Baseball's most fearsome injury.

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May 20 2004 5:02 PM

Labrum, It Nearly Killed Him

Why the torn labrum is baseball's most fearsome injury.

Nen: sidelined by a bum shoulder
Nen: sidelined by a bum shoulder

The San Francisco Giants' Robb Nen, one of the best relief pitchers in baseball, had off-season surgery in 2002 to "clean up loose particles" in his shoulder. What Nen didn't know is that he had a torn labrum, the fearsome modern baseball injury that strikes down pitchers quickly, stealthily, and painfully. Eighteen months and three surgeries later, Nen is still waiting to throw his next major-league pitch. The leading minds in baseball medicine are flummoxed by the labrum. Doctors can't agree on how to detect a tear, don't know the best way to fix one, and aren't sure why, almost without fail, a torn labrum will destroy a pitcher's career.

Leading baseball surgeon Dr. James Andrews estimates that 85 percent of pitchers make a full recovery after an ulnar collateral ligament reconstruction, aka the once risky Tommy John surgery. (USA Today has even called the surgery the "pitcher's best friend.") But if pitchers with torn labrums were horses, they'd be destroyed. Of the 36 major-league hurlers diagnosed with labrum tears in the last five years, only midlevel reliever Rocky Biddle has returned to his previous level. Think about that when your favorite pitcher comes down with labrum trouble: He has a 3 percent chance of becoming Rocky Biddle. More likely, he'll turn into Mike Harkey, Robert Person, or Jim Parque, pitchers who lost stamina and velocity—and a major-league career—when their labrums began to fray.

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The labrum is a thin matrix of collagen seated between the head of the humerus (bone of the upper arm) and the glenoid fossa (the shallow depression where the humerus fits). It functions both as a shock absorber, cushioning the blow when the bones in the shoulder collide, and as part of the joint's connective structure. The kinetic forces required to throw a baseball—a major-league pitcher's arm moves at 23 rotations per second—routinely rip apart the structures designed to keep the shoulder together. The most common variety of labrum tear is a SLAP—superior lesion, anterior to posterior. The SLAP tear feels like a "catch", a slight click or pop in the normal overhand motion.

Shoulder injuries tend to present themselves as pain and tenderness with a concurrent loss of speed on the fastball. A torn labrum is no different. But because it's positioned between two bones, a damaged labrum is far more difficult to detect than other shoulder problems, like a torn rotator cuff. Doctors are only now getting the diagnostic tools to detect labrum tears, so it's impossible to say how many great hurlers of the past suffered the injury. Even today it's tough to tell which pitchers have labrum trouble. Baseball teams often consult with multiple orthopedists and radiologists in an attempt to reach a consensus. One team's policy is to show an MRI to five doctors—majority diagnosis rules. The only way to know for sure that your pitcher has a torn labrum is to conduct exploratory surgery.

If an operation is necessary, the surgeon either enters the shoulder with a scalpel or pops in one to three arthroscopes outfitted with cameras and cutting instruments. The doctor then cleans up the tear and reattaches the labrum using sutures, much as they would with a deep cut to the skin. While newer techniques involve specialized devices that standardize the anchors and sutures, shoulder surgery is still far more complex and risky than, say, an elbow reconstruction.

Coming off a 15-10 season in 2000, Mike Sirotka was a key player in an off-season trade between the Blue Jays and White Sox. Before he ever put on a Blue Jays uniform, Sirotka's left shoulder started barking. The culprit: a torn labrum. While he had been a coveted commodity just a few months before, the Sox and Jays now treated Sirotka like the plague—Commissioner Bud Selig ultimately had to force the Blue Jays to accept the trade. Sirotka, now 33, did have surgery to repair the labrum. After missing three full seasons, he tried a comeback this year. The Cubs released him in spring training.

The Seattle Mariners, perhaps more than any other team, have suffered on account of the labrum. When Seattle drafted 6-foot-10 Ryan Anderson in 1997, it seemed preordained that the titanic lefty would be the next Randy Johnson. Then Anderson had labrum surgery. He missed the entire 2002 season—and every season since. The Mariners' 25-year-old right-hander Gil Meche has already missed two full years on account of labrum-related ailments. Meche returned to the majors in 2003, but faded badly in the second half.

Position players have labrums too. Angels third baseman Troy Glaus may miss the rest of the year with his "frayed" labrum (there's no difference between a fray and a tear). Last year, Dodgers slugger Shawn Green lost a significant amount of power because of a severe labrum tear. Labrum tears also show up irregularly on the football field—the Raiders' Rich Gannon (throwing shoulder) and the Seahawks' Matt Hasselbeck (non-throwing shoulder) are part of the labrum brigade—usually when a quarterback's arm gets planted into the ground at an unnatural angle.

Still, nothing taxes a shoulder like throwing a baseball. Even if a pitcher has an ideal throwing motion, the labrum suffers. Unlike the rotator cuff, a series of four small muscles that holds the shoulder in place and decelerates the arm, the collagen-based labrum can't be strengthened. As of yet, there aren't any reliable techniques to prevent labrum injuries. Anecdotal evidence suggests that the best way to avoid injury is to keep your pitcher from throwing while fatigued. But fatigue is exceptionally difficult for a pitching coach or manager to measure—and one wrong guess can lead to the operating table.

Roger Clemens returned from a torn rotator cuff to win six Cy Young Awards and an MVP. Kerry Wood struck out 20 in a single game during his rookie year, had his elbow rebuilt, and came back throwing just as hard. But pitchers with torn labrums will have to wait a while longer for their Tommy John surgery. So far, the message from the nation's orthopedic surgeons is: We can't rebuild them. Dr. Anthony Tropiano, a top baseball arm doc, says the best available treatment option today is to do nothing. "We call it conservative treatment," he says, "but that's just a euphemism for a little rehab and a lot of prayer."

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