When pitchers hear the words shoulder surgery, it often means that their careers are over

While Tommy John surgery for pitchers remains on the rise in Major League Baseball, operations for shoulder-related issues have decreased as failed procedures prompted new protocols for treatment.

Shoulder procedures have derailed numerous careers of All-Star pitchers from Steve Busby to Robb Nen to Johan Santana, the only Met to throw a no-hitter.

Busby had 56 victories — including two no-hitters — in his first three full seasons (1973-75) with the Royals. By 25, he was believed to be the first pitcher to undergo what would become known as “dreaded’’ rotator cuff surgery.

“Everybody had a pretty good idea that those types of surgeries was fraught with a lot of issues and not at all as predictable as we’d like it to be,’’ Mets team physician David Altchek said recently. “It was not a good time. We’ve gotten past it by preventing it, which is the most powerful thing.’’

Busby cannot forget what famed orthopedic surgeon Frank Jobe — who in 1974 performed the first Tommy John surgery by reconstructing the ulnar collateral ligament in John’s left elbow — told him after his own surgery.

“He said ‘I think you want to find a different occupation,’ ’’ Busby, 68, said from Arlington, Texas. Busby’s post-surgical record was 8-9 over his next four seasons, and he was done after the 1980 season. He was 30.

Major League Baseball does not release injury or surgical statistics. According to Massachusetts-based Baseball Injury Consultants, a privately owned firm that has tracked injuries on major-leaguers dating to the 1940s, 92 shoulder surgeries have been performed in this decade, compared with 184 Tommy John surgeries. Shoulder surgeries peaked at 166 from 2000-09. Tommy John surgeries have increased every year since the 1970s. BIC has recorded 412 surgeries, with 340 since 2000. Yankees starter Jordan Montgomery had the procedure on June 7.

Tommy John surgeries have been more successful than shoulder procedures. Kerry Wood, who at 20 struck out 20 batters in a game for the Cubs in 1998, came back from Tommy John surgery, but his career declined largely because of shoulder issues.

NEW PROTOCOLS

Before the widespread use of MRI technology in the early 1980s, arm surgeries were largely nonexistent. Hall of Fame righthander Jim Palmer said Orioles manager Hank Bauer told him in 1968 that his arm pain “was in my head,’’ and Palmer responded, “Hank, then how comes it hurts when I throw?’ ’’

Palmer said he received a cortisone-like injection in his biceps tendon and later treated what was diagnosed as a torn infraspinatus muscle in his shoulder with ice, rehabilitation and an anti-inflammatory drug similar to Motrin. “The next year [1969], I went 16-4,” Palmer, 72, said from Baltimore. He also was second in the American League in ERA (2.34).

While conservative treatment worked for Palmer, it didn’t for Mel Stottlemyre. The former Yankees righthander and pitching coach was out of baseball by 32 because of a torn rotator cuff. The Society for American Baseball Research said Stottlemyre was given cortisone injections in his shoulder years before he was diagnosed with the tear in 1974, the last of his 12 years in the big leagues. He was released the following season.

New protocols for treating shoulder injuries began appearing during the last decade and the number of operations declined. The advent of platelet-rich plasma and stem cell treatments also warded off surgery.

But the advancements didn’t come soon enough to help former All-Stars Mark Gubicza, Mark Mulder and Mark Prior, who share similar stories about trying to make it back from shoulder surgeries.

“Complete and utter frustration,’’ Mulder, 40, said from Scottsdale, Arizona. “I remember thinking to myself, ‘I’m never going to come back from this.’ ”

Mulder said he visited Dr. Lewis Yocum, another renowned orthopedist, in 2007 and was told, “The shoulder to us doctors to this day remains somewhat of a mystery.’’ Yocum also told him he fell into the percentage of those who would not come back after surgery. “Knowing that gave me relief,’’ Mulder said. “You can only get hit over the head by a bat so many times before you finally go ‘enough.’ ’’

Gubicza, 55, speaking from Anaheim, said, “I still have to take a few Advil to this day’’ when he tries to throw recreationally.

Prior, 37, a bullpen coach with the Dodgers, added, “You start talking about interior capsule surgery, tears, and compound that with the rotator cuff, I knew it was an uphill battle.’’

Of those three, only Gubicza, who had surgery at 27, was able to remain in the big leagues beyond 30.

If the surgeries weren’t working, why did the procedures continue?

“That’s a good question,’’ Astros team doctor David Lintner said from Houston. “The prevailing belief now and then was you only operate on a pitcher’s shoulder when they just can’t be effective as they are. You’d only embark into the surgical theater when everything else has failed. [But] the natural tendency is to fix what’s damaged, whether it’s the labrum or the rotator cuff.’’

Yankees team physician Christopher Ahmad added, “Number one, when we first started learning about diagnosing shoulders with MRI scans, we found a lot of problems in the throwing shoulder. MRIs showed us that they have labral tears and rotator cuff tears. And because there were tears, we got aggressive and fixed them. We thought we were doing a good job, but what ended up turning out after we operate on them and fix them, they weren’t coming back the way we wanted them to. The return to play at the same performance was terrible, less than 50 percent by far, some studies being as low as 30 percent. So our enthusiasm for operating started to drop.

“You start getting MRIs of pitchers’ shoulders, pitchers who get a pain in their shoulders, you’ll see tearing of the rotator cuff,’’ Ahmad continued. “It doesn’t necessarily mean a full tear, so when you have a pitcher that’s throwing with pain in his shoulder, unable to get better and [MRIs] that say ‘uh, oh, the rotator cuff is damaged,’ the reasonable conclusion is that damage is the culprit. So when all else fails, you proceed with surgery, which was the rationale of the time. Experience is the greatest teacher, and what we found with rotator cuff repairs, which in the general population is very successful, in the throwing population, not so much.’’

MLB medical director Gary Green said it would be “fairly accurate’’ to term the success rate of past rotator cuff surgeries at 55 percent. The degree of success, however, is unknown.

As for the success rate of Tommy John surgery, Green referenced pitchsmart.org, a website founded in 2014 by MLB and USA Baseball. According to the site, “Most studies have concluded that 70-80 percent of pitchers return to their previous level of competition following surgery assuming that they follow rehab protocols.’’

TREATMENTS TO AVOID SURGERY

Rangers team physician Keith Meister said new conditioning techniques have become the protocol for warding off shoulder-related injuries. “Our pre-rehab programs are far better at targeting weak areas of the throwing shoulder,’’ he said from Arlington. “A more inclusive program to include lower-body and upper-body conditioning in an offseason program that better protects the throwing shoulder. A lot of the stuff that doesn’t end up in the statistics are the short periods of inflammation that a shoulder has that used to alarm us. We see changes on the MRI and we panic. We’d be much more aggressive in our treatment where now there’s a much more hands-off approach. Hands off meaning non-surgical.’’

The advent of platelet-rich plasma and stem cell treatments also warded off surgery. Bartolo Colon’s prolonged stay in the major leagues was aided in 2010 by the stem cell procedure, which extracted stem cells from his own bone marrow. The treatment was used to repair Colon’s partially torn rotator cuff and ligament damage in his elbow and shoulder. His missed the 2010 season but returned in 2011 and is in the Rangers’ rotation this season at 45.

A handful of pitchers were helped by shoulder surgery. Roger Clemens returned from rotator cuff surgery early in his career.

Orel Hershiser was a big success for Jobe, who performed anterior labrum reconstruction in 1990, two seasons after Hershiser set the major league record for consecutive scoreless innings at 59. Hershiser, now a broadcaster with the Dodgers, said there was minimal tearing of the rotator cuff but added, “It was supposed to be career-ending. Dr. Jobe looked at me [before the surgery] and said, ‘Sorry.’ But he let me start throwing at about 11 months and I made it back to the big leagues in 13 months.’’ Hershiser pitched another 10 seasons.

Two-time Cy Young Award winner Bret Saberhagen, who pitched for the Mets for three-plus seasons in the 1990s, had surgery performed by Altchek in 1995 to remove dead tissue from his rotator cuff and shoulder and to repair ligament damage. He had two good seasons with the Red Sox after that.

But surgical failures appeared to outweigh the successes. Santana, a two-time Cy Young Award winner, had surgery at 31 in 2010 for torn ligaments in his right shoulder and pitched in only one more big-league season. Agent Peter Greenberg did not respond to requests to make Santana available for an interview.

Nen, the former Giants All-Star closer, had 129 of his career 314 saves from 2000-2002. He had two saves against the champion Angels in the 2002 World Series. But he had persistent problems with his rotator cuff, underwent three surgeries and never pitched in a big-league game again.

Gubicza said, “I would have loved to have had the opportunity for a PRP shot or a stem cell injection rather than going for surgery. I would have had my hand raised up in a minute. I would have loved to see what my career would have ended up being. I wish I had the technology out there right now to be a pitcher in this day and age.’’

Busby, who had a longer career as a broadcaster than as a major-leaguer, lamented what might have been. “The only thing I’ve said to myself is I wished I had the opportunity to find out,’’ he said. “We lost three straight playoffs to the Yankees [from 1976-78]. One more [healthy] pitcher might have put us over the hump, and I would have liked to have found that out. It got to the point where it was either surgery or retirement. And, at 25, that was difficult to stomach.’’