What's next for Shohei Ohtani and the Angels in the wake of his torn UCL?

Los Angeles Angels' Shohei Ohtani walks off the field after being taken out of the game during the second inning in the first baseball game of a doubleheader against the Cincinnati Reds Wednesday, Aug. 23, 2023, in Anaheim, Calif. (AP Photo/Mark J. Terrill)

Shohei Ohtani has an ulnar collateral ligament tear and cannot pitch for the rest of the season.

The latest news was as crushing an on-field blow to the Angels as they have had. And shocking for the baseball world, which has grown accustomed to the superhuman abilities of the two-way star.

What is next for Ohtani and the Angels? Here are answers to some questions fans might have:

What is the ulnar collateral ligament (UCL)?

The UCL is the ligament on the inside of your elbow that provides stability to it and restricts the movement of the arm from going too far to the side when throwing.

Read more: Shohei Ohtani tears a ligament and won't pitch again this season; Mike Trout goes to IL

How do players injure their UCL?

Angels starting pitcher Shohei Ohtani warms up before Wednesday's game against the Cincinnati Reds.

“In baseball and overhead sports in general, when you’re throwing, you put a lot of stress on the inside of the elbow,” said Dr. Eric Bowman, an orthopedic surgeon and assistant professor in the department of orthopaedic surgery at Vanderbilt Medical Center. Bowman also is the head physician for Vanderbilt University’s sports teams and the Nashville Sounds minor league baseball team. He is not Ohtani’s physician and spoke to The Times as an expert on UCL injuries.

“Unfortunately in people who throw, that ligament can develop degenerative changes over time and can eventually tear,” Bowman said.

Do certain players tend to injure their UCL more than others?

“The forces that are placed on this ligament during the pitching motion are tremendous. So it’s a ligament that is prone to failure in high-velocity pitchers,” said Dr. Alan Beyer, an orthopedic surgeon and executive medical director of the Hoag Orthopedic Institute.

Beyer is not Ohtani’s physician and spoke to The Times as an expert on the injury. He also offered that taller pitchers can be somewhat more susceptible to UCL injuries. Ohtani is 6 feet 4.

“A 6-foot-something pitcher puts more force on their elbow than a 5-foot-10 pitcher because the levers that are delivering the force are longer,” Beyer said. “So there’s more leverage, more force applied.”

How common are UCL tears?

Shohei Ohtani watches from the dugout during a game against the Yankees.

As it relates to professional players, Bowman said there has been an increase in UCL reconstruction surgeries — also known as Tommy John surgery — over the years because pitchers are throwing harder. A survey in 2018 indicated that 26% of major league pitchers and 19% of minor league pitchers had UCL reconstructions.

“The numbers have dramatically increased over the past decade or so and in large part because the pitch velocity has gone up,” Bowman said, adding: “A lot of pitchers, probably most pitchers at the major league level, have some degenerative changes in the UCL and in the elbows in general. And sometimes they’re able to compensate and protect it. In other situations, that doesn’t occur very well and they can either completely tear the UCL or further injure it.”

Can UCL tears be prevented?

“That’s an enormous area of debate,” said Dr. David W. Altchek, co-chief emeritus of the HSS Sports Medicine Institute and medical director for the New York Mets. Altchek is not Ohtani’s physician and spoke to The Times as an expert on the type of injury.

“There’s a direct correlation between the velocity you throw and the incidence of UCL tears,” Altchek said. “So a particular player [throwing] 100 mph… puts them in the high-risk category, in my opinion. What adds to the high-risk category can be throwing weighted balls. ... I understand that throwing weighted balls increases your velocity, but they also, in my opinion, increase your risk of injuring your UCL.”

Read more: Hernández: Angels failed to stop Shohei Ohtani from a disastrous injury that alters his future

Is Tommy John surgery the only way to repair a UCL tear?

Shohei Ohtani delivers against the Houston Astros at Angel Stadium on May 9.

The need for Tommy John surgery depends on the severity of the tear, but tearing a UCL at the professional or amateur level almost always leads to surgery, Beyer said.

Bowman said more conservative treatments start with rest and rehabilitation. As far as receiving platelet rich plasma (PRP) injections — as Ohtani had in 2018 after he tore his UCL for the first time — there is not strong evidence they help or hurt in patients with a first-time tear, as medical professionals still are collectively reviewing data on the effects of PRPs.

“The idea behind PRP is that there’s some growth factors in there that might stimulate a healing response,” Bowman said. “That’s the theory behind why it may work.”

There's also a fairly new procedure called a UCL repair. Ohtani, who has already torn his UCL more than one time and had Tommy John surgery in the past, would not likely be a candidate for this, Bowman inferred.

"But a lot of our younger players, we're starting to do more repairs," Bowman said. "Where, the ligament overall looks good, they just kind of tore it off one end or the other and we can actually do a repair and get them back on the field much closer to six months. For our younger players, that makes a big difference."

What is the success rate of players returning from Tommy John surgery?

“It works,” Altchek said. “Done correctly, people can come back at the same level.”

For patients seeking to come back after more than one Tommy John surgery, however, the chances of returning at the same level begins to decrease, Altchek said.

"Once you start getting out there... that number drops in half," Altchek said. "So three Tommy Johns, you're fighting to get back."

What is the typical return time from Tommy John surgery?

The range is 12 to 14 months, though some patients have pushed to return after about 10 months, Bowman said. A return to pitching in games also depends on when a pitcher is injured.

Will Ohtani continue batting and will he have Tommy John surgery again?

Shohei Ohtani delivers against the Dodgers at Angel Stadium on June 21.

Ohtani traveled with the Angels to New York, where they will play the Mets in a three-game series, their first stop in a nine-game trip. Ohtani will continue to be the designated hitter, the Angels said. As for whether he will need Tommy John surgery again, that remains to be seen.

“I know how bad he wants to play, but with that being said, I think he needs time to wrap his head around it, talk to the people close to him,” Angels general manager Perry Minasian said Wednesday night. “We’re in the process of getting second opinions, which are obviously important. ... Once the information is there, he’ll make the right decision on what he wants to do and we’ll support whatever he decides.”

Read more: Why are the Angels one of two MLB teams whose radio announcers don't travel?

Why can Ohtani continue batting?

The UCL is less affected when batting, Bowman said, so players with UCL injuries can often continue to hit as long as it's not hurting them.

"I wouldn't think that it would do additional damage, that it wouldn't be repaired if they decided to do a reconstruction again," Bowman said.

In the progression of baseball activities to return from Tommy John surgery, hitting is usually one of the early baseball activities players return to.

"First you start tossing and hitting is one of the earlier things that you can start doing," Bowman said, "and then as your throws get further and more velocity, then you build up to working basically off the mound and starting pitching. There is a progression. Hitting seems to be less stress, and so they can often go back to playing sooner from that standpoint."

What does this mean for the Angels rotation the rest of the season?

Ohtani cannot pitch. The Angels rotation already was struggling with him as the ace of the staff. Without him, they perhaps can try to continue with the six-man rotation for the remainder of the season with Lucas Giolito, Patrick Sandoval, Reid Detmers, Tyler Anderson, Chase Silseth and Griffin Canning.

However, the six-man rotation was necessary only to keep Ohtani pitching every sixth or seventh day. Without him, they could weigh moving someone to the bullpen and going with a traditional five-man rotation.

Of those pitchers, Silseth had the most recent success, going five or more innings and giving up no more than two runs in four of his last five starts.

What does the recent injury news mean for the Angels season?

Shohei Ohtani delivers against the Pittsburgh Pirates on July 21.

Combined with the news that Mike Trout would be heading back to the injured list — because of the soreness he was experiencing in his left hand from playing Tuesday, his first game back after missing 38 — and where the team sits in the standings, it is hard to believe it will get better for the Angels.

Trout and Ohtani were key pieces of the Angels’ postseason push. The Angels do not know if Trout will return after the minimum 10 days on the IL. For what it’s worth, what Trout is dealing with will continue to be pain tolerance until the offseason, when he can rest for a longer stretch of time.

Ohtani still can hit, as he did in 2018 when he finished the season as a designated hitter after tearing his UCL in June. But the Angels (61-67) are 10½ games behind the Seattle Mariners for the final American League wild-card spot with 34 games left.

“No one’s quitting in that room,” manager Phil Nevin said Wednesday night. “I’m not quitting. No one’s quitting in that room. I won’t allow it. The coaches won’t allow it, the players won’t allow it. Room hurts, this sucks.”

Read more: New documents reveal how the Angels tried to pull the strings at Anaheim City Hall

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This story originally appeared in Los Angeles Times.