Another Excellent Discussion of what was likely happening with the Astros Ace by JoshuaTheAT
For the Previous discussion about Bregman go here
Now we move on to Lance McCullers. One of the most important factors to keep in mind when evaluating and treating an injury is past injury history of the structures involved. A quick refresher on Lance’s right elbow. During the 2016 season Lance was on and off the IL with shoulder and elbow injuries. (I mention the shoulder injury because often the two go together) In August 2018 Lance was diagnosed with a forearm strain. He was shut down and returned to pitch out of the bullpen for the Astros in the playoffs. He then had Tommy John surgery on that elbow shortly after the season. (Tommy John surgery=UCL tear) Lance probably pitched with a partially torn UCL in the playoffs, but fought through it to try and go back to back. Lance missed all of 2019, and was limited in innings in 2020 because of the shortened season. Which brings us to 2021 where he pitched the whole year until the ALDS where he was diagnosed with another forearm strain. Something worth noting: this year was the first time Lance has gone over 100 innings since 2017, and the most innings he’s ever thrown in a year in professional baseball. So he has quite an extensive injury history.
Below are two diagrams of the elbow anatomy and I think this illustrates why forearm strains and Tommy John surgery often go hand in hand. The UCL (ulnar collateral ligament) is the primary stabilizer of the medial (inside) elbow. A lot of force is put on this ligament while throwing, specifically when the arm is fully cocked back and the beginning to move forward. As I’m sure you know, Tommy John surgery is a season-ender. And depending on timing can cost you 2 season, see Justin Verlander. Forearm strains in pitchers are almost always near the elbow, where the muscles also act like an extra component of the UCL, stabilizing the medial elbow. So an injury to the forearm muscles can put more load on the UCL which can cause a tear.
It is possible that is what happened to Lance in 2018. So dealing with another forearm strain after Tommy John surgery immediately put up red flags for the Astros’ sports medicine team. While they didn’t officially rule out McCullers until the World Series roster was announced, I believe this was for a “competitive advantage”, he was never coming back.
The Astros front office has made a large financial investment in Lance and are planning for him to be the ace of the rotation for the next 5 years. They have to look at the long term risk of another serious injury to Lance’s elbow by pitching through a strain vs. the short term gain of giving them 10ish innings in the ALCS/WS. The calculus with this is pretty easy, especially after you look at success rates of a second Tommy John surgery on an individual. The study "Revision Medial Ulnar Collateral Ligament Reconstruction in Baseball Pitchers: Review of Epidemiology, Surgical Techniques, and Outcomes" by Dr. Lucas Keyt and his colleagues shows that the success rate is somewhere between 46-80 percent. Return to play takes between 15-20 months. Both these measures are much better in first time UCL reconstruction. A revision surgery would cost Lance 2 seasons, $32 million in payroll for the Astros, and leave a gaping hole in the rotation. Not a risk McCullers or the Astros could take. The good news is this: It has been reported that there is no structural damage to Lance’s elbow. With extended rest time and time to build back up, I believe Lance McCullers will report to Spring Training in February 100% and ready to be the staff ace for the Astros.
A disclaimer about everything I write: This is all speculation. I can give my opinion on a situation but there are times I will be dead wrong. Evaluating an athlete in front of you can be difficult at times, so doing it from in front of a screen is next to impossible. But I think I can give you an informed opinion/a rough estimation of what to expect regarding severity and recovery time for a given injury. Again: I AM NOT A DOCTOR. I WILL BE WRONG. When I get something wrong I will be the first person to admit it.
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