By John Erardi
The Cincinnati Enquirer

PHOTO GALLERY

Photos of Saturday's game

Two days ago, Ryan Dempster and Denny Neagle - current and former Reds starting pitchers, respectively - exercised on adjacent tables at Tri-Health Physical Therapy at Summit Woods in Sharonville. They matter-of-factly flexed their newly repaired elbows, fully expecting to be pitching at their best two years from now, after having undergone "Tommy John" surgery.

There's at least an 85 percent chance they will return successfully.

They can only imagine how much less certain major-league pitcher Tommy John was 29 years ago when he first came out of the ligament-replacement operation later named for him. That surgery was performed on the pitcher by orthopedic surgeon Frank Jobe in 1974.

John returned to the majors in 1976, going 164-125 in 14 seasons after the surgery.

"If I was at this point even 10 years ago, I'd have had a lot more apprehension about it," said Neagle, now a Colorado Rockie. "It's down to such a science now, it gives you confidence and trust and peace of mind that if you do the rehab, you're going to make it back. I'm going to keep following the advice of Lonnie (Reds assistant trainer Lonnie Soloff) and my therapist in Denver to a T. That's the key now."

The 85-percent success rate for Tommy John surgery is up from about 60 percent 10 years ago, according to USA Today.

Dempster's and Neagle's surgeries took only about an hour apiece - compared to the three-hour ordeal John endured three decades ago. Reds team medical director Dr. Timothy Kremchek did the Dempster and Neagle operations.

In Tommy John surgery, a tendon is taken from the hamstring or forearm and grafted into the elbow.

"You sew a tendon in with the ligament, and over time that tendon becomes a ligament," Kremchek said.

Tunnels are drilled in the humerus and ulna bones, and the tendon is woven into a figure-eight around the existing ligament, usually three or four times. Sometimes the tendon is long enough to loop around only twice; sometimes, as with Dempster, it can make a fifth loop.

"I got six," Neagle told Dempster, trying to one-up him.

But he was joking; he got four.

Still, without vigorous rehabilitation, the number of loops doesn't matter.

"The technology is so good nowadays," Dempster said, "that once you decide who you want to do your surgery - there are only about six surgeons in the country who do so many of these Tommy John surgeries that they are just as good as the other guy - that it comes down to rehab after that," Dempster said.

According to USA Today, more than 75 pitchers who have appeared in the majors the past two seasons have had Tommy John surgery; that's one in every nine pitchers who have passed through "The Show" since 2001.

Dempster said it's "amazing" how many pitchers, even the best of them - such as Mariano Rivera, Eric Gagne, Kerry Wood and John Smoltz - have had Tommy John surgery. He didn't know about Rivera and Gagne until he began studying up on the surgery while getting ready for his own.

Kremchek, who had done only about 10 of these surgeries when he started with the Reds seven years ago, did "60 to 70" last year.

Of those 60 to 70, "four or five" were big-leaguers, "five or six" were high schoolers and the rest were major-college pitchers and minor-leaguers, Kremchek said.

He said the youngest recipient of the surgery was a 14-year-old pitcher from Louisville. Pitchers from a 200-mile radius file into Cincinnati to have Kremchek do their arm surgeries: 26 major colleges are represented, as are minor-league teams of seven big-league organizations.

Kremchek said a few weeks ago he was talking to a staffer and was told that eight beds in a row in postop were filled by pitchers of varying experience who had just had Tommy John surgery.

It takes a full year to rehabilitate from the procedure and usually about a full season of pitching to return to form. Dempster, who had Tommy John surgery Monday, on Friday said he already could straighten his pitching arm farther than before the surgery.

"I liken pitchers' arms to cars, in a way," Dempster said. "Most are going to require repairs, some of them major, to keep them going. Some are lucky - blessed - and they don't need repairs. But a majority of pitchers are going to have something: inflammation, tendinitis, biceps problems, or something serious like the shoulder or elbow. The harder you run a car - or an arm - the more likely you're going to have to put new parts in. I've thrown over 1,000 innings, and I'm only 26 years old. That doesn't even include the minor leagues and high school."

Neagle turns 35 in September. He said he's one of the older established starting pitchers to have Tommy John surgery. ("Johnny Franco, who's 42, had it, and he's come back," Neagle said of the former Reds closer.) On the personal advice of Atlanta Braves starter-turned-reliever John Smoltz, Neagle is going to go to the bullpen to round himself back into form, then try to work his way back into the rotation.

Neagle said he chose Kremchek for his surgery because he believes in him.

"This is the same guy who on three different occasions had to convince (former Reds general manager) Jim Bowden that I didn't need shoulder surgery in '99," Neagle said. "I came back in the second half of '99, throwing as good as I did at any time in my career. Doc Kremchek knows pitchers' arms."

The other reason Neagle chose Kremchek is because of his rehabilitation team, which is second to none, Neagle said.

Neagle had pitched for Minnesota, Pittsburgh and Atlanta before coming to Cincinnati in 1999, and he said the Reds had "cornered the market" on shoulder-strengthening exercises.

Which prompts the following question: What is the root cause of the physical breakdown of so many Reds minor-league pitchers in recent years? Twenty-some Reds prospects have had their arms operated on in the past year; more than 60 since 2000.

Are the guys being drafted not strong enough? Are they being overworked? Is the instruction not sound? Reds officials said they are in the process of working out individual, year-round plans for each of the organization's pitchers, and working to make sure they don't exceed their pitch counts and innings counts.

There is a trend toward protecting minor-league pitching talent, as opposed to stressing it. The Reds might be playing catch-up in that department, judging by their own assessments.

But Alan Schwarz, the senior writer for Baseball America, said some other organizations - "even Atlanta," an esteemed organization for developing pitchers - have had a slew of arm surgeries in recent years. He doesn't believe the Reds' number is inordinately high.

The operative word there might be "inordinately."

Some Reds officials believe the number is high. One coach of a Reds minor-league team recently joked that the organization immediately should give all its draftees Tommy John surgery, because "they're going to end up having it, anyway."

Kremchek makes the point that 90-plus percent of those Reds minor-league pitchers who have had arm surgery of various kinds return to the same minor-league level or higher after surgery and rehabilitation.

But wouldn't it be better to avoid it altogether?

Kremchek agreed it would and said his staff and the Reds are working on finding the answers to the dilemma.

Some Reds officials think one reason the organization's minor-leaguers are breaking down is because they all are being taught the same pitching motion - a compact, efficient motion thought to be mechanically sound.

But it might be working against some pitchers' natural strengths.

The Reds plan to scrutinize this and all other aspects of their development program to determine what works best.

Meanwhile, Kremchek believes the shoulder holds the key to pitching health.

"I believe that a lot of our Tommy John surgeries come about as a result of something being wrong with the shoulder," he said.

Shoulder strength should come first, he said, because the ulnar collateral ligament by itself cannot withstand the torque applied to it by a hard-throwing overhand pitcher. All the muscles in the arm and shoulder need to be strong, he said.

"Keeping a close eye out for fatigue - indicated by the pitcher's (arm angle) dropping down - is a key to protecting the arm," Kremchek said.