New Canaan pitcher Dan Rajkowski was on a path that many high school pitchers find themselves.
After a successful sophomore season in 2012, Rajkowski spent the summer playing baseball and traveling to showcases in hopes of being noticed by college and professional scouts.
It was after throwing 60 pitches at a showcase in Florida when Rajkowski first felt severe pain in his elbow.
Rajkowski thought the feeling in his arm was nothing more than typical soreness, but when he resumed throwing after Christmas that year, the pain quickly returned.
"It kept bothering me, so I took a MRI in February and there was a slight tear in my UCL," Rajkowski said. "(Me and my doctors) made the decision to try and throw through it and do some rehab."
After six weeks trying to rehab his arm with no improvement, Rajkowski and his doctor decided his best option was surgery to replace his ulnar collateral ligament, a procedure commonly referred to as "Tommy John Surgery," named for the Yankees' pitcher who first successfully underwent the procedure in 1974 while with the Dodgers.
On April 17, 2013, Rajkowski underwent the surgery.
He then spent all winter and fall going through the painful process of rehabbing before finally being cleared to play this March, just ahead of his senior season.
"It was pretty painful at times and a lot of work," Rajkowski said. "Once I got my range of motion and started doing shoulder exercises, I started throwing four months after surgery and lightly tossing and then come nine months post-surgery, I was able to throw off a mound like 70-80 percent. It progressively got better, better, better, and I worked on my pitch count and got into a routine by the end of October."
Rajkowski was back on the mound for New Canaan this spring, though on a strict pitch count.
Years ago, stories like Rajkowski's would be unusual, but over the past 20 years, the number of youth and high school players getting Tommy John surgery has jumped dramatically.
That number jumped to 10 percent in 1995, 18 percent in 1999 before reaching a peak of 32 percent in 2008.
The numbers have not continued to rise since 2008 but have remained steady with at least 25 percent of youth and high school pitchers undergoing the surgery each year since.
Meanwhile, the numbers of young American professional pitchers with the injury also continues to rise with over 20 major league pitchers already receiving the surgery this year.
Many people involved with the major leagues feel the damage to the pitchers' arms is not occurring at the pro level but is more likely caused by overuse and overthrowing at the youth level. "American prospects" is an important distinction because the number of UCL injuries is dramatically higher in American-born players than Latin American prospects. The claim is that these American prospects are already suffering from compromised elbows when they sign their professional contracts.
The players breaking down fully once in the pros at least have access to MLB medical and rehab facilities and are getting paid millions while they recover.
Players going under the knife while still in high school and college get no such luxury, missing full seasons of play and possibly placing their baseball futures at risk.
So, why is it a procedure once used mostly on aging professional players becoming more prevalent in pitchers at the youth level?
Nobody is quite sure of the exact cause of UCL injuries. More likely it is a combination of factors coming together to accelerate the onset of the injury.
Dr. Paul Sethi of Orthopaedic and Neurosurgery Specialists in Greenwich says the ability to diagnose more accurately, players and coaches being more aware of the injury and the increased demand put on young arms have all contributed to the increase in the procedure.
"The main factor is most likely overuse combined with poor mechanics," Sethi said. "There is also more awareness of both the injury and the surgery and there is not as much fear involved because the players and parents know that they can be back playing within a year."
Sethi has been performing the surgery for over a decade, learning from Dr. Frank Jobe, who performed the procedure on Tommy John himself.
Sethi has seen players as young as 11 years old come into his office with the injury, but said most of the patients having the surgery are over 16.
He said having the surgery too young is not recommended because the athlete has so much more growing to do.
"This procedure is meant for players who are going to be playing at the next level," Sethi said. "We try to avoid surgery in athletes with open growth plates. We need to be very careful with young developing arms."
For the young athletes whose growth plates have closed, research shows that UCL reconstruction is a successful option.
The popular consensus is throwing too much is one of the main culprits behind the increase in ligament replacement surgeries.
ASMI published a study in 2011 showing those who threw more than 100 innings in a given year were 3Â½ times more likely to require elbow surgery than those who threw fewer than 100 innings.
One hundred innings is one thing, but with increased specialization many pitchers now throw year-round, and the lack of rest is causing young arms to suffer injuries not previously seen.
Therefore, the question becomes can the injury be prevented?
The website Stop Sports Injuries states that regulating how much a young pitcher throws and how long he rests between appearances goes a long way toward avoiding injury.
The recommendations from SSI are as follows: 7-8 year-olds, 50 pitches per outing; 9-10, 75 pitches; 11-12, 85 pitches; and 13-16, no more than 95 pitches.
Little League Baseball has adopted rules that fall in line with this research and also requires minimum days off once pitch counts are reached.
The rest runs from no days off if the player throws less than 20 pitches to at least four days off for a player under 14 who throws 66 pitches.
It is also widely recommended players do not pitch for at least two to three months in the offseason.
TROUBLE WITH THE CURVE
Years ago breaking balls were not allowed in games played by 12-year-olds, but now they are accepted as part of the game.
This increased stress on the arm, usually from poor mechanics, also results in increased injuries.
Most experts agree players under 15 should not be throwing breaking balls.
SSI recommends players throw fastballs and changeups until at least 15 years of age.
Curveballs can be worked in at age 15, sliders at 16 with forkballs and screwballs waiting until 17 years of age.
Players trying to "snap" their curves and sliders generally compromise proper mechanics for increased movement.
Screwballs are quite rare among players in today's game, but the problem with fork- or split-finger fastballs is that when the fingers are spread around the seams of the ball, it stresses the hand, which in turn puts more stress on the elbow.
Players hoping to be seen by scouts have limited options in the Northeast, leading to the rise of summer showcases.
Professional and college coaches gather as high school players come in for a day to show off their abilities.
The problems arise when a pitcher trying to make a good impression overthrows as many as 60 pitches, all at max effort, then possibly attends another showcase a few days later and does the same thing with no coach to rein him in.
"A lot of guys, that's their only chance," said Kevin Huber, the assistant baseball coach at Yale University. "We see guys throwing year-round, and on top of that, they attend these showcases and blow it out on Tuesday and then come back and do the same thing Wednesday afternoon."
Huber is also the founder of the Connecticut Blue Jays Baseball Club, which is comprised of high school players and plays up to 60 games over the summer.
Having feet in both the collegiate and summer youth worlds gives Huber a unique perspective on how young arms are treated.
Huber said he and his staff on the Blue Jays are aware of the risks and demands put on young arms and, while they try to win, protecting young arms is more important to them.
"We want to curtail a kid possibly getting hurt," Huber said. "We limit all of our pitchers to pitch counts. It does not behoove us to win at the expense of an injury."
Rajkowski blames his injury not on overuse but rather poor mechanics and an inconsistent delivery.
Rajkowski threw in a style known as an "inverted W" where the throwing arm whips back behind the shoulder, thus putting more stress on the elbow.
"I threw a lot freshman and sophomore years and I played short when I didn't pitch," Rajkowski said. "In my opinion I don't think I was ever overused. Mechanics were a big part of it because I had an `inverted W' whip. Mechanics are a big issue with elbow injuries."
Watching how a pitcher throws can give a good indication of an arm injury waiting to happen, according to Huber.
"When you look at a guy's arm slot and the effort he exerts, you can tell he's a UCL waiting to happen," Huber said. "It's about the physics of the delivery. If they don't have clean delivery or clean arm slot, they are more likely to get hurt. You can teach a lot of things but arm slots are hard to teach."
REST OR SURGERY
Players coming in with UCL injuries are usually given the option of resting and rehabbing before surgery.
St. Luke's pitcher Bobby Forese missed this, his senior season, after attempting to rest an injury he first felt last season but tried to pitch through.
Forese played through August last summer, attending multiple showcases during that time before finally shutting himself down from August to October.
His pain returned while throwing in January and by February it became too much to bear.
Forese tried to rehab without surgery, but by April of this year realized surgery was his only option.
He said had he not intended to play baseball at Colby College next year, he never would have had the surgery, but now that he has, he feels confident in making a full recovery.
"I thought about trying to play through it, but I wouldn't be able to pitch, just play field, and I did not want to do that," Forese said. "I threw pretty much year-round sophomore and junior year taking just a small break, maybe two months, just to get my strength back up."
Forese hopes to be back to full strength by next April but is not sure if he will have to redshirt a season at Colby before pitching in an actual game again.
`JUST LIKE JOGGING'
Pitch counts, lack of breaking balls and mandated rest are rules meant to protect young players, but what can the player do themselves to prevent injury?
The first thing out of many coaches' and doctors' mouths was "long toss."
"Long toss is just like jogging," Sethi said. "Long toss stretches out the arm without max effort. The Jobe exercises are something else I recommend."
The Jobe exercises are a series of stretches, light weights and calisthenics designed to strengthen the shoulder thus putting less stress on the elbow.