Little is known about pitching performance or lack of it among Major League Baseball (MLB) pitchers who undergo operative treatment of rotator cuff tears.
Objective:To assess pitching performance outcomes in MLB players who needed operative treatment of rotator cuff tears and to compare performance in these athletes with that in a control group of MLB players.
Design:Case-control study.
Setting:Publicly ailable player profiles, press releases, and team injury reports.
Patients or Other Participants:Thirty-three MLB pitchers with documented surgery to treat rotator cuff tears and 117 control pitchers who did not he documented rotator cuff tears were identified.
Main Outcome Measure(s):Major League Baseball pitching attrition and performance variables.
Results:Players who underwent rotator cuff surgery were no more likely not to play than control players. Performance variables of players who underwent surgery improved after surgery but never returned to baseline preoperative status. Players who needed rotator cuff surgery typically were more experienced and had better earned run erages than control players.
Conclusions:Pitchers who had symptomatic rotator cuff tears that necessitated operative treatment tended to decline gradually in performance leading up to their operations and to improve gradually over the next 3 seasons. In contrast to what we expected, they did not he a greater attrition rate than their control counterparts; however, their performances did not return to preoperative levels over the course of the study.
Keywords: pitching, clinical outcome, shoulder
Key Points.Pitchers who had operative treatment of symptomatic rotator cuff tears tended to he a gradual decline in performance before surgery and to improve gradually over the 3 seasons after surgery.
The attrition rate was not greater in pitchers who had operative treatment than in the control pitchers.
Pitchers who had surgery for rotator cuffs tears did not return to their preoperative performance levels during the study period.
Rotator cuff tears (RCTs) can cause great pain and dysfunction in both work-related and non–work-related activities of daily living, as well as loss of shoulder motion and strength. Without treatment, full-thickness RCTs can be career-ending injuries for professional athletes. Although tears often occur in patients aged 40 years and older,1,2 overhead athletes, particularly professional baseball pitchers, present a unique cohort of athletes at great risk for this type of overuse injury.
Professional baseball pitchers subject the rotator cuff to supraphysiologic loads that lead to rotator cuff tendinitis, partial-thickness RCTs, and, in advanced stages, full-thickness RCTs.3–5 At one time, RCT was considered a career-ending injury for a Major League Baseball (MLB) pitcher. As the approach to the operative and nonoperative management of RCTs in athletes has evolved over the past 3 decades, the goal of operative treatment of partial-thickness and full-thickness tears in these elite-level athletes also has changed. Whereas pain relief and restoration of function are considered good outcomes in a general population, the goal for MLB pitchers is to return to athletic competition with the same preinjury performance ability.
Subjective patient-derived outcomes and physician-derived physical examination variables often are improved after rotator cuff surgery in elite pitchers; however, return of players to athletic performance at high levels has been variable.4,6,7 Mazoué and Andrews4 reviewed the results of 12 professional pitchers who underwent repair of full-thickness RCTs of the dominant shoulder and noted that only 1 player (8%) was able to return to a high competitive level of baseball without great shoulder dysfunction. Similarly, Reynolds et al6 examined preoperative and intraoperative findings of 82 professional pitchers who had undergone debridement of partial-thickness RCTs and found that most athletes returned to competitive pitching; however, returning to their previous levels of competition remained a challenge for many players. Little is known about postoperative pitching performance among pitchers who return to MLB play. Performance outcomes he been described in MLB pitchers who he undergone repair of the ulnar collateral ligament8 and repair of isolated glenoid labral injuries.9 Therefore, the purpose of our study was to describe pitching performance outcomes in MLB players who needed surgery to treat RCTs and to compare performance variables and return to play between these athletes and a randomly selected cohort of MLB players. We hypothesized that players who had operative treatment of RCTs would be less likely to return to play in any given year than a randomly selected group of players. In addition, we hypothesized that rotator cuff surgery (RCS) would he a deleterious effect on athletic performance variables.
METHODSOur main outcomes of interest were performance-based factors that were continuous measures; therefore, a power analysis was conducted based on the ttest for independent samples. For an α level of .05 and a power of 0.8, a harmonic mean number of 50 players was necessary to detect a medium standardized difference (Cohen d = 0.5) for the outcomes of interest. Our study exceeded this number, with 33 affected players and 117 control players (harmonic mean = 51 players).10
Data were reviewed for 33 MLB pitchers who pitched in at least 1 MLB game before undergoing surgery to treat RCTs. All pitchers appeared in more than 1 game before surgery, and most pitchers appeared in several games during multiple seasons. Pitchers were identified from team injury reports, press releases, and player profiles indicating that they underwent surgery to treat RCTs in their pitching shoulders. We did not determine whether a patient had a partial-thickness or a full-thickness tear. Furthermore, we could not determine the surgical approach or technique. Data obtained were ailable via Article XIII, Section C of the Major League Baseball Players Association's collective bargaining agreement, which provides standards for injury reporting in MLB. It states, “Application by a Club to the Commissioner to place a Player on the Disabled List shall be accompanied by a Standard Form of Diagnosis” that “shall be completed by the Club physician.”11
Surgery was performed between 1976 and 2003. Age and MLB pitching experience were determined at the time of surgery. Body mass index (BMI), throwing handedness, all-star status, and pitching role (starting or relief pitcher) were recorded for each pitcher (Table 1). Body mass index was calculated from height and mass data. The date of return to MLB play was recorded, and the duration from surgery to return was calculated. Mean innings pitched (IP) per season, earned run erage (ERA), walks and hits per inning pitched (WHIP), and strikeouts per 9 innings (K/9) were compared for each MLB pitcher for 3 seasons before (preindex seasons 1, 2, and 3) and after (postindex seasons 1, 2, and 3) surgery. Preindex season 1 was defined as the season immediately before the operative year, and postindex season 1 was defined as the season immediately after the operative year. This resulted in a study duration of 7 consecutive seasons for each player. The ERA is the erage number of earned runs allowed per 9 innings pitched. An earned run is any run scored by the opposing team for which the pitcher is held accountable. Walks and hits per inning are determined by dividing the sum of walks and hits by the total number of innings pitched. The K/9 is defined as the sum of strikeouts divided by 9 innings. These are standard measures of pitching performance in MLB.
Table 1.Demographics of Pitchers in the Rotator Cuff Surgery and Control Groups
Variable Group ta χ2 p Rotator Cuff Surgery (n = 33) Control (n = 117) Baseline earned run erageb,c 3.93 ± 1.01 5.95 ± 2.41 4.71 NA