Saturday, July 12, 2014
Inquirer Daily News

Rotator cuff surgery still eluding modern science

(AP Photo/Jeff Roberson)
(AP Photo/Jeff Roberson)

Mark Mulder is coming back to baseball, and here come the feel-gooderies.

"It's fitting that it's with the Angels too, one of the teams in baseball so obviously linked to a film. Because if Mulder, 36, can pull this off, it will be a tale for the movies. Even if he doesn't, it'll still be the most intriguing comeback story of the 2014 baseball season."

--Mike Oz, Big League Stew

It's a bit of a stretch to compare Joseph Gordon-Levitt just wanting his family back, Danny Glover rage-throwing a rack of bats, and Mark Mulder returning to baseball in real life, but it’s a comeback story! It doesn’t need to make sense!

Anxious as we are to begin threading the narratives for 2014, Mark Mulder hasn’t quite had his story optioned by a studio just yet, though with his minor league deal with the Angels, he is closer to pro ball than a lot of us thought he would ever be again. When news surfaced that the 36-year-old Mulder who packed in his chewed up rotator cuff and left baseball in 2008, was planning a return, the obvious jokes flew that the Phillies were interested in the starter, having a need for pitching and an endless soft spot for veterans with injury-riddled histories.

Just before Christmas, Mulder worked out for a small gathering of teams, one of which was, in fact, the Phillies.

So, what can an aging hurler staging an improbable comeback expect to accomplish? What can the team who signed him look forward to – and how glad should we be that it wasn’t the Phillies?

The rotator cuff is the name given to the collective of muscle surrounding the bones and nerves in the shoulder that make the arm move away from and back toward the body, which, if you’ve ever seen a pitcher throw, is paramount to the basic principles of their profession. Therefore, tearing it is hugely detrimental to a career. While baseball players are common victims of the malady, it shows up in anybody whose career involves a lot of repetitive arm waving, from cheerleaders, to weight lifters, to orchestra conductors. But in any case, a rotator cuff tear, like a recurring night terror, is something people just simply don’t want to talk about.

"The cuff is made up of muscles, tendon… you can’t fix it as well as Tommy John," says Justin Shaginaw, a Philadelphia physical therapist and athletic trainer. "A lot of times they’ll have to reconstruct. Those sort of surgeries [Tommy John] tend to go a lot better."

Here’s a story on rotator cuff surgery – which Mulder has undergone twice – that is simply titled "You don’t want this." Even the the handful of baseball executives who they got to stomach an interview on the topic couldn’t avoid grimacing.

"It's frightening to hear those words… when I hear rotator cuff tear, obviously you get really worried and you're concerned about a guy's future. It's definitely a very severe injury now as much as it was in the past." – Former Astros GM Tim Purpura

"The statistics show pitchers often don't return to their customary level." –Royals GM Dayton Moore

The most alarming part is that, unlike a UCL (Ulnar Collateral Ligament) issue in the elbow requiring Tommy John surgery, rotator cuff surgery remains too complex a notion for modern science to catch up. 

"If you look at those two areas, with respect to the elbow, in terms of the nature of the injury, the UCL is the ligament with a very good blood supply to it," says the Phillies' team physician, Dr. Michael Ciccotti. "That good blood supply can help that to heal."

The shoulder, where the rotator cuff lives, does not have as plentiful a blood supply, limiting the healing capabilities after surgery.

Dr. Ciccotti has not only been with the Phillies for two decades, but also served as the head of the MLB Team Physician Association, while being very involved with research in this area. His findings have helped uncover something even more alarming: depending on how the injury happens, a rotator cuff issue may lull a player into a false sense of security, as it can initially improve their pitching.

"What we think is that some of the changes that occur in the rotator cuff, partial fraying or straining or even partial tearing, may actually be adaptive," he says. "Some of the changes that we see in these structures allow that pitcher more shoulder flexibility; that allows them to throw a ball with greater velocity."

32-year-old Jesse Crain, also recovering from rotator cuff surgery, has gotten a deal with the Astros for 2014. Crain's got a few years on Mulder, and half the rotator cuff surgeries, but he's recent proof that comebacks aren't impossible from this deceptive ailment. Mulder's return, however, was said to require a more "creative" contract with a Major League team.

As we reach into the baseball void of mid-winter and pull out threads connected to nothing, "comeback stories" look all the more inspiring. But Mulder's just may not last very long, given the nature of his injury.

"Somehow he’s defying the odds, because they are definitely stacked against him," Shaginaw says. "He was changing his mechanics, so whether it’s that, whether he did rehabilitation to correct some underlying problems that were causing this shoulder issue, or he’s just really lucky... My guess is if he comes back and pitches, it’s not going to last very long. He’s reached the mileage on that shoulder, and even if he comes back, it'll be for maybe a season."

There is a reason Mulder is a low risk - with incentives, his deal will be around $6 million. The Angels, simultaneously in mid-pursuit of Masahiro Tanaka, have space and money to gamble. The Phillies are pushing their aging core for the win in 2014, once again blaming injury, not decline, as the reason for an offensive slip in 2013 (and 2012). Of course, failing to acknowledge that an increase in injuries is a likely sign of decline is a bit of willful ignorance, but... hey. They are also no stranger to the injury. Pitching prospect and former 2014 rotation contender Adam Morgan was diagnosed with a small rotator cuff tear in June, and continues to recover.

Fortunately, while the rotator cuff stays ahead of the curve, Dr. Ciccotti says that science isn't far behind.

"We're learning more and more about the injuries that occur in these athletes putting huge forces through their elbow and their shoulder," he says. "We're learning how to hopefully better diagnose them, better treat them non-operatively, or if they need surgery, better surgically treat them, and how to rehabilitate them post-surgery more thoroughly. But ultimately, we might be able to prevent them from occuring by identifying them early on so that we can eliminate the need for any surgical treatment and a long absence from a sport."

"The results of our treatment are improving because we have a better concept of this whole amazing activity of throwing the ball," Dr. Ciccotti concludes.

"Rotator cuff" remains, for the time being, a phrase any GM should be wary of, and teams' interest in Mulder despite his past injuries is a testament to his initial talent. It's a great story, but for now, medical science seems to know how it ends.

Justin Klugh Philly.com Sports
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