What is happening inside Cliff Lee's elbow?

Dr. James Andrews' phone call to the Phillies yesterday did not bring the good news for which they had hoped. Instead, it was confirmed that the tear in starting pitcher Cliff Lee's common flexor tendon had not progressed since he left a game because of elbow discomfort back in July 2014.

The injury has left Lee with few options, and the often grinning lefthander has even gone so far as to contemplate the end of his career. This is a man who has earned the devotion of fans, teammates, and coaches for his seemingly otherworldly endurance; however, it's that same quality that has left his elbow ligaments straining to repair themselves.

"It's a pretty rare injury to have," Justin Shaginaw, coordinator of sports medicine for Aria 3B Orthopaedics and athletic trainer for the U.S. Soccer Federation, says of Lee's issue. "All the research shows most elbow pain in pitchers is [coming from] the ulnar collateral ligament, which requires Tommy John surgery."

But Tommy John is becoming a young man's game, with more and more recipients of the procedure returning to play without issue. In fact, young starters such as Matt Harvey and Jose Fernandez, who missed 2014 after TJ surgery, probably benefitted from undergoing it now, rather than late in their careers when ligaments are far more worn down – in general, a younger pitcher's body can take more surgery than the body of, say, Cliff Lee.

Lee, at 36 years old, isn't throwing with a 20-year-old elbow anymore, and his injury is yet another indication of not only his advanced career but also his historically deep outings.

"It's an older pitcher's injury," Shaginaw explains, citing a study by Dr. David Altchek, the big name for Tommy John surgery up in New York, in which he compared eight players undergoing Tommy John and flexor tendon issues with players receiving solely Tommy John surgery. "The players with [Lee's injury] were all 30 and above, where the common age for his Tommy John patients was 20.7 years, so it's probably more of a wear-and-tear injury."

Many have theorized that Lee's workhorse demeanor would eventually contribute to his health. Last year was the first time he didn't surpass the 200 mark in innings pitched since 2009, and in 2010, he led the league in complete games. Nobody was complaining in April 2012, when Lee came back out of the dugout in San Francisco to throw a 10^th shutout inning against the Giants (a performance in which he still threw only 102 pitches, 81 for strikes, and the Phillies wasted by losing in 11 innings).

It has been Lee's MO over the years – he's a workhorse, a grinder, who always wants the ball – and while these are cited as valuable assets for a big-league pitcher, they also make it less likely that he will be able to return to the Phillies rotation in the present. In Altchek's study, players with flexor tendon problems rarely came back from surgery; however, some of that was due to their being over 30 years old, which always results in lower return rates.

The theory is that in cases like Lee's injury, they are indicative of one ligament attempting to compensate for stress on another, Shaginaw explains. "In these cases, the ligament is already stretched or loose, but not completely torn. The muscle is trying to stabilize the elbow due to the laxity/looseness in the Tommy John ligament. Over time, the muscle is injured because of it trying to do the work of the Tommy John ligament."

This is something the Phillies in all likelihood know and have tried desperately to smooth over in the past few months. Things must be pretty messy inside Lee's elbow, however, if months of recovery time can pass, yet it only takes two innings to unravel his season.

"Knowing [Phillies head trainer Scott Sheridan] and the Phillies well, I'm making the assumption that they've done their job as far as rehab's concerned and that they've fixed everything that they can fix from a biomechanical standpoint," Shaginaw says, but if Lee is still experiencing discomfort, then Shaginaw concludes, "I can't see him getting better with continued rehab."

It has been the same non-surgical rehab that Ruben Amaro says hasn't worked, leading to surgery as the next option – not ideal for a pitcher in his late 30s. The Phillies are clearly not prepared to throw in the towel on their $25 million investment for 2015, saying that Lee could attempt to "throw through" the issue, a plan that sounds slightly hazardous.

Shaginaw stipulates that "throwing through it" is not a recommended remedy at every stage of the game – "If he were in his 20s, they would have done the surgery already." But in Lee's case, all you can do – as Lee often does – is shrug.

"I think their thought process is at this point, you might as well let him throw through it," Shaginaw theorizes. "And if he can't throw through it and he wants to continue to play, they're going to do the surgery with the expectation of probably pretty low chance of returning to the same level."