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http://espn.go.com/mlb/story/_/id/13185173/velocity-puts-fernandez-elbow-risk
MIAMI -- Before he underwent Tommy John surgery on his right elbow more than 13 months ago, Miami Marlins ace Jose Fernandez enraptured the baseball world with a fastball that was among the best in the game.
In 2013, when he was named NL rookie of the year, his fastball averaged 94.9 mph, third best among MLB starting pitchers, according to FanGraphs. Naturally, his fastball was scouted heavily during his rehab outings as a measure of assessing his recovery. The fact that he flashed fastball speeds of 95-97 mph out of the gate had fans excitedly clamoring for his MLB return, which will happen Thursday at Marlins Park against the San Francisco Giants.
EDITOR'S PICKS
Let's hope all is well with Jose Fernandez
Thursday's return of the hard-throwing Marlins ace will be met with both excitement and anxiety, since he'll be doing the very thing that led to Tommy John surgery more than 13 months ago.
Sutcliffe: How slider hurts Fernandez's elbow
But that electric velocity is accompanied by increased stress across the elbow joint, a fact not lost on Dr. Neal ElAttrache, who repaired Fernandez's elbow. ElAttrache, a renowned orthopedic surgeon of the Kerlan-Jobe Clinic in Los Angeles and team physician for the Los Angeles Dodgers, has performed numerous TJ surgeries but sees young flamethrowers such as Fernandez as a higher risk subset due to the force they are capable of generating.
That potential risk is precisely why ElAttrache insisted the progression of Fernandez be controlled both in terms of time and volume, although he was making excellent progress in rehab and never experienced a setback.
"Jose has been doing great throughout his rehab," ElAttrache said. "But," he added, "there was no reason to accelerate his return. Even an extra month matters."
In addition to the subset of younger pitchers whose elbows failed them last year, another even more concerning statistic manifested itself: the marked increase in revision (repeat) TJ surgeries. As outlined here in April, the number of revision TJ surgeries performed in 2014 accounted for more than one-third of the number of total TJ surgeries. One-third of those revisions were players who were fewer than three years removed from their original procedure.
Those revision statistics further contributed to the caution exercised with Fernandez throughout his rehab course.
"With the recent increase in not only ligament tears but re-tears [of the graft], the concern is trying to match the graft maturation to the stress imparted on it," ElAttrache said. "The harder he throws, the more mature you want the graft."
There are currently no absolutes about what constitutes the "perfect" window of time for a pitcher to return to the mound following TJ surgery; the process is still evolving as medicine works to better understand the injury and subsequent rehabilitation. Individual timelines with increasing variability are being established as teams take into account a player's particular set of circumstances, including, but not limited to, the health of his elbow (whether the ligament injury was isolated within an otherwise pristine joint or whether there were significant degenerative changes present), other arm concerns (such as prior shoulder problems), pitching history (types of pitches thrown, years and volume of pitching) and other potential risk factors.
Progressions are based on medical staff evaluations and observations combined with player feedback. Once the decision is made to ramp up to a major league outing, the hope is that the process leading to that point has been sound.
Even then, there are no guarantees against setbacks, even minor ones. After undergoing TJ surgery in 2010 and returning one year later, Detroit Tigers pitcher Joe Nathan, then with the Minnesota Twins, was sidelined again within weeks with a flexor strain. (Nathan came back after a month and went on to pitch successfully for five years until he re-tore his ulnar collateral ligament this spring. He has since undergone revision surgery). Washington Nationals ace Stephen Strasburg, perhaps more comparable to Fernandez in terms of age at the time of his TJ surgery and also a higher velocity thrower, returned for his first full season in 2012 but later had to undergo surgery more than a year later to remove debris from the elbow. St. Louis Cardinals pitcher Adam Wainwright underwent a similar procedure two years following his return from TJ surgery.
This is not to suggest doom and gloom for Fernandez by any means. In fact, Strasburg, Wainwright, Nathan and many others have returned to deliver solid seasons following their original surgery. Subsequent "cleanup" procedures are not altogether surprising and may simply be a byproduct of adaptations of the elbow following UCL reconstruction.
To date, there has been nothing but positive chatter about Fernandez in terms of his rehab and recovery. And he appears to have been a model patient, exercising restraint at the advice of those in charge of his care. By his own admission, patience is not a characteristic that comes easily to Fernandez.
"The one thing I never had is patience," Fernandez said, "but I had to learn. Dr. ElAttrache helped me because he would explain everything about how the process worked. Then, I understood."
The Marlins' medical staff, front office and Fernandez all believe he is now ready to take the next step. ElAttrache concurs: "There appears to have been a reasonable amount of time. Jose has been progressively ramping up, building volume."
Now comes the big moment for Fernandez, a return to the major league mound. After more than 13 months away, the excitement and the emotion will feel different. Just ask Arizona Diamondbacks pitcher Daniel Hudson, who who underwent two elbow surgeries before returning to the major league mound last September after his original graft tore during rehab. Hudson told ESPN's Pedro Gomez that his first outing was anything but a standard turn in the rotation.
"It was tough to fight back the emotions of the night," Hudson said. "I felt like I was making my debut again."
While getting through that first MLB outing is significant, it isn't the end of the recovery process. Fernandez is likely to be held to a pitch count in his first outing similar to that of his final rehab start (approximately 90). There will be a debriefing after Thursday's game -- and again the next day -- to discuss how his arm is working and how it's feeling. Fernandez will get at least two starts under his belt and then benefit from the rest imposed by the All-Star break. With each progressive outing, his pitch count will gradually go up, and his confidence in the arm will do the same. His routine will eventually shift from that of a pitcher who is recovering to one who is simply preparing for his next start.
And at some point along the way, if all continues to go well for Fernandez, stepping on the major league mound will start to feel like just another day at the office.
In 2013, when he was named NL rookie of the year, his fastball averaged 94.9 mph, third best among MLB starting pitchers, according to FanGraphs. Naturally, his fastball was scouted heavily during his rehab outings as a measure of assessing his recovery. The fact that he flashed fastball speeds of 95-97 mph out of the gate had fans excitedly clamoring for his MLB return, which will happen Thursday at Marlins Park against the San Francisco Giants.
EDITOR'S PICKS
Let's hope all is well with Jose Fernandez
Thursday's return of the hard-throwing Marlins ace will be met with both excitement and anxiety, since he'll be doing the very thing that led to Tommy John surgery more than 13 months ago.
Sutcliffe: How slider hurts Fernandez's elbow
But that electric velocity is accompanied by increased stress across the elbow joint, a fact not lost on Dr. Neal ElAttrache, who repaired Fernandez's elbow. ElAttrache, a renowned orthopedic surgeon of the Kerlan-Jobe Clinic in Los Angeles and team physician for the Los Angeles Dodgers, has performed numerous TJ surgeries but sees young flamethrowers such as Fernandez as a higher risk subset due to the force they are capable of generating.
That potential risk is precisely why ElAttrache insisted the progression of Fernandez be controlled both in terms of time and volume, although he was making excellent progress in rehab and never experienced a setback.
"Jose has been doing great throughout his rehab," ElAttrache said. "But," he added, "there was no reason to accelerate his return. Even an extra month matters."
In addition to the subset of younger pitchers whose elbows failed them last year, another even more concerning statistic manifested itself: the marked increase in revision (repeat) TJ surgeries. As outlined here in April, the number of revision TJ surgeries performed in 2014 accounted for more than one-third of the number of total TJ surgeries. One-third of those revisions were players who were fewer than three years removed from their original procedure.
Those revision statistics further contributed to the caution exercised with Fernandez throughout his rehab course.
"With the recent increase in not only ligament tears but re-tears [of the graft], the concern is trying to match the graft maturation to the stress imparted on it," ElAttrache said. "The harder he throws, the more mature you want the graft."
There are currently no absolutes about what constitutes the "perfect" window of time for a pitcher to return to the mound following TJ surgery; the process is still evolving as medicine works to better understand the injury and subsequent rehabilitation. Individual timelines with increasing variability are being established as teams take into account a player's particular set of circumstances, including, but not limited to, the health of his elbow (whether the ligament injury was isolated within an otherwise pristine joint or whether there were significant degenerative changes present), other arm concerns (such as prior shoulder problems), pitching history (types of pitches thrown, years and volume of pitching) and other potential risk factors.
Progressions are based on medical staff evaluations and observations combined with player feedback. Once the decision is made to ramp up to a major league outing, the hope is that the process leading to that point has been sound.
Even then, there are no guarantees against setbacks, even minor ones. After undergoing TJ surgery in 2010 and returning one year later, Detroit Tigers pitcher Joe Nathan, then with the Minnesota Twins, was sidelined again within weeks with a flexor strain. (Nathan came back after a month and went on to pitch successfully for five years until he re-tore his ulnar collateral ligament this spring. He has since undergone revision surgery). Washington Nationals ace Stephen Strasburg, perhaps more comparable to Fernandez in terms of age at the time of his TJ surgery and also a higher velocity thrower, returned for his first full season in 2012 but later had to undergo surgery more than a year later to remove debris from the elbow. St. Louis Cardinals pitcher Adam Wainwright underwent a similar procedure two years following his return from TJ surgery.
This is not to suggest doom and gloom for Fernandez by any means. In fact, Strasburg, Wainwright, Nathan and many others have returned to deliver solid seasons following their original surgery. Subsequent "cleanup" procedures are not altogether surprising and may simply be a byproduct of adaptations of the elbow following UCL reconstruction.
To date, there has been nothing but positive chatter about Fernandez in terms of his rehab and recovery. And he appears to have been a model patient, exercising restraint at the advice of those in charge of his care. By his own admission, patience is not a characteristic that comes easily to Fernandez.
"The one thing I never had is patience," Fernandez said, "but I had to learn. Dr. ElAttrache helped me because he would explain everything about how the process worked. Then, I understood."
The Marlins' medical staff, front office and Fernandez all believe he is now ready to take the next step. ElAttrache concurs: "There appears to have been a reasonable amount of time. Jose has been progressively ramping up, building volume."
Now comes the big moment for Fernandez, a return to the major league mound. After more than 13 months away, the excitement and the emotion will feel different. Just ask Arizona Diamondbacks pitcher Daniel Hudson, who who underwent two elbow surgeries before returning to the major league mound last September after his original graft tore during rehab. Hudson told ESPN's Pedro Gomez that his first outing was anything but a standard turn in the rotation.
"It was tough to fight back the emotions of the night," Hudson said. "I felt like I was making my debut again."
While getting through that first MLB outing is significant, it isn't the end of the recovery process. Fernandez is likely to be held to a pitch count in his first outing similar to that of his final rehab start (approximately 90). There will be a debriefing after Thursday's game -- and again the next day -- to discuss how his arm is working and how it's feeling. Fernandez will get at least two starts under his belt and then benefit from the rest imposed by the All-Star break. With each progressive outing, his pitch count will gradually go up, and his confidence in the arm will do the same. His routine will eventually shift from that of a pitcher who is recovering to one who is simply preparing for his next start.
And at some point along the way, if all continues to go well for Fernandez, stepping on the major league mound will start to feel like just another day at the office.
the pride of Northern Virginia 
