Shohei Ohtani, the Los Angeles Angels’ two-way wunderkind, left his start against the Astros on Sunday after a third-inning velocity dip and will likely require Tommy John surgery to correct a torn UCL. That means Ohtani is done pitching not just for the rest of 2018 but probably for all of 2019 as well. Ohtani, by virtue of being an international superstar as both a pitcher and a hitter, is one of very few athletes who can accurately be called unique and is one of the most exciting, fussed-over, and important players in the game. The UCL is the most fussed-over body part in baseball. So the most scrutinized piece of connective tissue in baseball, if not all of American sports, has failed.
“The ulnar collateral ligament (UCL), a stretchy, triangular band in the elbow that holds together the upper and lower arms, plays no favorites. If you throw a baseball, it can ruin you,” Yahoo Sports columnist Jeff Passan wrote in his book The Arm. That one of baseball’s best and most prominent national writers would devote a monograph to this tiny piece of tissue underscores its importance. The UCL is not designed to withstand the repeated violent overhand motion required to pitch a baseball, doubly so for modern pitchers, who, like thoroughbred racehorses, have outgrown their ligaments. As a result, UCL replacement, known as Tommy John surgery, has become almost routine, and the 12-to-18-month layoff it requires has become part of the pattern of a pitcher’s career.
Ohtani had minor UCL damage when he came to the United States a little less than a year ago, but an MRI of most pitchers’ elbows would reveal some damage to the ligament, and until June Ohtani’s underlying injury was only of minor concern. In June, Ohtani went on the disabled list with a more severe sprain of his UCL, and while he returned to the lineup as a DH in the meantime, he didn’t pitch until this past Saturday, when he lasted just 2 1/3 innings against the Astros.
It’s not a guarantee that Ohtani will get surgery soon — there’s been no announcement yet, and hours after it was revealed that his UCL injury had worsened, Ohtani not only started at DH but went 4-for-4 with two home runs, a walk, and a stolen base. But if he does get surgery, he’ll most likely miss all of next year and head into 2020, the last year of Mike Trout’s contract, having thrown just 51 2/3 innings in the majors. But in a perverse way, the Angels are lucky Ohtani aggravated his elbow injury when he did, because he came very close to missing not just all of 2019 but most or all of 2020 as well.
Tommy John surgery isn’t career threatening anymore, but it’s an enormous inconvenience, particularly for Ohtani and the Angels, who are trying to put together a competitive team before Trout’s contract is up. Because losing a pitcher for a year and a half can cause a team’s plans to founder, players and their clubs have tried to find ways to avoid Tommy John and return from a torn UCL in less time. Last year, Royals reliever Seth Maness became the first pitcher to return to the majors with an internal brace on his UCL, a surgical procedure from which he recovered in just nine months. Others have opted to treat moderate sprains and strains with platelet-rich plasma injections, which have been used to promote healing in other connective tissue injuries.
The results of PRP injections as a treatment for a UCL injury are mixed. In 2014, Masahiro Tanaka had a PRP injection, came back in two months, and has held up just fine since. Aaron Nola had a PRP injection in August 2016, came back the following April, and has been one of the best pitchers in baseball since his return. But according to the Tommy John database compiled by Hardball Times writer John Roegele, about half of the UCL cases treated with PRP — a list that includes a few position players — ended in Tommy John surgery anyway. Some pitchers cut a year or more off their return time, while others turned one lost season into two by delaying the start of the recovery process.
Sometimes, a PRP treatment is augmented by an injection of stem cells. Roegele’s database includes just six such cases out of more than 30 total PRP treatments, but four of those six patients, including Ohtani, were Angels pitchers; in fact, every single Angels pitcher who’s had his UCL injury treated with PRP has also gotten a stem cell injection.
Assuming Ohtani goes under the knife, five of those pitchers — Ohtani, Andrew Heaney, Garrett Richards, J.C. Ramírez, and Rubby De La Rosa — will have ended up getting Tommy John surgery anyway. The sixth, former Padres minor leaguer Yimmi Brasoban, had a PRP and stem cell injection after the 2016 season, returned in June 2017, and after 22 appearances and a 4.71 ERA in Double-A last season, is out of organized baseball. He’s currently pitching for Napa of the independent Pacific Association.
Richards received a stem cell injection in May 2016 but didn’t pitch in the big leagues that year. When he returned at the start of 2017, after an 11-month layoff, he lasted less than five innings before leaving the game with nerve irritation in his biceps and wasn’t heard from again until September.
All told, Richards made one start in the 15 months after his stem cell injection and just six within the standard 18-month recovery window. Richards threw 104 innings in 24 big league starts before he got his elbow ligament replaced this July. And he’s the lucky one — neither De La Rosa nor Ramírez made it 10 big league innings before his UCL gave out, and Heaney didn’t make it back at all. He had Tommy John surgery just two months after his stem cell injection without ever returning to action. Tommy John surgery requires a longer recovery time than PRP injections and sometimes requires revisions, but the replacement UCL usually lasts the better part of a decade before it gives out.
The scarcity of not only these cases but the information about them makes it difficult to draw conclusions. Because teams are cagey about players’ medical information, which in any other industry would be entirely confidential, it’s hard to know the true extent of any of Ohtani’s three elbow injuries. Or, for that matter, what Angels GM Billy Eppler meant when he said Ohtani’s MRIs came back “clean” during the rehab process. It’s also tough to draw medical inferences of any kind about Richards, who has a Job-like medical history: In addition to elbow and bicep injuries, Richards suffered a season-ending patellar tendon tear in 2014.
However this is what we do know: The Angels are essentially the only team that’s used stem cell therapy to treat UCL injuries, and through four cases, it hasn’t worked. Luckily for the Angels, and for Ohtani, they lost nothing by pursuing their particular approach to UCL injury treatment. If Ohtani had undergone Tommy John surgery in June, he still probably wouldn’t have been ready to pitch in 2019, and even now, he ought to return to the mound by opening day 2020 and to the batter’s box well before that.
The worst case scenario wasn’t Ohtani’s elbow ligament failing after 49 pitches, it was that Ohtani’s elbow ligament would last another four or five starts to close the 2018 season, then fail in the spring of 2019, as Ramírez’s did, costing him the bulk of two seasons on the mound rather than one. Ohtani’s likely surgery isn’t catastrophic — rather, it represents the narrow avoidance of catastrophe.