There were two usual elbow surgeries for baseball players and three possible outcomes.

Outcome 1: Tommy John surgery to reconstruct the ulnar collateral ligament for the second time in less than seven years. Outcome 2: Tommy John surgery and flexor tendon surgery. Outcome 3: Flexor tendon surgery.

Detroit Tigers left-hander Tarik Skubal, who needed flexor tendon surgery in mid-August 2022, went under the knife without knowing what procedure Dr. Neal ElAttrache, the head team physician for the Los Angeles Dodgers, would perform.

"Which one is he going to do?" Skubal said in late September 2023, recounting a pivotal moment in his young career. "I didn't know until I woke up. That's obviously a stressful thing."

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Skubal returned from flexor tendon surgery, and the 10½-month rehabilitation process, in July 2023 and made 15 starts to finish the season. He posted a 2.80 ERA with 14 walks and 102 strikeouts across 80⅓ innings, including a 0.90 ERA with four walks and 43 strikeouts across 30 innings in his final five starts.

He was worth 3.3 fWAR from July 4 through Oct. 1, ranking No. 1 among pitchers and No. 10 when including position players. When healthy, Skubal graded as the best pitcher in baseball last season.

"It's about being a more well-rounded pitcher and not just a fastball-only pitcher," Tigers manager A.J. Hinch said Sept. 24. "Very few pitchers can get away with being a fastball-only pitcher, especially as a starter. That was the difference for Tarik. It's just not being one dimensional."

Skubal — who turned 27 recently — is a dark horse candidate for the American League Cy Young Award in 2024.

To get where he is now, Skubal had to recover from the second elbow surgery in his baseball career and implement adjustments recommended by his pitching coaches.

"There's a lot of growth in this game, and you don't realize it," said Skubal, who enters his fifth MLB season despite only 75 games of experience. "I'm not saying I'm this experienced, veteran pitcher, but me as a rookie, I was in a much different place than I am right now."

The injury

Everything changed when Skubal walked off the mound Aug. 1, 2022, at Target Field in Minneapolis. He removed himself from the game after five innings and 77 pitches due to left arm fatigue. It was the day before the trade deadline, but the Tigers didn't trade Skubal.

Justin Wakefield, who trains Skubal at APEX Performance Facility in Arizona during the offseason, watched the game on TV and recognized the velocity decline in the fifth inning. Once Skubal didn't return for the next inning, Wakefield sent a text message in search of more information.

"He said his forearm wasn't loosening up," Wakefield said. "It's one of the scariest things as a pitcher, and especially as a trainer, you know the symptoms of things."

Skubal avoided the reality of his situation for the next two weeks.

He knew something was wrong, likely requiring another elbow surgery, but he didn't want to admit it. He rested, took anti-inflammatory medication, received hours of treatment and resumed throwing, only to face a setback. He went through that cycle a couple of times before accepting his fate.

ElAttrache reviewed the MRIs and determined Skubal needed Tommy John surgery, flexor tendon surgery or both. Before the procedure, Skubal asked ElAttrache to give him a new ulnar collateral ligament if there was even the slightest damage. After surgery, Skubal learned his flexor tendon had to be repaired, but his ulnar collateral ligament was in perfect condition.

A perfect UCL, thus avoiding Tommy John surgery, was the best-case scenario.

"There was some positive stuff because (ElAttrache) said, 'With your UCL, I couldn't have made it look better myself,'" Skubal said. "That gave me a lot of comfort, especially being that I already had Tommy John once. To have that surgery seven years ago and it still look really, really good with the volume of throwing I've done, I'm very confident in that. My arm feels great now."

Skubal underwent Tommy John surgery in 2016 at Seattle University. He missed the entire 2017 season, returned for the 2018 season and was selected by the Tigers in the ninth round (with the No. 255 overall pick) in the 2018 draft.

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A different pitcher, Los Angeles Dodgers right-hander Walker Buehler, needed the worst-case scenario in his exploratory surgery. The two-time All-Star pitcher landed on the injured list June 10, 2022, with elbow discomfort. Less than three months later, ElAttrache performed both Tommy John surgery and flexor tendon surgery.

It was Buehler's second Tommy John surgery in the span of seven years.

"Last offseason, I rehabbed and worked out every day from September all the way to when I flew to Lakeland in January to start my throwing program," Skubal said, "so from September through December. It was a lot of work, but when you come back and compete at the highest level, it's all worth it."

The rehab

After surgery, Skubal called Wakefield — his trainer since rehabbing from Tommy John surgery as a college athlete in 2016 and 2017 — to break down the four-month plan for the offseason.

Wakefield didn't include Skubal's left elbow in the workout program at the beginning of the offseason. In the early stages, the progression of the recovering left arm was guided by the physical therapist while Wakefield trained the rest of the body.

"But I do a ton of cross-education training, so his other arm and his legs," Wakefield said. "We would come up with ways he could hold the bar without using that arm. We got creative so that we could still attack and build the performance side of things as he's rehabbing."

In the later stages, Wakefield received clearance from the physical therapist and put Skubal through a series of exercises for his left arm. It was the final hurdle for Skubal to clear before starting his throwing program.

Skubal needed the strength of his recovering left arm to match the strength of his healthy right arm. Doing so was a step-by-step process. He increased the strength, increased the speed of movement and then increased the range of motion.

"The last box I needed to check: He needed to be completely symptom free," Wakefield said. "He needed to be able to move things fast, he needed to have full ranges of motion, and in the gym, nothing could hold him back. There's nothing gnarlier than throwing, and if you can't get through an exercise, there's no reason you should be throwing yet."

The workouts at the beginning of the offseason, even without the ability to use his left arm, helped eliminate setbacks in throwing program and were pivotal to the way Skubal performed once he returned to the mound. Maintaining strength in the offseason meant he didn't need to build strength in the season.

A lot of credit goes to Wakefield.

"I was doing every normal upper body exercise," Skubal said. "I would put my arm in a strap, and I would do some shoulder stuff without having to use my forearm. You have to get creative, and he's very creative. Some of the exercises, I'm like, 'Where the (expletive) did you come up with this?' But you get creative in those scenarios. I think it works."

The return

Skubal traveled to Lakeland, Florida, home of the Tigers' spring training facility, in January 2023 to continue his rehabilitation and begin his throwing program, more than four months after surgery.

He was blown away by the structure of the Tigers' throwing program, especially the progression of volume and distances.

"It's honestly the best throwing program in terms of progression," Skubal said. "My Tommy John throwing program (in college) was not like that. I had a very cookie cutter program, and this one was a little bit more dynamic in working with the athlete."

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Skubal completed his throwing program in Lakeland during spring training and Detroit during the regular season to stay close to the pitching coaches. He also spent time in Detroit between rehab starts.

The Tigers' pitching coaches — pitching coach Chris Fetter and assistant pitching coaches Robin Lund and Juan Nieves — assessed how Skubal's body moved based on data obtained from Hawk-Eye systems. The trio of coaches offered suggestions to optimize Skubal's body movements.

Skubal listened.

He tweaked his mechanics.

"I'm open to trying anything, and right when I tried it, it helped right away," Skubal said. "There are some limitations with my body, just like there are limitations with every thrower. Some things, there are other ways I can create that momentum and energy.

"I don't want to give away the secrets, but there are some things you can change with foot direction and where you put your weight on your feet that will help you a lot."

The mechanical adjustments led to a significant increase in four-seam fastball velocity, from averaging 94.1 mph across 21 starts in 2022 to 95.8 mph across 15 starts in 2023. Even better, Skubal didn't feel like he was exerting more energy to get to more velocity.

His mechanics felt easy and natural.

Skubal also changed his workout routine when he began his rehab assignment in early June. His offseason trainer takes a backseat to the Tigers' staffers during the season, but Skubal keeps in touch with Wakefield and consulted him about working out after his starts, rather than working out the next day.

"Once he has a start, go get his lift in and empty the tank," Wakefield said. "That's one thing we tweaked this year. As he's getting healthy, we wanted to try the new approach of keeping our high days high and our low days low. The following day, he can have a full recovery and doesn't need to have a strength day."

The Tigers' staffers, namely strength/conditioning coach Nelson Perez and performance coach Shane Wallen, helped Skubal understand what workouts were best for his body.

Skubal immediately applied the new workout routine.

He trusts his trainers with his career.

"I don't want to have another surgery," Skubal said. "I want my best baseball to be ahead of me."

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In 2023, Skubal ranked in the 100th percentile in expected ERA (2.28), 96th percentile in walk rate (4.5%), 96th percentile in strikeout rate (32.9%), 91st percentile in chase rate (33.5%) and 85th percentile in whiff rate (31.3%).

He threw 36% fastballs, 24.5% changeups, 20.6% sliders, 12.2% sinkers and 6.8% curveballs. He decreased the usage of the slider and increased the usage of the changeup between the 2022 and 2023 seasons.

The changeup, which had a whopping 50.6% whiff rate, is the best pitch in his repertoire and an elite weapon against right-handed hitters. He primarily uses sliders and sinkers in rare matchups with left-handed hitters.

"I'm still very confident in my slider, but I get a ton of right-handed bats," Skubal said, "and they're generally better at hitting (sliders) than changeups away."

Skubal, who doesn't become a free agent until after the 2026 season, recovered from flexor tendon surgery and implemented numerous adjustments. He changed his mechanics, workout routine and pitch mix, and he set himself up for what could be the best season of his young career.

He has all the makings of being the Tigers' ace for at least the next three seasons, as long as he stays healthy.

"I still get sore, but it's different," Skubal said. "I'm sore, but there's no stiffness. It's like if you worked out your arms. There are some positives. Maybe there was something wrong, or something going on, for years prior that I didn't know. I was like, 'Oh, this is how it always feels.' But it feels really, really good. The stuff coming out of my hand is the best that I've ever done it. I'm very confident with where I'm at."

Contact Evan Petzold at epetzold@freepress.com or follow him @EvanPetzold.

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This article originally appeared on Detroit Free Press: How Detroit Tigers P Tarik Skubal overcame flexor tendon surgery