The Arm (4 page)

“That's high-tech art right there,” Conte whispered. “Notice how quiet it got? Everyone knows this is technically difficult.”

The drill buzzed and emerged with a bloodied bit. It was 11:31. A normal Tommy John surgery takes seventy-five minutes. This had already gone twice as long, and it wasn't close to done. Dustin Volkmer, a surgical fellow at Kerlan-Jobe, continued filming the procedure and snapping pictures with an iPhone. ElAttrache couldn't remember another revision with a blown flexor mass, so he wanted to document it for future such cases, rare though they may be.

“Graft,” ElAttrache called. Quinn retrieved it from the bean-shaped pan. ElAttrache tugged at it. Still nothing. “Fat part of the graft,” he said.

Then, finally, movement.

“Here it goes,” ElAttrache said. “Here it goes.”

The room perked up.

“A little oil?” he said. “I do not want to break this thing.”

Quinn, the nurse, squirted a dab of mineral oil where graft met tunnel. The tendon started to slide.

“Whew!” ElAttrache said.

Sutures pulled the graft through the ulna and out the second hole. ElAttrache looped it into the humeral tunnel and used two more sutures to guide them down their respective paths. He measured where he needed to trim the tendon so it would fit perfectly, detached both ends from the suture sherpas, and removed it from Coffey's elbow.

No longer was the allograft white. Blood covered it as ElAttrache began trimming it to size. He admired the finished product. “I love the length,” he said. After using the titanium chamfer to smooth the ulnar tunnel, ElAttrache once again slinked the tendon through, this time for good. He knotted the sutures strong and true.

The hard part was over. At 12:12, just as the Dodgers were about to take the field a few miles away, ElAttrache tied the final three knots. He lifted Coffey's limp arm in the air with the help of two others. He bent it at the elbow and rotated it in and out,
like Coffey does on every pitch. If the graft slacked, ElAttrache would need to start over.

“OK,” he said, “feel that.”

“Whoo!” Shin said. “That's tight!”

ElAttrache sutured the new UCL to the remaining shreds of the old one. A suction tube drained away a river of blood. Every few minutes, Quinn cleared blood clots and tossed them into a biohazard wastebasket nearly filled to the brim. ElAttrache moved down to the flexor mass, the muscles that connect the elbow to the wrist, and began to fix their torn tendon and reattach them. The dried blood on his gloves was almost black. He took a deep breath and groaned. “My ass is numb,” ElAttrache groused.

He had been parked in the same swivel chair for three hours. ElAttrache gently carried the ulnar nerve to its new location, away from the bone and protected by subcutaneous fat, a precaution to keep it away from bone chips that could develop, sever the nerve, and leave the hand useless.

ElAttrache hooked the first stitch to close Coffey's wound at 12:48. He cinched the final one six minutes later. After nearly four hours, Todd Coffey had a new arm.

J
ENNIFER COFFEY SAT IN THE
chair closest to the waiting-room door, glancing at it every few minutes, hoping ElAttrache would walk through and assure her everything had gone well. She played a slot-machine app on her iPad to pass the time. Her whole morning felt like a game of chance.

She was a newly minted baseball wife, five months pregnant but barely showing. She felt that awful cocktail of nerves and fatigue. Coffey had kept her up most of the previous night, asking rhetorical questions, catastrophizing—the dead guy and what comes next and life without baseball and on and on and on.

“You think one thing,” Jennifer said, “and your mind takes you further and further into the future. Not just now, but once
he starts playing again. How many years does he have left to play? He has to be precise and particular and so careful. One more thing goes wrong and he's done. I don't know if anyone has had a third Tommy John. I think the more it happens, the less likely you are to return.”

It wasn't just his career causing her the agita. Where would they have the baby? Pasadena, where they moved for the summer? Phoenix, where Coffey would rehab? Milwaukee, where she grew up? Rural North Carolina, their offseason home? Their wedding gifts were in Wisconsin still, and she wasn't going to be able to travel soon, and—she stopped midsentence. The door into the waiting room opened. ElAttrache and Stan Conte appeared.

“He did great,” ElAttrache said.

She sighed.

“He has a very big graft,” ElAttrache said. “The only issue was I wasn't able to use his own tissue. It was precariously short. And I could see through it. It was a little bitty thing. This was much better tissue.”

“On my son, in that circumstance, I would've used the allograft,” Conte said. “I think that's the best chance for him to get back. It really is.”

“The allograft—is his body going to accept it?” Jennifer said.

“When you transplant his own tendon, there are still some living cells that emit chemical signals to attract blood vessels and things like that,” ElAttrache said. “The same thing is going to happen on this, in the environment it's in, because it's a very vascular environment. That process may be a little slower. We don't know that clinically, but we think it's correct. It's definitely safe tissue to use. And it works.”

“So,” Jennifer said, “when will he be back?”

“I don't see this being a twelve-month return to competition,” ElAttrache said. “And based on the time of the year, the chances of him making it back for next season aren't good. He just needs more time.”

Jennifer would deal with their onerous year ahead soon enough. After nearly five hours, she just wanted to see her husband. She thanked ElAttrache and Conte and headed back to the recovery area, where Coffey, supine on a bed, was regaining consciousness. He wore a hospital gown and booties on his feet. He would leave two hours later with pain meds to be taken every four hours. Best of all, his fingers weren't at all numb from the handling of the ulnar nerve.

The first question Coffey asked Jennifer wasn't about the dead guy. He knew it had been likely, and he'd get used to it. Nor was it about the rehab. His relentless optimism told him he would be back in twelve months, and so he'd aim for twelve months. And it wasn't about the baby, or how Jennifer was feeling, or where they would move, or anything of that ilk. Like Neal ElAttrache, Todd Coffey was a man who kept his promises. And the day his elbow failed, he had made a promise to his teammates that he'd never forget them. Not even Propofol could break it.

He looked at Jennifer, smiled, and asked: “What's the score?”

D
OCTORS CONSIDER TOMMY JOHN SURGERY
one of the most successful medical procedures ever because it solved a problem. When an elbow ligament tore, it could be fixed. Baseball rejoiced. “We thought elbows were solved,” former Red Sox general manager Ben Cherington said. “So we stopped thinking about them.”

Because an answer for elbow issues existed, the sport never bothered to concern itself with the root cause of such injuries. Maybe it was mechanics, the way a player throws the ball and its effect on his body. Perhaps it was usage, the volume of pitches or innings in a single game, over a whole season, or even longer. Certainly a player's genetic makeup could factor in, too, or how hard he threw, or what pitches he preferred, or his between-start workouts, or his diet, or any other sort of measurable factor.

Tommy John surgery, it turned out, was a paradox, the procedure that worked too well. It lulled baseball into a false sense of security, and by the time the sport realized what had hap
pened, an epidemic was on its hands. Elbows are breaking more than ever and younger than ever. And while the rash of Tommy John surgeries that spread across Major League Baseball over the last five years took out some of the game's finest pitchers, children ages fifteen to nineteen make up a disproportionately high number of patients. Baseball is thus left scrambling to figure out how to keep its million-dollar arms healthy while fixing a feeder system that keeps sending damaged goods to major league teams.

“It's a huge issue,” said Rob Manfred, Major League Baseball's commissioner. “You know why it's a huge issue? Because that's a competitive space, and the single biggest competitive advantage baseball has in that space is the fact that it may be the safest sport your kid can play. It still doesn't mean that we don't have a responsibility to make the play of the game as safe as possible for kids. And we do. We take that seriously.”

Over the last two decades, baseball's youth apparatus has been filched and privatized, and the single-sport-specialization craze has transformed the game. The best players spend most weekends year-round traveling to tournaments across the country. They participate in so-called showcase events, in which maximum-effort throws and pitch velocities that light up radar guns separate the elite from the rest.

In hindsight, the results were predictable. Stephen Strasburg, the right-hander with a 102-mph fastball who shattered signing-bonus records out of college, blew out his arm twelve games into his rookie season with the Nationals. More big names followed: New York Mets ace Matt Harvey, Miami Marlins wunderkind José Fernández, Texas Rangers star Yu Darvish.

Latin American countries, where the best kids spend their early teen years playing baseball for a living so they can cash in with bonuses at sixteen, were hardly spared: Iván Nova and Danny Salazar from the Dominican Republic, Martín Pérez and Carlos Carrasco from Venezuela, even José Contreras, the forty-year-old Cuban. Every day, it seemed, another went down. During one
two-week span early in the 2014 season, nine players underwent Tommy John.

The number one pick in the draft two months later, Brady Aiken, didn't sign with the Houston Astros because of an abnormality in his elbow and eventually needed Tommy John. Two more first-round picks in 2014, Jeff Hoffman and Erick Fedde, were chosen despite their blown-out elbows, and potential number one picks in 2015 (Michael Matuella) and 2016 (Cal Quantrill) underwent Tommy John while still in college. “It's almost like it's a sci-fi film where they're going to take the best and the brightest with a light ray coming down,” Oakland Athletics GM Billy Beane said. “The ligaments remaining are the ones you don't necessarily want pitching for you.”

Arm injuries are nothing new. In the days of three hundred– and four hundred–inning seasons, plenty of pitchers were injured. Sports medicine, in its nascent stages, had next to no understanding of how the arm worked. Salaries were minuscule, and the cost of losing a player was negligible. Today, the science for progress exists. It's lunacy to call arm injuries the cost of doing business when the business loses hundreds of millions of dollars as a result of them annually. Baseball nevertheless has fostered an environment in which all thirty teams treat pitchers' health as proprietary information instead of banding together to solve the sport's greatest mystery. “Teams are hesitant to invest because they think they're going to seed the money and then everyone is going to share in the information,” New York Yankees president Randy Levine said. Competition gets in the way of the greater good, greed in the way of greater health, and any advances that could rejigger the system at lower levels stay in-house. “This is one where you need the it-takes-a-village approach,” Beane said. “We've got to stop pretending we know the answers. Because whatever we're doing doesn't seem to be working.”

As injuries piled up, teams panicked and started treating their best young players with kid gloves. In 2012, the Toronto Blue
Jays sent their three top pitching prospects—Noah Syndergaard, Aaron Sanchez, and Justin Nicolino—to Class A Lansing. Syndergaard looked like a Nordic god, six feet six and 240 pounds, all muscle and blond hair. Sanchez was a six-foot-four twig with lightning in his right arm. Nicolino typified the command-and-control left-hander who kills batters softly.

For their first five starts of the season, each was limited to three innings pitched. This seemed senseless. No studies showed that unusually short outings keep pitchers healthier long-term. The restrictions felt similar to the thinking that limits most current major league starters to around one hundred pitches: a guess. I emailed then–Blue Jays general manager Alex Anthopoulos and asked why the team was handling young arms with restraint bordering on alarm.

“Overall, there's not much science to what we do,” he wrote. “Just being overly cautious with our young arms. We have no evidence that shows it's the right way to go but we prefer to err on the side of caution.”

Never before had I heard Anthopoulos, a studious sort whose analytical bent helped him land his job, admit to making a choice about vital pieces of his franchise's future with “no evidence.” He personified a game spending a billion and a half dollars a year on something it didn't understand.

Baseball is a constantly evolving sport, challenging itself and its entrenched beliefs with rigorous self-examination. The current trend toward defensive shifts stemmed from a simple, epistemological question: What is a position? No boundaries define it, so why confine players to certain areas when the numbers show hitters deposit balls in certain pockets more often than others? The game struggles more with macro questions. It's why baseball has now settled on the reductive strategy for handling pitchers: throw them less. The fallacy of treating something as unique as a pitcher's arm collectively may be the acme of baseball senselessness.

Here's the truth: they're scared. And maybe they should be. A new generation of kids raised in travel-ball and showcase culture is throwing harder than ever, and the results are troublesome. “UCL reconstruction is becoming a victim of its own success,” wrote Brandon J. Erickson, an orthopedic surgeon, for the
American Journal of Orthopedics
, “as younger and younger athletes who will likely never play at the major league level are undergoing this procedure at an alarming rate.”

For a 2015 paper, Erickson used a supercomputer to access a private medical database that cataloged five years' worth of injuries. He typed in code 24346—UCL reconstruction with a tendon graft—and found 56.8 percent of cases were performed on teenagers. Surely some suffered from delusions of grandeur, others from overeager surgeons, but the reality of the numbers frighten those in baseball who understand what's happening.

This problem is only getting worse.

A
T A YOUTH-BASEBALL COMPLEX SOUTHEAST
of Phoenix, a ten-year-old boy named Harley Harrington stood on top of a mound and twirled pitch after gorgeous pitch. Harley's motion was a study in biomechanical beauty, his legs driving efficiently, his hips swiveling at just the right time, his non-throwing arm tugging down and pulling through his torso, and his right arm unfurling so smoothly it looked machine-taught. His peers chucked the ball; Harley delivered it.

He came here in March 2015 from San Diego with a traveling baseball team called the Show, which recruited some of the best ten-and-under kids in Southern California to compete in high-level tournaments like this one, the Spring Championship Super NIT in Gilbert, Arizona. Hundreds of other teams in all age groups, some as young as seven years old, came from around the country to feed the excesses of American youth baseball personified by the Big League Dreams complex. Built near a farm, it reeked of
cow dung. Local politicians still kick themselves for spending more than $40 million to develop the campus for the private company that runs ten more such facilities across the West Coast.

Four fields, each built in the scaled-down image of a famous major league stadium, surrounded a central hub of video games, flat-screen TVs, bad food, and, most important, copious beer. The taps started flowing around eight a.m., when some fathers lubed themselves to forget they'd been conned into traveling hundreds of miles for games that just as easily could've taken place ten minutes from their houses. The youth baseball–industrial complex can hypnotize even the most mindful.

Nicola and Martin Harrington never expected to find themselves in a facility like this. Nicola once was a pop star in England whose band, the Simon Cowell–backed Girl Thing, fizzled amid great hype. Much of the drama involved Nicola's secret relationship with Martin, a music producer. They married, had Harley, left England, and ended up in Los Angeles, where a friend of Martin's told him that now that his boy was American, he needed a baseball glove. Harley fell in love with the game and showed enough aptitude that he craved better competition.

All Martin knew about the United States' travel-sports industry—whose estimated revenues now range from $7 billion to far more—was that it seemed crazy. Not just the cost of hotels or the time away from work, all so a kid could play at a novelty stadium or win a cheap championship ring, but the children on other teams who cowered in fear of criticism from their parents.

Three former number one overall picks in Major League Baseball's draft had played for the Show: National League MVP outfielder Bryce Harper and two pitchers, Stephen Strasburg and Brady Aiken, both of whom bear scars on their elbows. While Harley started as an outfielder, his coaches quickly recognized the fluidity with which he threw a ball. Pitchers spend a lifetime trying to look as natural pitching as Harley did the first time he stepped on a mound.

“Having been around some really good players in our program, sometimes we single out kids who remind us of others,” said Hector Lorenzana, one of the Show's longtime coaches. “We had the privilege of having Bryce Harper since he was eight and a half, nine years old. We see flashes in things kids do at certain ages. And it reminds you of other players who have come through. Harley is one of those.”

At the Spring Championship Super NIT, whose champion qualifies for an even bigger tournament later in the year at Disney World, the Show ran roughshod through its bracket to reach the semifinals, where it unleashed Harley. He mixed fastballs and off-speed offerings, all from the same release point, each pitch faster and crisper than his peers'. Harley exited in the fourth inning after fifty-two pitches, well short of the tournament limit of eight innings with no maximum pitch count. Martin always kept track of how many Harley had thrown, and when the Show squeaked out a victory to get into the finals, he approached Lorenzana about Harley's availability for the next game.

“Going in the same day back-to-back,” Lorenzana said, “is a huge no-no for us.”

And yet Martin Harrington, conscientious enough to download an app to track his son's usage, a voracious enough reader to realize that the rash of Tommy John surgeries points back to excessive and unnecessary throwing by children, wanted his son to pitch in the final game, if need be.

“It's not like it was the morning and there was a four- or five-hour gap,” Martin said. “To me it was about two hours, and he'd thrown fifty pitches. I thought it wasn't a problem to throw twenty more. Honestly, I don't think the Show is going to abuse a kid to win a medal. That's not how they're going to do it. But he had more left in him. Harley is one of those kids where he has unfinished business. He doesn't need to show them he's the best. But I think he felt shortchanged in the semifinals. I knew he wanted to go out there and finish it off.”

Another coach lobbied Lorenzana, too, pointing to Harley's parents. “Look at the mom! Look at the dad!” he said. Both were pictures of fitness. Also working in Harley's favor was that unlike almost every top travel-ball player, he actually took time away from baseball, spending his summers in England or playing club soccer. The single-sport-specialization malady that affected kids across the US landscape did not apply.

Still, nobody knew. Not Lorenzana, not Nicola or Martin Harrington, not the doctors urging coaches and parents to pump the brakes on excessive use. Nobody could say whether putting Harley in for a second time would cause damage years down the road. Every kid and every arm is different.

At 4:15 p.m., in the fifth inning of a blowout game the Show led, about two and a half hours after he had last pitched, Harley Harrington went back out to win a tournament for a group of ten-year-olds.

“If it was anyone other than Harley, we'd have shied away from it,” Lorenzana said. “There are some horses you're going to ride a little longer. There's no science. There's no process. You just don't know.”