Why having multiple Tommy John surgeries won’t hurt Nathan Eovaldi’s value

Nathan Eovaldi is about to hit the marketplace, and he’ll be in for a large payday.jim davis/globe staff file

Update: On Dec. 6, Nathan Eovaldi and the Red Sox reached an agreement on a new deal.

Nathan Eovaldi is perched to command a windfall, one of the most sought-after pitchers on the free agent market. The righthander is defined chiefly by his age (28), overpowering stuff, and recent postseason dominance as he arrives on the open market.

The fact that he has undergone two Tommy John surgeries — an initial reconstruction of his ulnar collateral ligament in high school, and a revision surgery in 2016 — is almost an afterthought.

In a way, that development is startling. The idea that a two-time Tommy John recipient could be seen as something other than an extreme risk illustrates how drastically the landscape has changed over the last decade.

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Lefthander Chris Capuano can still recall the sinking feeling in spring training of 2008 that accompanied the news that he’d require a second Tommy John surgery.

“It was pretty demoralizing,” recalled Capuano, who had just completed his four-month offseason rehab from an unrelated surgery on his right (non-throwing) shoulder when he blew out. “There was nobody prominent that I could find who had two and had returned to a high level. At that time, I don’t know what gave me hope.”

Capuano had to trust that his relative youth (he was 28 at the time), his strong conditioning regimen, and his willingness to follow a rehab protocol would permit him to come back. In contrast to his straight-line rehab from his first Tommy John surgery, Capuano’s second comeback came with significant setbacks, foremost a pinching or banging sensation in the back of his elbow when he faced live hitters, sufficiently unsettling that he had to consider that his career might be over.

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He navigated those setbacks largely alone before finally breaking through and returning to games, first in the minors at the end of 2009 and then in the big leagues — first out of the bullpen, then in the rotation — with the Brewers in 2010. He then signed a one-year deal to pitch in the Mets rotation in 2011, and his durability and performance proved good enough to convince the Dodgers to sign Capuano to a two-year, $10 million deal.

“I was being compared in negotiations, using comparables that were guys that hadn’t had surgery or hadn’t had Tommy John,” recalled Capuano. “Just the fact that I was being compared to those showed [the two surgeries] weren’t really a deal-breaker holding teams back.”

In his first season with the Dodgers, Capuano was teammates with a young, rocket-armed righthander who had come back from his own Tommy John surgery: Nathan Eovaldi.

Capuano and Eovaldi were again teammates with the Yankees in 2015, so when Eovaldi tore his repaired UCL in 2016 and learned that he’d need a revision Tommy John surgery, Capuano could offer the sort of counsel that no one else had been able to.

Related: Now campaigning against Tommy John surgery: Tommy John

“I still talk to Nate from time to time,” said Capuano. “Him having seen someone like me go through it at an older age and come back and have five or six years after . . . hopefully it provided some inspiration that there was nothing limiting him, nothing holding him back.”

Eovaldi certainly pitched like that in 2018, particularly in October (“It was like a video game,” Capuano beamed), but with the benefit of a growing sample of pitchers who have undergone multiple Tommy John surgeries, what do the data say about the risks?

A study published this year in the Journal of Shoulder and Elbow Surgery reviewed 1,429 Tommy John surgeries on professional baseball players between 1974 and 2016, including 93 “revision” surgeries. Until this decade, revision Tommy John surgeries were rare; the first one took place in 1996, and there were no more than five in any year through 2011. But with the massive rise in total Tommy John surgeries, there likewise has been a significant increase in second-time (and third-time) surgeries, with 10-20 performed per year since 2012.

Of those players, roughly 63 percent returned to their previous professional levels (or advanced beyond them) — slightly off the 73 percent who came back from first-time UCL reconstructions, but not a big enough gap to characterize as statistically significant given the smaller sample size of revision surgeries.

“I would have thought the returns from the revision surgery are worse,” said Glenn Fleisig of the American Sports Medicine Institute. “But when we look at Christopher Camp’s study, it doesn’t really look that way.”

Indeed, Fleisig said the chief risk appears to be whether a pitcher returns to his prior level from a second Tommy John surgery. There is a survival effect. Roughly 20-25 percent of pitchers never make it back from a first or second Tommy John, but those who do appear at no greater risk than other pitchers who hadn’t undergone even a single Tommy John procedure.

And in Eovaldi’s case, the specifics appear particularly strong. According to Dr. Christopher Ahmad, the Yankees’ head physician who performed Eovaldi’s second Tommy John surgery in 2016, the first procedure was well-executed.

The tunnels that were drilled into the bone to hold the reconstructed ligament were properly located and held up well for the eight years between surgeries. Ahmad was able to use those same tunnels rather than drilling new ones, which would have carried greater risks. He thus approached the new ligament — using a larger tendon (the gracilis, drawn from the leg, rather than the palmaris longus tendon from the wrist) — with confidence.

“It’s kind of like if your car isn’t aligned well and you change the tires because they’re wearing out, they’re just going to wear out again,” said Ahmad.

In Eovaldi’s case, the alignment was proper, so a new set of tires, followed by a careful rehab protocol throughout 2017 and workload management in 2018, permitted him to return to the pitching Autobahn, working with a triple-digit fastball and mid-90s cutter that did not come with any undue physical toll.

“He’s already demonstrated that he’s back to throwing as hard with absolutely no elbow symptoms,” said Ahmad. “I did an end-of-season evaluation on him and his elbow checked out perfectly on physical exam and also on an MRI scan.

“His reconstruction is looking so good by imaging and exam that I don’t put him in the same category as a pooled group of revision Tommy Johns.

“The exam was good. Never had symptoms related to his ligament. Has an MRI that looks good. And his performance has been so exceptional. He’s had not just a regular season but an extended season with the postseason. All of that says that this guy is going to be very strong going forward.”

Evidently, the baseball industry agrees, which is why Eovaldi seems poised to land a significant deal, perhaps a four- or even five-year contract.

With the number of “revision” Tommy John surgeries growing, Eovaldi will serve as a poster child for possibility and the idea that a player can come all the way back from the procedure — to the point where the market doesn’t seem inclined to put an asterisk on his projected performance.

“It’s really fabulous as a testament to medicine and surgery and science that we can say that a guy who’s had a revision Tommy John surgery is back and he’s in the same risk pool as someone else,” said Ahmad. “It’s pretty cool.

“My mission is to preserve dreams and careers. It’s really great. There’s not a patient who comes in and sees me in the office who doesn’t comment on Nathan Eovaldi’s postseason with a team that won the World Series. His durability, his roles coming out of the bullpen and starting, and his effectiveness — even his effectiveness against the Yankees — was really tremendous.

“For all those reasons, he is a landmark.”

The industry appears to agree, putting Eovaldi in position to get paid. With lefthander Patrick Corbin — the consensus top free agent pitcher, who is now five years removed from his Tommy John surgery — off the board after agreeing to a reported six-year, $140 million deal with the Nationals, Eovaldi’s market is ready to heat up, writes Peter Abraham.