30 Questions: Marlins


Why is Josh Johnson a risky draft pick?

Color me skeptical when it comes to promoting a pitcher whose last season ended with an injury that in some way involved his throwing arm. Earlier this year, I expressed concern about Adam Wainwright, whose 2010 season ended due to stiffness in his throwing elbow, and everyone now knows how 2011 turned out (in case you missed it, Wainwright tore his ulnar collateral ligament early in spring training and has since undergone Tommy John reconstructive surgery). This is not to say that Wainwright's injury was certain to happen, just that there was a rationale for being cautious. There is clearly no way to definitively predict who will succumb to a major season-ending injury; there are only hints as to which players might be at risk as the season begins.

The hint of risk surrounds Florida Marlins ace Josh Johnson. No one can say that Johnson is decidedly headed down the path toward a season-threatening injury. And Johnson has already faced -- and overcome -- one of the big threats to a pitcher's arm, the tearing of the ulnar collateral ligament (UCL). In 2007, he underwent Tommy John surgery to reconstruct his UCL and the reinjury rate following repair of that ligament is exceptionally low.

So why worry?

The worry stems from the fact that Johnson's season ended when he was shut down in September because of shoulder inflammation and an upper back injury. Any time shoulder inflammation is in the conversation, it raises a flag because shoulder issues in a pitcher are known to be more problematic than elbow injuries. (And last year, colleague Jerry Crasnick wrote about the differences in the recoveries from elbow surgery versus shoulder surgery.)

We know the act of pitching takes a toll on the body of a pitcher. We also know that the two primary areas that tend to break down are the throwing elbow and shoulder. The elbow is a fairly stable joint with primary motion occurring in one direction. The shoulder is far more complex than the elbow when it comes to directional movement and it is precisely the amount of mobility the shoulder allows that renders it vulnerable. The types of injuries that occur at the elbow tend to be more specific (bone spurs, ligament sprains) and more predictable when it comes to recovery. At the shoulder, injuries range from the vague (bursitis, tendinitis, strain) to the specific (labral tear, rotator cuff tear) and the outcomes are all over the map. Whether surgery is a part of the equation or not, how well an athlete recovers and how long it takes to do so varies widely.

Furthermore, new data suggests there may be a correlation between players who undergo Tommy John surgery and subsequent injuries to their pitching shoulder. While there is no definitive link, it is a topic of discussion in sports medicine circles and is currently being studied more closely. It makes sense from a mechanical perspective. Players often feel something is amiss prior to actually suffering a catastrophic injury. They also tend to try to press through discomfort (especially if it's mild) and end up compensating in other areas as a result. Studies of throwers have shown that as shoulder muscles fatigue, the strain across the elbow increases. If there are subtle strength changes in the shoulder, the potential of increased injury risk at the elbow exists.

Certainly the reverse can be true as well. If there are limitations at the elbow, such as loss of motion due to a bone spur, for example, it would not come as any surprise that a pitcher's shoulder would suffer the consequences as the forces change up the kinetic chain. Inadequate strength or even inefficient use of the trunk and leg muscles can also lead to a pitcher's placing more demand on the shoulder itself. It's important to note that Johnson believes the primary issue that affected him at the end of last season was his upper back. He felt the upper back led to compensations that affected his throwing shoulder. Was it enough to compromise the long-term health of his shoulder or was it just a fluke? Was this episode superimposed on the unnatural physical demands of the act of pitching a tipping point? Indeed, these are the unanswered questions, but they are the questions that raise the specter of risk.

So is there reason for optimism?

Sure. Johnson indicated that treatment he received to address the upper back has him in good shape for the season. It is always essential to get to the root of the problem when it comes to athletic injuries. The symptomatic area is often the primary focus of treatment while the true source of the symptoms is overlooked. In those cases, the symptoms are bound to return, perhaps with far-reaching consequences. If, as Johnson reports, the actual source of last year's symptoms has been fully addressed, it is certainly encouraging news.

Johnson also says he began a strengthening regimen in the offseason. He plans to maintain a strength and flexibility program in-season in an effort to stay healthy. If he carries out that regimen, this is certainly another point in his favor. It also suggests that Johnson was concerned enough by how his season ended to take steps to guard the health of his throwing arm.

Let me be clear. I'm rooting for Josh Johnson. It would be fantastic if all athletes could stay healthy throughout their careers. The fact is, however, that athletes will continue to suffer injuries playing competitive sports. Pitchers in baseball will wear out their throwing arms simply because of the physics of their profession; the ones who don't, at least in this era of sport and sports medicine, are the exceptions. The majority of those injuries are the result of repetition and overuse. Signs of wear and tear start making themselves known in the form of shorter episodes of pain and inflammation, sometimes with increasing frequency as the tissue becomes less tolerant of the activity. And while there are some pitchers with known pathology (abnormal findings) in their throwing arm who continue to defy logic and perform without incident, the majority, if they pitch long enough, will see that breakdown catch up to them.

When it comes to fantasy sports, it's all about risk versus reward in defining value at draft time. Every fantasy owner needs to evaluate his or her own "risk-aversion." If risk makes you want to run in the other direction, then even the small warning signs take on big significance when it comes to establishing value on draft day. In the case of Johnson, his past performance has him ranked among our top 20 starting pitchers, but concerns about how well he'll hold up keep him out of our top 10.

Sure, any pitcher can fall victim to a sudden season-ending injury (just ask Jake Peavy and Stephen Strasburg owners last year), but when there are hints that there might be trouble in paradise (see: Adam Wainwright), fantasy owners need to decide whether they still want to put a big chunk of their eggs in that basket.

Stephania Bell is a physical therapist who is a Board Certified Orthopedic Clinical Specialist and a Certified Strength and Conditioning Specialist. She is a clinician, author and teacher with extensive experience in the area of orthopedic manual therapy and sports medicine. You can e-mail her here.