When the Red Sox revealed that Chris Sale’s elbow was acting up again this spring, there was a chorus of folks who felt like his wacky throwing motion — which begins with his body closed off to the hitter and finishes with his arm flying from a low-three-quarter arm slot and slinging high-90s heaters to the plate — was prone to injury.
That he finally needed Tommy John surgery, they said, seemed inevitable.
“People have been telling me this was going to happen for years,” Sale said when he discussed his elbow injury three weeks ago. “I don’t know if they get to say, ‘I told you so,’ or if I made it long enough to where that’s dissolved, I’m not worried about that. I’ve done what I’ve done and I’m at where I’m at.”
But talking to doctors, pitching coaches and injury prevention experts, two of whom work for other MLB clubs, the idea that Sale’s elbow injury was “expected” is unrealistic, and is based more on myth than scientific evidence.
And it’s led one expert to wonder if we can toss out the idea that there are any “safe” pitching mechanics at all.
“I think it’s one of those things where I’ve gone in and out of different opinions over the course of my career,” said Eric Cressey, who owns and operates Cressey Sports Performance in Hudson.
This winter, after the New York Yankees overhauled their medical team following an injury-laden 2019 season, Cressey was hired to lead the Yankees’ strength and conditioning program.
“To be honest, I think the industry as a whole is trending in the direction of — if you look at all the research, and Ben Hansen (a senior biomechanical engineer for the White Sox) is the guy to talk to — the conclusion he’s come to is, for the most part, mechanics are shockingly not predictive of injuries,” Cressey said.
In that case, why don’t more people try to pitch like Chris Sale? Or other pitchers who’ve had success with unusual mechanics?
Mechanics are “probably something we can look at a lot more as it relates to optimizing performance,” Cressey said.
How it started for Sale
When Sale first arrived at Florida Gulf Coast University in 2008, he was just another over-the-top left-handed pitcher. He finished his freshman year with a 3.47 ERA in 21 appearances, mostly out of relief.
The next year, he looked totally different.
“He got better real quick,” said FGCU head coach Dave Tollett.
Between seasons, Sale ditched the more traditional delivery and transitioned to the one he has today. It’s vicious to watch, but it drastically changed the effectiveness of his pitches.
“The fastball got better real quick,” Tollett said. “Boy, he really made a jump.”
Sale went from being an above-average reliever (he was originally drafted in the 21st round by the Colorado Rockies in 2007 before going to college) to a dominant starter, posting a 2.72 and 2.01 ERA in his final two seasons at FGCU before the White Sox drafted him 13th overall in 2010.
But something else stood out about the delivery that Sale developed as a 19-year-old.
“The slot he’s in right now is probably his natural slot, if you just watch him play catch,” Tollett said.
It’s why the White Sox never made an effort to change him. And after just 11 minor league appearances, Sale was called up to the majors in the same year he was drafted.
Longtime White Sox pitching coach Don Cooper was asked about Sale’s funky delivery in 2016.
“I didn’t see anything wrong (with that),” Cooper told late Globe writer Nick Cafardo. “I’d be crazy to change anything. I’d have to have my head examined.”
Because there’s such a wide variety of data involving pitching mechanics, and particularly arm slots, as they relate to injury risk, the recommendation is often to go with what’s most comfortable.
“I want guys to move as naturally as they can,” said Red Sox pitching coach Dave Bush. “And each of us is built with a different throwing motion based on how our bodies are made up. And if that’s the way Chris moves naturally and most fluidly, that’s the way he should pitch.
“I think the worst thing we can do is force someone into a style that doesn’t suit their body.”
It could have been random luck
Dr. Brian Waterman currently serves as the associate professor of orthopaedic surgery at Wake Forest Baptist Medical Center. He’s the team physician for Wake Forest University’s baseball team, and for the White Sox’ High-A affiliate in Winston-Salem. He once served as a team physician for the White Sox and worked with Sale.
Last January, together with Dr. Kristen Nicholson, Waterman helped create a state-of-the-art lab at Wake Forest to study pitching mechanics as they relate to injury.
“We’ve sunk about a half-million dollars of equipment and technology into it,” he said.
They’re still learning, but he’s made a few conclusions as it relates to arm slots.
“We’ve looked at angular velocity and hip-shoulder separation,” Waterman said. “Within that, we’ve looked at how the slot changes your pathomechanics, adverse attributes that create heightened risk of injury.
“We haven’t found much difference in that.”
Another key point: “We’ve also shown that velocity is not necessarily a predictor of increased torque in the elbow,” Waterman said.
So for all the concern about Sale throwing harder than ever before during the 2018 season, we can put to rest the notion that it increased his risk of injury.
It is worth noting, however, that Waterman found evidence to support increased stress on both the elbow and shoulder as it relates to horizontal adduction, or the movement of the arm horizontally across the body. With Sale’s throwing motion resulting in a lot of cross-body movement, it’s possible that it could increase his risk.
But where both Waterman and Cressey agree is that the best way to predict injuries is looking at a pitcher’s past.
Has he been hurt before? At what age? And what did his previous MRIs look like?
Waterman said MRIs on shoulders and elbows reveal at least some form of injury in around 80 percent of throwing athletes. And those MRIs can predict future injury.
“The pathology is there,” he said.
Until his elbow first became a problem last fall, Sale never had any elbow problems but for missing six weeks with a flexor muscle strain in 2014. And until his shoulder inflammation in late 2018, he hadn’t had shoulder issues either.
He had thrown over 1,600 big league innings before needing surgery.
“If you look at the research, and this is why I think Sale is an interesting case,” Cressey said, “because the only thing that predicts being healthy is having been healthy. The biggest risk factor for injury is a previous injury.
“Throughout the industry, you look at a lot of these guys that are durable starters into their 30s, guys like Corey Kluber, Max Scherzer and Justin Verlander, they’re guys that have made it past that initial threshold. They’ve got to 29, 30 with a pretty substantial workload. It’s the guys that are 20 to 27 or so, those guys are really vulnerable because that’s when they’re going through their increase in workload.”
No desire to change
Coming into spring training this year, the Red Sox didn’t think Sale would get hurt again.
He had dealt with elbow soreness last fall, when some wondered if he’d need Tommy John surgery, but a visit to Dr. James Andrews resulted in Andrews confidently telling Sale that all he needed was a platelet-rich plasma injection.
According to Sale, Andrews told him, “Throw some PRP in that thing, see you in a few weeks and we’ll be good to go.”
Sale came into camp feeling as good as he ever has.
“That’s the frustrating part of all of this — he was making regular progress,” Bush said. “We felt good about what he was doing. We were monitoring stress on his elbow and radar gun readings — all the stuff we have access to now, where in the past, we didn’t. There was nothing that looked out of line.”
Even if Sale changed his delivery, which he said he has no intentions of doing, there’s no guarantee it’d help him stay healthy. And it could make him drastically less effective.
“Big leaguers come in all shapes and sizes,” Cressey said. “And the challenge is, if you take a guy like Chris Sale, and you make him normal, you clean up the arm action, don’t make him as closed off, you might take away exactly what makes him spectacular. You make his delivery less deceptive. The slider isn’t sweeping like it is.
“Baseball players thrive on being different than the norm. If you want to throw an average major league fastball, there’s a good chance you’re not going to be an average major league pitcher. You’re going to be in Double-A, getting rocked.”
That’s not why the Red Sox traded for Sale, that’s not why they extended him, and that’s not what makes him a pitcher on a Hall of Fame track.
“We can have everyone look nice and pretty and smooth,” Bush said. “But the goal is to get big leaguers out. To do that, we have to everyone on the edges of what looks normal or what appears normal.”
There’s not enough evidence to suggest anything about Sale’s injury could’ve been prevented with a different delivery. And until last fall, there weren’t glaring injuries in his past to suggest it might be coming.
This is one example of Tommy John surgery that might’ve been the result of random luck.
