The 2023 American League Cy Young Award winner, Gerrit Cole, is on the injured list with elbow trouble. The 2022 AL Cy Young winner, Justin Verlander, is out with shoulder inflammation. The 2021 AL Cy Young winner, Robbie Ray, will miss the first half of the season as he makes his way back from Tommy John surgery. The 2020 AL Cy Young winner, Shane Bieber, just learned he will miss a year or more because his elbow needs surgery, too.

That list barely hints at the scale of what has become a full-fledged pitcher injury epidemic, one forcing Major League Baseball to confront the realities of a new era in which velocity, spin rate and swing-and-misses are chased with unprecedented myopia and rewarded with unprecedented payouts.

The full list of injured pitchers reads like a Cy Young ballot for an entire generation, packed with once-promising stars who never fully returned to form and established names who will have to bounce back to remain in pitching’s upper echelon.

In the past week alone, Nick Pivetta, Framber Valdez, Spencer Strider, Jonathan Loáisiga, Eury Pérez and Bieber joined the club of pitchers who will miss time because of elbow injuries or surgeries. That club already included Cole, Ray, Lucas Giolito, Shohei Ohtani, Jacob deGrom, Sandy Alcantara, Kyle Bradish, John Means, Luis Garcia, Félix Bautista, Shane McClanahan, Germán Márquez, Liam Hendriks, Tyler Mahle, Jeffrey Springs and Shane Baz.

But expand the parameters to include injuries of any kind, and the true range of the epidemic becomes clearer: Verlander, Max Scherzer, Brandon Woodruff, Clayton Kershaw, Kodai Senga, Eduardo Rodriguez, Josiah Gray and Justin Steele are all on the injured list. It is easier to list aces who are healthy than it is those who aren’t, but that would risk tempting fate: The reality of elite pitching in 2024 is that, even for the healthiest of aces, injury seems like only a matter of time.

Though the problem is escalating, it is not new. For the past decade or so, MLB has seen the number of Tommy John surgeries required by its pitchers rise steadily. Ten years ago, renowned orthopedic surgeon James Andrews declared the rising prevalence of the procedure, which repairs the ulnar collateral ligament in the elbow, “an epidemic.” It has only grown since. When Andrews announced his retirement earlier this year, he summed up his explanation in an interview with MLB.com: “These kids are throwing 90 mph their junior year of high school. The ligament itself can’t withstand that kind of force. We’ve learned in our research lab that baseball is a developmental sport. The Tommy John ligament matures at about age 26. In high school, the red line where the forces go beyond the tensile properties of the ligament is about 80 mph.”

MLB is conducting a wide-ranging study of pitchers at all levels to examine the origins of the issue and help develop recommendations to address it, according to a spokesman. That study is not expected to be completed before the end of this year.

The cause of the problem, most pitchers and baseball insiders agree, is multifaceted – though one would not know it from the way MLB and the players union have recently engaged on the matter. The union issued a statement last week offering concerns that the pitch clock, implemented before last year and shortened ahead of this one, is causing the jump in injuries because pitchers do not have enough time to prepare for each pitch.

MLB fired back in a statement of its own that cited a study conducted by Johns Hopkins, which has yet to be published, that it says found no evidence of correlation between pace and injury. MLB also scolded the union, saying its statement “ignores the empirical evidence and much more significant long-term trend, over multiple decades, of velocity and spin increases that are highly correlated with arm injuries.”

But while the governing bodies point fingers, the players seem more than capable of understanding that the problem is nuanced and difficult to solve. When he addressed reporters after a rehab outing last week, Verlander said that while it was easy to blame something like the pitch clock, “in reality, you put everything together, and everything has a little bit of influence.

“I think the biggest thing, the style of pitching has changed so much. Everybody is throwing the ball as hard as they can and spinning the ball as hard as they can. It’s hard to deny those results, obviously. It’s a double-edged sword. How can you tell somebody to go out there and not to do that when they’re capable of throwing 100? A young guy comes up, throws one 95 and gives up a big homer, everyone’s like, ‘What the hell, man?’ ”

The emphasis on velocity and spin rate at the major league level trickles into the offseason, too. Oakland veteran Alex Wood posted a thread on X in which he said pitchers throwing at moderate and high intensity through the offseason – presumably to maintain or build velocity and spin rate – is “being overlooked” in the discussion about injuries.

“When I first came into professional baseball in 2012 as soon as the season ended I usually wouldn’t touch a baseball until at least December and I definitely wouldn’t be off a mound until at least sometime in January. I knew a few veteran players (All Star types) that wouldn’t even throw their first bullpen until they got to spring training in February!!” Wood wrote. “If you told a young player today that they had to take 8-10 weeks off throwing in the offseason and couldn’t touch a mound until at least the middle of January they would think you were crazy.”

Indeed, MLB has tried to address the changing approach to pitching many times over the past few years. It cracked down on sticky substances, used to better grip the baseball, to try to limit skyrocketing spin rates. It implemented a three-batter minimum to prevent relentless matching up late in games. But at times, the concern has felt more aesthetic than health-related: The starting pitcher used to define games, to serve as the big draw, eat innings and ensure there weren’t more pitching changes late in games than runs scored.

MLB and its players discussed several solutions to this problem during their most recent collective bargaining negotiations. Scherzer, for one, was a proponent of the double hook – take out the starter, lose the designated hitter, a rule he and others believe would force teams to leave starters in longer. That idea, like many others, remains on the table.

Yet the problem is not just that teams are pulling starters earlier in favor of high-octane relievers but also that more and more starters are not as capable of pitching late into games when given the chance. The same problem exists when it comes to rules limiting the number of pitchers a team can carry: The goal of such a rule is to force teams to leave pitchers in games longer because they have fewer options to replace them. Pitchers knowing they need to pitch longer, the thinking goes, would have to limit the number of pitches they throw with max effort to throw more pitches total, which could reduce strain.

But many of today’s more elite pitchers became elite largely by building themselves and their repertoires around maximizing spin rates and velocity. Those that have had success and earned big checks one way seem unlikely to dial things back voluntarily. And if they do, more change could mean more injury risk. Changing how teams can use pitchers does not guarantee those pitchers will change how they pitch.

What, then, could actually solve the problem? Well, one hard-to-fathom option would be to limit how hard pitchers can throw or limit how much spin their pitches can have. If a pitch is over 100 mph, for example, it’s a ball. If a fastball has a spin rate above 2,500 revolutions per minute, it’s a ball. The idea is, at the moment, as uncomfortable as it is unrealistic. But drastic change might be needed.

While no one aches for billionaire owners losing millions in salary to pitchers who cannot pitch, fan bases do ache for rotations picked apart by injuries year after year. Winning the World Series requires winning the war of pitching attrition, which often means playing the biggest games of the season without the very starters paid to pitch them. As data has forced the industry to redefine elite pitching ability, it also has diminished the definition of durability. The pitcher injury epidemic has reached crisis proportions, and a vaccine is nowhere in sight.

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