Injury and Economic Burden of Shoulder and Elbow Injuries in Major League Baseball Pitchers: A Retrospective 11-Year Analysis (2015-2025)

Abstract

Background:

Shoulder and elbow injuries are a significant source of morbidity among Major League Baseball (MLB) pitchers, yet comprehensive injury and economic burden analyses remain limited.

Purpose:

To quantify the epidemiological and economic burden of shoulder and elbow injuries among MLB pitchers from 2015 to 2025, including trends in injury incidence and salary lost over time.

Study Design:

Descriptive epidemiological study.

Methods:

All MLB pitcher injured list (IL) placements for shoulder and elbow injuries from 2015 to 2025 were identified using publicly available databases (ie, Fangraphs, Spotrac). Salary lost was calculated using the daily rate methodology and adjusted for inflation in US dollars, based on the 2025 inflation rate. Injury incidence rates were calculated per 1000 athlete-exposures. Linear regression assessed temporal trends in injury costs and incidence.

Results:

A total of 1122 MLB pitchers sustained shoulder or elbow IL placements during the study period, comprising 2365 total IL stints and $3.33 billion in cumulative salary lost. Elbow injuries accounted for 68.3% ($2.28 billion) and shoulder injuries 31.7% ($1.06 billion). Ulnar collateral ligament (UCL) injuries were the costliest diagnosis ($1.29 billion, 539 events). Significant increasing trends were observed for overall injury incidence (slope = 0.187 per 1000 athlete-exposures per year, P < .001), with elbow incidence rising 2.9 times faster than shoulder incidence (elbow slope = 0.140 per 1000 athlete-exposures per year, P < .001; shoulder slope = 0.047 per 1000 athlete-exposures per year, P = .022). Relief pitchers demonstrated 27.4 IL days per 1000 pitches compared to 15.3 for starters, representing approximately 80% higher injury burden per pitch.

Conclusion:

Shoulder and elbow injuries among MLB pitchers represent a substantial and growing time-loss and economic burden, with cumulative salary lost exceeding $3.3 billion over the study period. Elbow injuries accounted for most of this burden, and UCL injuries represented the single costliest injury category. These findings quantify the considerable financial and roster burden associated with shoulder and elbow IL placements among MLB pitchers.

Keywords

shoulder elbow baseball/softball epidemiology injury prevention motion analysis/kinesiology economic and decision analysis

Injuries to the shoulder and elbow have long represented a major source of morbidity, time loss, and health care utilization among baseball pitchers, with an increasing incidence over time.^4,11,14 In Major League Baseball (MLB), upper extremity pathology accounts for a substantial proportion of injured list (IL) placements and missed playing time—representing approximately 50% of all recorded injuries—with important consequences for roster stability, player availability, and organizational cost.¹⁰ Recent league reports indicate that both shoulder- and elbow-related IL days have increased in recent seasons, even as pitchers throw fewer innings per season and per game.¹⁸ These patterns suggest that the burden of shoulder and elbow injury in professional baseball remains both substantial and exponential, warranting increased surveillance and characterization.

A large proportion of the existing literature on throwing-related injury in baseball has focused on elbow ulnar collateral ligament (UCL) surgery and its consequences, including return to play and financial cost.^20,24,34 These studies have demonstrated that UCL surgery alone is associated with substantial direct and indirect costs, including salary paid during recovery and opportunity costs related to missed playing time.^20,24 Other upper extremity injuries, including rotator cuff and labral pathology as well as non-UCL elbow conditions such as impingement, loose bodies, osteochondral pathology, and ulnar neuritis, also account for a substantial share of IL placements and missed days^5,26 but have received comparatively less systematic attention in league-wide epidemiologic and economic analyses.

Several studies have described the epidemiology of MLB injuries using public databases and league surveillance systems, including analyses of overall IL trends,^3,4,25,26 and body part–specific injury patterns using MLB's Health and Injury Tracking System (HITS).^2,7,13,15,28 These studies have been essential in establishing baseline injury rates, identifying commonly affected anatomic regions, and tracking changes over time. However, these prior evaluations often combine pitchers and position players, aggregate all upper extremity injuries into a single category, or do not distinguish between shoulder and elbow pathology, limiting their ability to characterize injury burden specifically among pitchers or by anatomic region. In addition, most do not stratify by pitcher role (starter vs reliever), do not link injuries to individual player salaries or time-loss costs, and, in the case of HITS-based analyses, do not permit player-level identification, precluding economic or longitudinal player-level analyses.

As a result, despite the recognized clinical and organizational impact of shoulder and elbow injuries in MLB pitchers, a comprehensive, contemporary assessment of their epidemiology and economic burden is lacking. Specifically, there is limited information describing (1) recent trends in shoulder and elbow injury incidence and time loss, (2) differences in injury patterns between starting and relief pitchers, and (3) the financial impact of these injuries at the league and player level. The purpose of this study was therefore to characterize the incidence, distribution, and economic burden of shoulder and elbow injuries among MLB pitchers using publicly available player-level injury and salary data, with stratification by anatomic region and pitcher role (ie, starter, reliever).

Methods

Study Design

This study was deemed exempt as Not Human Subjects Research under 45 CFR 46.102 by the Institutional Review Board at Columbia University Medical Center, as no human subjects were enrolled, and all data were obtained from publicly available sources. A retrospective analysis was performed to investigate the epidemiology and economic cost of shoulder and elbow injuries among MLB pitchers from the 2015 through 2025 seasons.

Data Collection and Injury Classification

A comprehensive list of all MLB injury reports related to the shoulder and elbow across the investigational period was identified using Fangraphs⁹ and Spotrac³³ injury databases, a methodology consistent with prior MLB injury research using public reports.^21-23,27 Because public IL reporting varies in diagnostic specificity, ranging from clearly defined procedures or structural diagnoses to nonspecific symptom-based terms (eg, “inflammation,”“soreness,”“tightness”), each IL placement was subsequently reviewed using a structured web-based search to (1) verify IL entry and return dates and (2) capture the most specific publicly reported injury description available. Searches combined player name, season/year, and injury-related keywords (eg, “Pitcher Name 20XX injury”) and cross-referenced official MLB injury logs, team press releases, and reputable media reports.^8,17 When multiple descriptors were available for a single IL placement, the most specific descriptor was used for subgroup assignment. Using this process, 2365 pitcher IL placements related to the shoulder and elbow were identified.

Injuries were categorized by anatomic location (shoulder or elbow) and further classified into report-based injury subgroups using the available descriptive terminology. These subclassifications were designed to consolidate closely related conditions into clinically coherent groups, given the inherent limits of public reporting, enabling an exploratory assessment of the epidemiologic and economic burden across commonly reported shoulder and elbow injury patterns. Elbow injuries were classified into the following categories: UCL (including terms such as “Tommy John surgery,”“internal brace procedures,” and “sprained UCL”), Flexor/Forearm (including “strained forearm,”“forearm tightness, soreness or inflammation,”“strained flexor tendon,”“strained elbow,”“elbow tendonitis,” and “flexor tendon repair or surgery”), Inflammation (including “elbow inflammation,”“elbow soreness, tightness or discomfort,”“elbow neuritis,”“ulnar nerve transposition,” and “elbow effusion”), Valgus Extension Overload (including “elbow impingement,”“elbow stress reaction,”“bone spur removal,”“loose body removal,”“debridement,” and “stress fracture repair”), and Other (including contusions and unidentified conditions).

Shoulder injuries were similarly classified into the following categories: Strain/Inflammation (including terms such as “shoulder inflammation,”“strained shoulder,”“shoulder discomfort or soreness or fatigue,”“acromioclavicular inflammation,”“shoulder tendinitis,” and “sprained shoulder”), Labrum/Capsule/Biceps (including “labral repair,”“SLAP repair,”“labral tear,”“SLAP tear,”“capsule repair,”“torn capsule,”“biceps tendinitis,” and “capsular tear”), Impingement (including “shoulder impingement,”“shoulder debridement,” and “shoulder bursitis”), Rotator Cuff (including “rotator cuff tendinitis,”“strained or torn rotator cuff,” and “rotator cuff repair”), Surgery (including shoulder surgery for “thoracic outlet syndrome,”“aneurysm,”“latissimus tendon repair,” and “cyst removal”); and Other (including contusions and unidentified conditions).

In-Season Availability and Cost Calculation

To estimate the time and salary unavailable to the club during the season of play, each distinct IL placement was converted into days missed and salary lost attributable to that stint, with multiple placements per player analyzed as independent events. Days missed were calculated as the calendar difference between the IL start date and the return date; if a player did not return before the season concluded, the season end date was used. Each player's annual base salary obtained from Spotrac³² was divided by 181 to estimate a daily in-season salary rate, consistent with prior MLB cost analyses.^20,24 In cases where contract data were unavailable, the MLB minimum salary for the year of injury was used.²⁰ Salary lost was then calculated as the daily rate multiplied by the number of in-season days missed for each IL stint, capped at the player's annual salary.^20,24 Therefore, this metric specifically measures rostered absence during the actionable 181-day season of play, rather than the total clinical duration of recovery, which may extend into the off-season.

To ensure fair comparison across seasons and account for inflation, all financial metrics were adjusted using Consumer Price Index (CPI) data from the US Bureau of Labor Statistics.³⁵ All inflation-adjusted values in this study are reported in 2025 US dollars. The adjustment was calculated by multiplying the nominal salary lost by the ratio of the 2025 CPI to the CPI of the year in which the injury occurred.

Career Workload Analysis

For the cumulative analysis of career injury burden, each player who had recorded at least 100 pitches in MLB during the study period was identified using Statcast pitch tracking data.³¹ The total number of pitches recorded during the study period was calculated for each player, along with their total days spent on the IL with shoulder or elbow injuries. Pitchers were classified into role groupings as either starting pitcher (SP) or relief pitcher (RP) based on the proportion of games in which they recorded pitches in the first inning. Pitchers who recorded first-inning pitches in greater than 50% of their games played were classified as SP, while those with 50% or fewer first-inning appearances were classified as RP.

Incidence Rate Calculation

Injury incidence rates per 1000 athlete-exposures were calculated by adopting the approach of Posner et al²⁶ and Platt et al,²⁵ modified to reflect pitcher roster spots (13 per team) rather than the full active roster (25 per team) used in those studies. One athlete-exposure was defined as 1 game per athlete on the active roster. For standard seasons (2015-2019, 2021-2025), total exposures were 162 games × 30 teams × 13 pitchers (63,180 per year). For the COVID-19 shortened 2020 season, pitcher exposures were 25,459.²⁵ Incidence rates were calculated as (number of injuries / athlete-exposures) × 1000.^25,26

Statistical Analysis

All data processing and statistical analyses were performed using Python version 3.13 with the pandas library (version 2.3) for data manipulation and the SciPy library (version 1.16) for statistical testing. Descriptive statistics were calculated for all injury and cost variables, including counts, sums, and means. Total salary lost was calculated for all shoulder and elbow injuries combined, as well as stratified by anatomic location (elbow vs shoulder), injury subgroup, pitcher role (SP vs RP), and season. To assess temporal trends in injury costs over the study period, linear regression analysis was performed using ordinary least squares regression, with season as the independent variable and total salary lost (inflation-adjusted) as the dependent variable. The slope coefficient was used to quantify the annual change in salary lost, and the coefficient of determination (R²) was calculated to assess model fit. The 2020 season was excluded from temporal trend analyses due to the COVID-19 shortened schedule (60 games), although all 2020 data remain included in summary tables. Statistical significance was determined using a 2-tailed test with an α level of 0.05. All figures and tables were generated programmatically using the matplotlib library for visualization and the python-docx library for document generation.

Results

Total Shoulder and Elbow Injury Burden

A total of 2365 IL placements related to shoulder and elbow injuries were identified among MLB pitchers during the 2015-2025 study period, affecting 1122 distinct pitchers. The cumulative inflation-adjusted salary lost due to these injuries was $3.33 billion (2025 USD), with an average of $1.41 million and 72.6 days missed per IL placement. Within the shoulder/elbow cohort, elbow injuries constituted most of the injury burden, accounting for 1376 IL events (58.2%) and $2.28 billion in salary lost (68.3% of total). Shoulder injuries comprised 989 IL events (41.8%) and $1.06 billion in salary lost (31.7%). Table 1 presents the yearly distribution of shoulder and elbow injuries stratified by anatomic location. Annual cohort-attributed injury costs ranged from $125 million in 2020 (60-game season) to $480 million in 2024. The 2020 season data were excluded from temporal trend analyses due to the COVID-19 shortened schedule.

Table 1

Yearly Summary of Shoulder and Elbow Injuries by Category (2015-2025) ^a

Season	Category	IL Events	Unique Players	Days Missed	Salary Lost (2025), $
2015	Combined	182	129	10,847	$235,629,613
	Elbow	100	70	6889	$173,903,376
	Shoulder	82	62	3958	$61,726,238
2016	Combined	159	149	12,323	$231,935,553
	Elbow	90	84	7883	$116,140,894
	Shoulder	69	68	4440	$115,794,659
2017	Combined	165	148	11,350	$232,919,111
	Elbow	88	81	7699	$149,356,076
	Shoulder	77	70	3651	$83,563,035
2018	Combined	202	175	13,595	$251,866,698
	Elbow	106	96	8291	$149,123,607
	Shoulder	96	81	5304	$102,743,091
2019	Combined	219	191	15,359	$311,685,445
	Elbow	122	108	10,937	$220,601,697
	Shoulder	97	87	4422	$91,083,748
2020 ^b	Combined	123	118	5070	$125,266,081
	Elbow	80	77	3755	$101,537,535
	Shoulder	43	42	1315	$23,728,545
2021	Combined	259	224	18,106	$355,147,959
	Elbow	145	129	12,584	$270,813,645
	Shoulder	114	100	5522	$84,334,315
2022	Combined	254	224	19,244	$297,828,371
	Elbow	148	137	13,261	$179,665,494
	Shoulder	106	95	5983	$118,162,877
2023	Combined	261	235	21,128	$424,047,005
	Elbow	159	144	13,721	$281,735,505
	Shoulder	102	95	7407	$142,311,500
2024	Combined	290	253	23,393	$480,334,564
	Elbow	179	166	16,812	$374,293,178
	Shoulder	111	100	6581	$106,041,386
2025	Combined	251	226	21,331	$386,767,301
	Elbow	159	149	14,566	$260,175,820
	Shoulder	92	88	6765	$126,591,481
Total	Combined	2,365	1,122	171,746	$3,333,427,701
	Elbow	1,376	764	116,398	$2,277,346,827
	Shoulder	989	638	55,348	$1,056,080,874

Combined = shoulder + elbow. IL, injury list.

The year 2020 was excluded from trend analysis due to the COVID-19 shortened season (60 games).

Linear regression revealed an increasing trend of combined shoulder and elbow injuries (slope = $22.35 million/year, R² = 0.786, P < .001; Figure 1), elbow injuries (slope = $17.93 million/year, R² = 0.628, P = .006; Figure 2), and shoulder injuries (slope = $4.41 million/year, R² = 0.422, P = .042; Figure 3).

Figure 1.

Trend in total salary lost due to combined shoulder and elbow injuries (2015-2025).

Figure 2.

Trend in salary lost due to elbow injuries (2015-2025).

Figure 3.

Trend in salary lost due to shoulder injuries (2015-2025).

Elbow Injury Subgroups

Among elbow injuries, UCL injuries represented the largest economic burden, with 539 IL placements among 340 unique players, resulting in $1.29 billion in salary lost (56.6% of elbow total; Table 2). Flexor/forearm injuries were the second most costly category at $477 million. The distribution of days missed and salary lost by injury subgroup is shown in Figure 4.

Table 2

Elbow Injury Subgroups ^a

Injury Subgroup	Players	Events	Salary (2025 Adjusted), Millions $	Total Days Lost
UCL	340	539	$1290.0	70,975
Flexor/Forearm	282	358	$476.8	19,696
Inflammation	271	328	$265.8	15,208
Valgus Extension Overload	100	115	$229.6	8708
Other	34	36	$15.2	1811

UCL includes Tommy John surgery, internal brace, and sprained/strained UCL. Flexor/Forearm includes forearm strains and flexor tendon injuries. Inflammation includes discomfort, neuritis, and soreness. Valgus Extension Overload includes impingement, bone spur removal, and debridement. Total Days Lost represents the cumulative days pitchers spent on the injured list for each injury group. UCL, ulnar collateral ligament.

Figure 4.

Distribution of days missed by elbow injury subgroup.

Shoulder Injury Subgroups

Among shoulder injuries, strain/inflammation represented the most common category, with 719 IL placements resulting in $631 million in salary lost (59.7% of shoulder total; Table 3). Labrum/capsule/biceps injuries, while less common (67 events), accounted for the second-highest cumulative days lost (8717) and salary lost ($171.6 million) among shoulder injury groups. The distribution of days missed by shoulder injury category is shown in Figure 5.

Table 3

Shoulder Injury Subgroups ^a

Injury Subgroup	Players	Events	Salary (2025 Adjusted), Millions $	Total Days Lost
Strain/Inflammation	496	719	$630.5	33,383
Labrum/Capsule/Biceps	54	67	$171.6	8717
Impingement	111	130	$119.3	6523
Surgery	33	36	$103.4	4453
Rotator Cuff	16	16	$26.8	1515
Other	19	21	$4.5	757

Strain/Inflammation includes strained shoulder and shoulder inflammation. Labrum/Capsule/Biceps includes labral tears/repairs, capsular injuries, and biceps tendonitis. Rotator Cuff includes rotator cuff strains, tears, and tendinitis. Total Days Lost represents the cumulative days pitchers spent on the injured list for each injury group.

Figure 5.

Distribution of days missed by shoulder injury subgroup.

Injury Burden by Pitcher Role

SPs accounted for 826 (34.9%) IL placements with $2.20 billion (65.9%) in salary lost, while RPs had 1539 (65.1%) placements with $1.14 billion (34.1%) in salary lost (Table 4). Among 2131 pitchers with recorded Statcast data, SPs threw 4.06 million total pitches and spent 61,997 cumulative days on the IL for shoulder and elbow injuries (15.3 IL days per 1000 pitches; Table 4, Figure 6). RPs threw 4.00 million pitches and spent 109,749 days on the IL (27.4 IL days per 1000 pitches). RPs demonstrated approximately 80% higher IL burden per in-game pitch thrown compared with SPs.

Table 4

Shoulder and Elbow Injuries by Pitcher Role ^a

Metric	SP	RP
IL events	826	1539
Unique players	330	792
Total days missed	61,997	109,749
Total salary lost (2025), $	$2,195,471,179	$1,137,956,522
Average salary per event	$2,657,955	$739,413
Total pitches (study period)	4,061,267	4,003,390
IL days per 1000 pitches	15.3	27.4

SPs defined as those with >50% of games with first-inning pitches. IL, injured list; RP, relief pitcher; SP, starting pitcher.

Figure 6.

Relationship between career pitch count and total days on injured list for combined shoulder and elbow injuries, stratified by pitcher role.

Injury Incidence Rates

Excluding 2020, the overall incidence rate for shoulder and elbow injuries combined ranged from 2.52 to 4.59 per 1000 athlete-exposures (Table 5). Linear regression demonstrated a significant increase in overall incidence over time (slope = 0.187 per 1000 athlete-exposures per year, P < .001). Elbow injury incidence increased significantly (slope = 0.140, P < .001), and shoulder injury incidence also increased significantly (slope = 0.047, P = .022). The slope for elbow injury incidence was 2.9-fold greater than that for shoulder injury incidence.

Table 5

Yearly Injury Incidence Rates per 1000 Athlete-Exposures ^a

Season	All IR	Elbow IR	Shoulder IR	Elbow/Shoulder
2015	2.88	1.58	1.30	1.22
2016	2.52	1.42	1.09	1.30
2017	2.61	1.39	1.22	1.14
2018	3.20	1.68	1.52	1.10
2019	3.47	1.93	1.54	1.26
2020	4.83	3.14	1.69	1.86
2021	4.10	2.30	1.80	1.27
2022	4.02	2.34	1.68	1.40
2023	4.13	2.52	1.61	1.56
2024	4.59	2.83	1.76	1.61
2025	3.97	2.52	1.46	1.73

Athlete-exposures calculated as games × roster × teams (63,180 for standard seasons; 25,459 for COVID-19 shortened 2020 season). IR = (injuries / exposures) × 1000. IL, injured list; IR, incidence rate.

Discussion

This study represents the largest comprehensive economic analysis of shoulder and elbow injuries among MLB pitchers to date, encompassing 2,365 IL placements over an 11-season period from 2015 to 2025. The cumulative inflation-adjusted cost of shoulder and elbow injuries during this period totaled $3.33 billion, with elbow injuries accounting for 68.3% of this burden ($2.28 billion) and shoulder injuries comprising the remaining 31.7% ($1.06 billion). UCL injuries alone were responsible for $1.29 billion in salary lost, representing the single most costly injury subgroup. Linear regression analysis demonstrated statistically significant increasing trends in both injury costs (P < .001) and injury incidence rates per 1000 athlete-exposures. Overall shoulder and elbow injury incidence increased significantly (slope = 0.187/year, P < .001), with elbow injury incidence rising at 2.9 times the rate of shoulder injuries (elbow slope = 0.140, P < .001; shoulder slope = 0.047, P = .022). These findings highlight the substantial financial and time-loss burden associated with shoulder- and elbow-related IL placements in MLB pitchers.

The epidemiological patterns observed in this study likely reflect differences in study design compared with prior investigations that combined pitchers with position players or analyzed all injuries together. Posner et al²⁶ reported that upper extremity injuries represented 51.4% of all disabled list entries from 2002 to 2008, while pitchers experienced 67% of their injuries in the upper extremity compared with only 32.1% among fielders. Camp et al,³ analyzing 49,955 injuries from 2011 to 2016, found no increase in the rate of injury over the study period, and rotator cuff strain/tear was the most common upper extremity diagnosis, followed by biceps tendinitis and UCL injury. However, these analyses combined all players (position players and pitchers) and did not differentiate injury burden by anatomic subsite within the upper extremity. By isolating pitchers and stratifying by elbow versus shoulder, the current study reveals that elbow injuries constitute the predominant burden in both days missed and economic impact. This finding aligns with the 2024 MLB Commissioner's Report on pitcher injuries, which highlighted growing concerns regarding elbow injury rates.¹⁸

Prior epidemiological studies have produced conflicting results regarding the relative burden of elbow versus shoulder injuries. Saper et al,³⁰ examining high school baseball players from 2005 to 2015, reported higher shoulder injury rates than elbow (1.39 vs 0.86 per 10,000 athlete-exposures), although they noted that a greater proportion of elbow injuries occurred among pitchers. Cross et al⁶ similarly found comparable rates between shoulder (16.1%) and elbow (16.0%) injuries in NCAA baseball but did not isolate pitchers. Fares et al¹⁰ analyzed MLB data and reported that elbow/forearm injuries were more common, specifically among pitchers, supporting our findings. The higher elbow injury burden observed in the present study is likely attributable to our focus exclusively on MLB pitchers, the population most vulnerable to repetitive stress from high-intensity pitching motion. Li et al¹⁶ demonstrated that pitchers had 27 times the rate of days missed due to elbow injuries compared with position players, underscoring the position-specific nature of this injury pattern.

A notable finding was the higher burden of IL days per in-game pitch among RPs compared to SPs. This metric reflects days missed per official game pitch and should not be interpreted as a time-based injury hazard by role. That distinction may help explain the contrast with Bullock et al,¹ who reported a higher injury hazard for Minor League Baseball SPs when exposure was measured over time. Rather than indicating that relief pitching is inherently riskier, the present finding more likely suggests that official game pitch counts do not fully capture total throwing exposure across roles. Relief pitchers may accumulate meaningful throwing load through warm-up activity, variable usage patterns, and shorter recovery intervals that are not reflected in in-game pitch totals. Accordingly, role-based comparisons should be interpreted within the context of the exposure metric used, and future studies should incorporate more granular measures of throwing volume, rest, and intensity to better characterize role-specific injury burden.

The financial magnitude of shoulder and elbow injuries identified in this study is substantial and extends prior estimates focused on specific pathologies. Conte et al⁴ reported $7.6 billion in total injury costs from 1998 to 2015, although this included all injury types across all positions. Sabesan et al²⁹ estimated approximately $3.5 million lost per year from labral repairs alone; by comparison, the current study found labrum/capsule injuries among pitchers resulted in $16.0 million in salary lost per year over the 11-year study period. Previous analyses of Tommy John surgery have quantified the significant economic impact of this single pathology. Mastroianni et al²⁰ identified 276 UCL surgeries among MLB pitchers from 2014 to 2024, with inflation-adjusted salary losses totaling over $1.26 billion. Meldau et al²⁴ reported 194 UCL reconstructions from 2004 to 2014, with a cost of recovery amounting to $395 million and an average of $1.9 million per player. The present study identified 340 unique players with UCL injuries treated operatively and nonoperatively over the study period, totaling nearly $1.3 billion in salary lost, consistent with Mastroianni et al.²⁰ Importantly, this study quantifies for the first time the substantial additional costs associated with non-UCL pathologies, including inflammatory conditions, strains, flexor injuries, and other diagnoses that collectively account for over $2 billion in additional salary obligations beyond Tommy John surgery alone.

Methodologically, this study employed 2 complementary approaches to characterize injury burden. First, consistent with prior investigations by Posner et al,²⁶ Platt et al,²⁵ and Martin et al,¹⁹ injury incidence rates were calculated per 1000 athlete-exposures, where 1 exposure equals 1 game on the active roster. Using this approach, incidence increased over the study period, with a steeper increase in elbow injuries than shoulder injuries. Second, for workload analysis, in-game pitches thrown were employed as the exposure metric rather than game-based exposures. While study period aggregates for pitch count precluded year-by-year trend analysis, the use of a pitch-based exposure metric and IL days as the outcome measure may better reflect true injury burden in pitchers within a given role, as these injuries arise from cumulative throwing load rather than mere roster presence.

The significant upward trends in both upper extremity injury incidence and inflation-adjusted salary lost are concerning from both player health and organizational perspectives. Conte et al⁵ first identified increasing disabled list trends from 1989 to 1999 and noted the absence of improvement despite advances in training and conditioning. The present study suggests that this pattern has persisted among MLB pitchers, with injury incidence increasing over the study period and annual salary lost reaching $480 million in 2024. Although some increase in financial burden may reflect rising salaries over time, the concurrent increase in inflation-adjusted costs and days missed suggests that the observed burden is not attributable to salary growth alone. Recent policy changes, including the pitch clock, have not demonstrably reduced injury rates; Puga et al²⁷ and Mastroianni et al²¹ found either no change or increases in specific injury categories following implementation. Taken together, these findings highlight the persistent and increasing burden of shoulder and elbow injuries in MLB pitchers and support continued surveillance and more detailed study of the factors contributing to this trend.

Limitations

This study has several limitations. First, injury data were obtained from publicly available sources, which do not capture diagnoses with the same specificity as prospective medical records. Reported injury descriptions are often nonspecific and may be inconsistently labeled across teams and seasons. As a result, injury subclassifications relied on broad analytic groupings constructed for this study from publicly reported descriptions rather than confirmed clinical diagnoses, introducing potential misclassification across categories and limiting inference at the level of specific pathologies. This reflects a necessary trade-off: while MLB's HITS can contain more granular clinical detail, its deidentified structure prevents linking injuries to individual salaries and contract outcomes, which is required for the present cost analysis. Second, the analysis captured only days missed during the regular season; offseason surgeries, rehabilitation time, and throwing restrictions are not reflected in salary lost calculations, meaning the true injury burden is likely underestimated. Additionally, although salary lost was adjusted to 2025 US dollars using the CPI to allow cross-season comparison, this method may not fully reflect baseball-specific salary inflation or relative payroll/luxury tax burden.

Third, the analysis included only IL placements, meaning injuries that occurred at the end of a contract term or among players who retired or remained unsigned were not captured. In addition, not all clinically meaningful arm injuries result in an IL transaction (eg, shorter “day-to-day” limitations managed without a roster move), which may further underestimate total burden. Players may continue to experience injury-related limitations that prevent future contracts, representing a cost to the player not quantified by team salary data as described in the UCL cost analysis by Mastroianni et al.²⁰ Fourth, as Fortney et al¹² demonstrated, a substantial proportion of pitchers have asymptomatic shoulder and elbow pathology on imaging, suggesting that reported injuries represent only clinically significant presentations of ongoing degenerative processes.

Conclusion

Footnotes

Final revision submitted April 12, 2026; accepted April 22, 2026.

One or more of the authors has declared the following potential conflict of interest or source of funding: C.S.A. is a paid consultant and receives royalties from Arthrex; he also serves as the head team physician of the New York Yankees. W.N.L. receives consulting and royalty fees from Zimmer Biomet.

Ethical approval for this study was waived by Columbia University Medical Center.

ORCID iDs

Morgan R. Dillon

Michael A. Mastroianni

Nicholas Frappa

Danil V. Chernov

Andrew J. Luzzi

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