KANSAS CITY, Mo. -- Royals manager Ned Yost has been around baseball his entire life, and he has a hard time recalling a season in which two pitchers needed Tommy John surgery.
Let alone four.
Felipe Paulino tore a ligament in his right elbow and likely will join Danny Duffy, Joakim Soria and Blake Wood in having reconstructive elbow surgery, putting a damper on the long-awaited return of catcher Salvador Perez from the disabled list.
The Royals said Paulino will get a second opinion from Los Angeles Angels medical director Dr. Lewis Yocum, but the right-hander said surgery is a certainty.
Yocum also performed Tommy John surgery on Duffy, Soria and Wood.
"You check around and see how many pitchers are going down with Tommy John this year. It's a very disturbing number," Yost said before Friday night's game against St. Louis.
"I don't have the reason why," Yost said. "I don't know why there's such a big number of guys going down with Tommy John surgeries this year, but we're not immune to it by any stretch of the imagination, and our numbers have added greatly to it."
The injury to Paulino is particularly devastating to the Royals because he had emerged as their most dependable starter, going 3-1 with a 1.67 ERA in seven starts this season.
Paulino opened the year on the DL because of a strained left forearm, and was coming off six innings of three-hit ball against Oakland when he hurt his groin June 6. He landed on the DL again, but was working his way back on a rehab assignment when he hurt his elbow.
He was pulled after throwing 54 pitches in three innings Wednesday night.
"It really surprised me," Paulino said. "I was just on my rehab, getting ready to make my start Monday, and it just happened."
Paulino said he knew something bad happened when he felt pain in his elbow, but he doesn't think the injury had anything to do with his strained forearm or the groin injury.
"I never felt that before," Paulino said. "I was supposed to go three innings, four innings, and in the third inning, something happened."
The Royals lost Duffy when the promising young left-hander was pulled from a start May 13 at the White Sox and was found to have torn elbow ligaments. Jonathan Sanchez has spent time on the DL this season, and fill-in starter Everett Teaford also has been hurt.
All told, Kansas City has used 10 starting pitchers this year.
"Obviously, it's changed our plans for the rest of the year," Yost said. "You've got to move on. What's happened has happened. It was a big blow when we lost Duffy. It was a big blow when we lost Soria and Blake Wood the same way. But the world doesn't stop turning. It gives somebody an opportunity that they might not have had otherwise to show what they can do."
It's unclear who will move into the rotation in Paulino's place, though Will Smith and Nate Adcock have made starts for Kansas City. Jake Odorizzi might finally get his chance at the big leagues after going 4-0 with a 2.41 ERA at Omaha, while fellow Triple-A prospects Mike Montgomery (3-3, 4.79) and Ryan Verdugo (5-2, 3.65) also could get a look.
The 22-year-old Perez made a big impression on the Royals late last season, hitting .331 with three homers and 21 RBIs in 39 games. It was enough for Kansas City to sign him to a $7 million, five-year deal that includes three team option years during spring training.
Perez tore cartilage in his knee on March 13, shortly after signing the new contract.
The Royals purposely took it slow with his rehab, making sure Perez could catch a full nine innings before he returned to the big league club, and he hit .340 during 12 games at Omaha.
"I feel more than great," Perez said. "I don't even want to think about (the injury), but it was probably one of the most frustrating things I've ever been through."
The Royals made roster space for Perez by optioning left-hander Tommy Hottovy to Omaha and transferring outfielder Lorenzo Cain to the 60-day DL. Cain has been out with a hip injury, but he's already spent more than 60 days on the DL, which means he can return at any time.
He resumed a rehab assignment this week and could be back before the All-Star break.