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As one of baseball’s most renowned surgeons, Neal ElAttrache feels the angst surrounding the sport.
That injuries are rising at concerning levels. That pitchers, even young ones, are breaking down more often than ever before. That baseball, like other sports where the threat of injuries has grown as players unlock more of their physical potential, is facing an almost existential epidemic from which even big stars haven’t been spared.
“So many guys are getting injured, and the best players in these sports are getting injured too,” said ElAttrache, an orthopedic surgeon for sports medicine at the Cedars-Sinai Kerlan-Jobe Institute and head team physician for the Dodgers and Rams. “It’s making news.”
Amid all that discussion, however, ElAttrache noted a flip side of the narrative that almost gets taken for granted now.
For all the injuries plaguing baseball’s modern era, players are also recovering from them better, and more consistently, than ever.
Andrew Friedman has long wanted to avoid making big decisions at the MLB trade deadline. He might finally get his wish because of the roster he has constructed.
And on Saturday night, at the Baseball Writers Assn. of America’s annual awards dinner in New York, he watched from afar as the sport celebrated some of the best recent examples.
This year, all of the BBWAA’s major four award winners — the MVP and Cy Young in each league — shared a common backstory. Each had once undergone a major surgery performed by ElAttrache earlier in their career. And each, aided by advancements in sports medicine and physical recovery, made it back to the pinnacle of the game.
Aaron Judge, the American League MVP, had shoulder surgery following his Rookie of the Year campaign in 2017. The procedure included loose-body removal and cartilage cleanup, costing him much of that offseason. But it didn’t derail his rise as one of the game’s top sluggers, with Judge hitting an MLB-most 58 home runs last season to earn his second AL MVP in the last three years.
Cy Young award winners Chris Sale and Tarik Skubal had their elbows operated on by ElAttrache more recently.
Sale, a perennial All-Star early in his career, missed all of 2020 because of Tommy John surgery — but has since returned to his pre-procedure heights, culminating in an 18-win season and NL-leading 2.38 ERA with the Atlanta Braves this past year.
Skubal, a burgeoning left-hander with the Detroit Tigers, also recorded 18 wins with an AL-leading 2.39 ERA in 2024 — despite being just two years removed from a flexor tendon surgery that ended his 2022 season.
Then there was Shohei Ohtani, who won the NL MVP award in his debut season with the Dodgers despite still working through his recovery from a second career Tommy John operation (both of which have been performed by ElAttrache). While the two-way star wasn’t able to pitch during the team’s World Series run, he earned his third MVP by recording the first 50-home run, 50-steal campaign in MLB history.
“All four of those were major surgeries,” ElAttrache said last weekend in an interview with The Times. “And what they go through to have this, the psychological and physical toll that they go through, it’s almost a year of recovery until they feel like themselves again. It’s really amazing that these guys are able to do it.”
Equally amazing to ElAttrache, however, is how routine such stories have become in baseball’s current era.
Where Tommy John procedures and major shoulder operations once threatened entire careers, they are now akin to a rite of passage for many big leaguers. And, thanks to medical advancements that have accompanied the sport’s growing injury numbers, many return to action as good — and in some cases, even better — than before.
“It’s become an expected thing that they come back from it,” ElAttrache said. “I think it would be a bigger story now if one of these guys, a big-time athlete, has an operation and doesn’t make it back. That would be big news.”
Like many medical experts around the sport, ElAttrache first began noticing changes in injury trends for pitchers about a decade ago.
Back then, the early integration of advanced data and analytics highlighted the importance of higher velocities and spin rates for pitchers. And before long, cutting-edge training programs (like heavy-ball throwing routines) and more physically taxing pitch shapes (like looping curveballs and Frisbee-esque sweepers) became widely popularized around the sport — especially among youth players who were not yet fully developed physically.
The Dodgers officially welcomed Roki Sasaki in a news conference at Dodger Stadium on Wednesday, and he will now prepare for a highly anticipated rookie MLB season.
What has followed is a generation of pitchers with better stuff across the board, but also more red flags for potential long-term injuries — from worn-down elbow ligaments to misshapen bones in their shoulder.
“We started seeing a lot more young guys coming into higher levels of baseball with really significant mileage and pathology in their elbows and their shoulders,” ElAttrache said. “They were breaking down and requiring surgery to allow them to come back in a younger part of their career.”
Thus, surgeons like ElAttrache have innovated new ways to help injured arms get back on the mound — comparing it to improvements in knee and ankle surgeries for football players who are also exerting more force in their running movements than in the past.
“We had to figure out, how do we get better at this?” ElAttrache said. “What do we do to give them better longevity?”
The biggest changes were to the surgeries themselves.
Thanks to the increased forces today’s pitchers put on their arms to generate velocity and spin, ElAttrache said traditional Tommy John operations, for example, were not lasting as long as they once did. So, he has adopted the increasingly popular “internal brace” technique into many of his procedures — in which the repaired elbow ligament is reinforced with a braided, permanent suture to “help share the load of the damaged ligament.”
“I can’t do the same types of surgeries, the same techniques that I did 15 or 20 years ago,” he said. “I have to continue to make sure that I’m doing something better.”
The diagnosis of potential injuries has also been re-evaluated.
Because so many young pitchers now arrive in the pros with pre-existing wear and tear in their arms, ElAttrache said a renewed emphasis has been placed on trying to repair injuries before the native tissue in impacted areas is completely compromised.
“We’re getting into those things before there’s so much damage that the native tissue is completely degenerated,” he said. “We make the diagnosis earlier.”
The result has been shorter recovery times, more effective rehabilitation programs and ultimately more success stories for players coming off major injuries.
Even for a two-time Tommy John recipient like Ohtani — who is scheduled to return to pitching from his 2023 Tommy John revision early next season — ElAttrache said the standard prognosis has grown more promising.
“Yeah, the [second Tommy John] revisions don’t have as good a track record historically,” he acknowledged. “But we’ve gotten a lot better at our results after revision for a lot of reasons … And I know what I’m gonna get from Shohei in rehab. He totally buys into the process.”
Of course, there are still underlying issues for MLB and its 30 franchises to address.
No one in Dodger blue was apologizing Wednesday, when the Dodgers introduced pitcher Roki Sasaki at a news conference.
ElAttrache has been among the many medical experts consulting the commissioner’s office and the league’s research committees in search of solutions to rising pitcher injuries. He is also a key voice in the Dodgers’ internal review of their own injury problems, set to participate in a series of organizational meetings that will focus on the issue — which has plagued the Dodgers as much as any MLB team — in the coming weeks.
“Where the focus is now is to be able to identify the [injury] risks, and how can we change it?” ElAttrache said. “If we identify an arm at risk, can we save them the injury?”
In the meantime, though, optimism does reign when it comes to injury recovery. This year’s quartet of award winners offered the latest reminder why.
“I think people lose sight of what it takes for these guys to go through this,” ElAttrache said. “For as common as it has become to read about these injuries, and what to expect [from the recovery process], we shouldn’t lose sight of the human endeavor that they have to go through to do that and try to come back and play.”
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