CINCINNATI -- The St. Louis Cardinals' four starting pitchers without the tell-tale scar of membership on their pitching elbow sat recently on their side of the Busch Stadium clubhouse discussing with a reporter something they hope they never have.
That was when Joe Kelly pierced the conversation with one word.
Tommy John surgery, he said, is inevitable.
"Everyone is going to get it one day," Kelly explained, leaning back in his chair as Shelby Miller, Michael Wacha, and Lance Lynn looked at him. "In the end, Tommy John is like death. It's going to get you."
Once a novel and miracle surgery that saved a few careers, the ligament replacement procedure that baseball knows as Tommy John surgery has become a ubiquitous presence in the game, as familiar as it was once revolutionary, just like the designated hitter or sabermetrics.
The parade of pitchers going for the operation already this season has become so long that baseball writers have used words such as "epidemic" to describe it, free of hyperbole. Hardball Times tabulated more than 30 pitchers who have had the surgery in the past nine months, and at least seven of them are having it for a second time.
The ligament replacement surgery and its 12-month recovery period have robbed the game of two of its brightest young pitchers, the Mets' Matt Harvey and just this month the Marlins' Jose Fernandez. Harvey started last year's All-Star Game and Fernandez won the National League's rookie of the year award. In between those honors, the Cardinals' Wacha, every bit as decorated as the other two young lions, won the National League championship series MVP award. Only he remains on the mound.
The Cardinals built last year's run for the National League pennant around young pitchers, and the organization has positioned itself as one of the industry leaders in developing and deploying young pitchers, from Wacha to Miller, Trevor Rosenthal to Carlos Martinez, and prospects Marco Gonzales and Alex Reyes on their way.
Young pitchers are their future, and not Wacha or Miller, Martinez or Reyes has had Tommy John surgery.
Inevitable is unpalatable.
"It is something that the industry cannot ignore," Cardinals general manager John Mozeliak said. "Putting resources to find ways to prevent it should be an all-hands-on-deck strategy... I think the last thing an organization wants to do is be in a position where they're not trying to protect the pitcher, but I don't know if we truly understand how to protect the pitcher."
IN THE BEGINNING
The surgery was invented by Dr. Frank Jobe and first performed in 1974 on Dodgers pitcher Tommy John. The concept was taking a tendon from another part of the body -- the wrist, for example -- and using it to replace a torn or ruptured ulnar collateral ligament. The ligament helps stabilize the joint and when it goes the pitcher used to go with it. Tommy John, the surgery, changed that.
So too did the rehab, which compared to the unknowns of shoulder surgeries and their recoveries is a predictable schedule of about 12 months.
The surgery, like any surgery, isn't foolproof. Experts suggest that 20 percent of the professional pitchers who have Tommy John surgery do not return to their previous ability. The Cardinals have in the past week seen the extremes of the procedure: Former closer Jason Motte returned successfully to the mound almost exactly 12 months after surgery and prospect Jordan Swagerty had to have a third procedure done because he's been unable to return from 2012 surgery. The Cardinals have five pitchers on their current staff, including ace Adam Wainwright, who have had ligament replacement surgery and returned to the majors. A sixth Cardinal, outfielder Matt Holliday, also has had Tommy John.
The Braves had three pitchers before mid-April need it this season.
That is anecdotal evidence of the alarming spike in Tommy John surgeries baseball has had in the last decade, and especially in the past five seasons.
In the seminal Game 6 of the 2011 World Series, the Cardinals got more than half of their 11 innings from pitchers who had or would soon have Tommy John surgery. That group included the starter (Jaime Garcia) and the eventual winner (Jake Westbrook). Of the 15 pitchers used by Texas and the Cardinals in that game, eight had had or now have had the elbow surgery.
Hardball Times writer Jon Roegele found of the 677 pitchers who appeared in a regular-season game last summer, at least 135 of them had had Tommy John surgery.
Will Carroll, an injury expert who writes for Bleacher Report, calculated the rate at one-in-three for the pitchers who started last season. The rate shocked him, but "worse," he wrote, "none of us had any idea when this change had happened or noticed the acceleration."
"It's rampant," Cardinals manager Mike Matheny said. Asked if it's become, as Kelly suggested, inevitable, the former youth-league coach added: "With as big and strong and fast as guys are getting, yeah it almost seems like it's kind of the thought process: 'I'm going to go until I blow and then I'll get a tuneup, and then let it fly again.' "
THE BIG QUESTION: WHY?
There are many theories for the rise in Tommy John surgeries.
Baseball reportedly is poised to invest in studies to unravel reasons behind so many ligaments coming undone. Technological and medical improvements in the past decade -- such as the clearer scans taken of elbows that reveal tears and wider availability of MRIs -- have to be a leading cause. Overuse often is cited. Youth focusing on one sport instead of the cross-training of yore is another common suggestion. The increased strength and focus on throwing with more velocity and more movement is mentioned as a possible root cause.
"With the physical strength players have today and the amount of torque they're putting on their elbow the amount of strength required to maintain, to hold up under the day-to-day rigors of throwing 90-mph-plus fastballs is a lot," Mozeliak said. "It may be too much. It's a fragile ligament. I don't think anybody knows how to strengthen the ligament before you begin the process. You strengthen muscles before you do anything, but not the ligament."
That hints at one approach the Cardinals have adopted in hopes its preventative.
The reality of an injury to a pitcher is such that it's virtually a given, and it is reflected in contracts. The Cardinals have drafted a player after he had the surgery (John Gast), traded for a pitcher coming back from Tommy John (Westbrook) and rewarded a pitcher (Wainwright) just back from Tommy John with the richest contract ever for a Cardinals pitcher. Mozeliak said signing long-term deals with pitchers "is a matter of probability. Few tend to go cradle to grave without something. You need to bake-in some DL time."
The club took great care last season to wrap Wacha and, to a lesser extent, Miller in virtual bubblewrap at times to protect them from overuse, strain. The Cardinals chart pressure-filled innings for their young pitchers, knowing that the wear from all pitches and all innings are not created equal. Miller and Kelly recall a policy that yanked them from low-level minor-league games if they had a single inning of 30 pitches.
While former team physician Dr. George Paletta, an accomplished Tommy John surgeon, helped the Cards craft their rehab program, they also have looked into what protective steps can be taken. Mozeliak described how the Cardinals have "an internal belief and approach of having a balanced body." The starters have between-appearance maintenance work that stresses total-body flexibility and strength, not just arm strength. The idea being that the more even the strength is the less strain it will put on the weakest link, be it ligament or something else. The trainer staff is constantly testing flexibility, range of motion and strength.
"We've looked a lot at it," Mozeliak said. "There's no silver bullet."
Such measures started young for the youngest of the pitchers the Cardinals are counting on. Miller did not throw a curveball until high school, and his adviser once expressed displeasure when he had 160 pitches in a game. Wacha's father didn't allow him to throw a curve until he was an upperclassman in high school, even when the young righty pleaded that his peers were doing it. He was just fine and healthy working with a fastball changeup.
Though they couldn't argue against it, both flinched when Kelly spoke up.
They'd rather not wait for the inevitable.
"That's just... scary," Miller said. "I don't even want to think about it."
That's OK. Everybody else around him is.
-- St. Louis Post-Dispatch