWARD

“I feel great,” Pelfrey said. “If people didn’t ask me about it all the time, I’d feel like I never even had the surgery.”

All three pitchers will be watched by their trainers and pitching coaches, and they will check in with their doctors and trainers as the season progresses.

“The surgeon will continue to follow the athlete and make sure he reaches the post operative milestones,” Oh said. “The staff is critical to get the player back. But the physical therapy is really, really important. They are both so critically important.

“There are examples of athletes who have had surgeries done who haven’t rehabbed correctly. It really is a coordinative effort between the athlete, the surgeon and the rehab team. Everybody has to buy in. There’s teamwork between all three parties.”

Lackey, Pelfrey and Gibson said they bought into that teamwork with their three doctors and three trainers. Now they can carry that attitude forward to their teams.

“It’s definitely great to be back on the mound,” Gibson said. “It’s great to be feeling like I’m part of the team again.”

All three pitchers will be watched by their trainers and pitching coaches, and they will check in with their doctors and trainers as the season progresses.

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WHO IS TOMMY JOHN?

Tommy John’s name has been attached so often with the surgery to reconstruct the ulnar collateral ligament that sometimes people forget his prowess as a pitcher. John, 69, pitched for seven big-league teams between 1963 and 1989.

On Sept. 25, 1974, John underwent the first surgery of its kind by Dr. Frank Jobe to reconstruct that ligament. John finished his career with a 288-231 record and a 3.34 ERA. He made the All-Star game three times after the surgery and once before it. He did not get voted into the Baseball Hall of Fame despite being the first to have the surgery that has revolutionized pitching in professional baseball.

John is retired in New Jersey. He still does motivational speaking presentations and founded the Tommy John Pitching Academy (tommyjohnpitchingacademy.com) He urged pitchers who have the surgery to take a full year to recover. And he urged parents not to have their children pitch year-round in order to try and avoid elbow injuries.

“The number of people who have had the surgery is going to grow exponentially, because you’ve got parents who buy into these year-round training programs,” John said. “They all think their kid is going to be the next Justin Verlander or Roy Halladay. They are the best pitchers in the world. They are the elite.

“Do they throw year-round? No. So why would your son, at age 10, why wouldn’t you want his program to replicate what the best in the world do? We’ve got to stop overuse sports injuries in young people.”

For those who do have the surgery, John urged them to have patience with the recovery process.

“One thing they have not been able to do in 40 years of the surgery is they’ve never been able to speed up the healing time,” John said. “It’s always been 12-to-15 months. Pitchers want to get back out there. I would have wanted to get back out there the next week, if I could have. Earlier doesn’t matter. If you rush back out there, you’re rolling the dice.”

John said when presented with the option of surgery, Dr. Jobe told him there were no guarantees that John could pitch again. John, however, concluded if he didn’t get the surgery, he would have a zero percent chance of pitching again.

“I thought about it for a millisecond,” John said. “I wanted to pitch again.”

Connect with: David Dorsey (Facebook), @DavidADorsey (Twitter).

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