No single medical procedure has had more impact on a sport than Tommy John surgery on baseball. Thirty-seven years after the first procedure to repair a pitcher's torn elbow ulnar collateral ligament (UCL), professional and collegiate baseball are in the midst of an epidemic of elbow injuries and surgery. A recent survey of Major League Baseball revealed that 25 percent of all pitchers had prior Tommy John surgery, and 17 MLB pitchers have already had the operation this year.
More pitchers had the surgery in 2014 than during the entire decade of the 1990's. Although it is clear that many players have been able to salvage their careers with the surgery, the operation has a dark side that the public and media have largely ignored.
The struggles of Jarrod Parker of the Oakland Athletics to recuperate his chronically damaged throwing elbow sadly point out the dangerous reality of Tommy John surgery. You are always one pitch away from disaster. The former first-round pick was throwing heat in Nashville 13 months after undergoing his second Tommy John repair, when he felt a sharp pain at the surgery site and experienced immediate elbow swelling. X-rays of the swollen arm confirmed the worst: he had fractured his elbow at the medial epicondyle.
He recently had surgery to fix the injury and now faces the loss of another season and perhaps the end of his career.
The disturbing part of all this is that after nearly a quarter-century of trying to eradicate elbow injuries in baseball through pitch count control and biomechanical analysis, more pitchers than ever are sustaining UCL injuries and turning to surgery—many for the second or third time. In 2014 alone, 50 percent of MLB UCL repairs were for revision. A recent survey of coaches, players and parents uncovered some glaring misconceptions about the procedure. For example, one third of coaches and parents and over half of all high school and college athletes believe the operation makes even healthy elbows stronger and enhances the ability to throw faster. News flash—it doesn't.
Let's take a close look at this and the other top-five myths about Tommy John surgery:
1. I'll throw harder after surgery.
False. You'll actually throw slower and less accurately. Analysis of MLB pitchers after Tommy John surgery has demonstrated performance declines in ERA, strike-zone accuracy, batting average against, walks plus hits per inning, innings pitched, percentage of fastballs thrown, and average fastball velocity.
2. The surgery is completely safe. Right?
Wrong. The complication rate after Tommy John surgery averages 20 percent, making it one of the riskiest procedures in orthopedic surgery. Ulnar nerve injury is so common after the procedure that many surgeons actually permanently move the nerve to the front of the elbow during the procedure. Other potential problems include infection, graft failure, and a persistent risk of elbow fracture—sometimes more than a year after the surgery, as Jarrod Parker and the Atlanta Braves' Gavin Floyd can attest.
3. At least surgery will get me back to where I was.
Maybe. One of the dirty little secrets of Tommy John surgery is that only 80 percent make it back, and only 67 percent stay on more than a season after primary surgery. The average career span after successful first-time surgery is less than three seasons, and the numbers are even worse for those unfortunates who re-injure their elbows and need revision.
4. That's OK, recovery after surgery is quick. I'll be back on the mound in a few months.
Ah, no. The average time to return to high speed throwing is 12 to 18 months, with nearly a year of arduous physical therapy required. The irony is that Tommy John himself suffered ulnar nerve problems after his surgery and took over three years to return to pitching.
5. All right, at least once I get back, I'll be good to go.
Wrong again. In fact, 25 percent of pitchers who have first-time Tommy John surgery need additional surgical procedures; 34 percent go on to have throwing shoulder problems; and 57 percent return to the disabled list at least one more time. The revision rate is rising, and Major League Baseball is getting wise to the whole situation. More pitchers have escape clauses in their contracts that allow professional clubs to jettison them if they finish the year on the DL, or punish them as they enter their arbitration year. Fear of Tommy John surgery is now leading many players to opt for less lucrative multi-year deals to give themselves some sense of security.
What can you do? The human elbow was never designed to withstand repeated high velocity throwing. In the lab, the UCL breaks at 32 newton meters torque (rotational force). The average fastball causes at least 55 newton meters elbow torque. That's like trying to throw five bowling balls at once. You don't have to be a math whiz to see the problem.
The best way to deal with Tommy John surgery is to never have it in the first place. Fix your pitching mechanics while you still can. Mix up your pitching speeds. Pay close attention to pitch count and innings pitched. Try not to pitch year round. Rest your arm whenever possible. If you do shred your elbow ligament, try to rehabilitate it before considering a trip to the operating room. Even Tommy John would tell you that.
- Conte SA, Fleisig GS, Dines JS, Wilk KE, Aune KT, Patterson-Flynn N, El Attrache N: "Prevalence of ulnar collateral ligament surgery in professional baseball players." Am J Sports Med, 2015; 43(5): published online before print April 29, 2015, doi:10.1177/0363546515580792
- Bell S: http://espn.go.com/mlb/story/_/id/12648769/what-missed-tommy-john-surgery
- Ahmad C, Grantham WJ, Greiwe RM: "Public perceptions of Tommy John surgery." Phys Sports Med. 2012; 40(2). doi: 10.3810/psm.2012.05.1966
- Makhni EC, Lee RW, Morrow ZM, Gualtieri AP, Gorrochurn A, Ahmad CS: "Performance, return to competition, and reinjury after Tommy John Surgery in Major League Baseball: a review of 147 cases." Am J Sports Med, 2014; 42(6): 1323-1332.
- Osbahr DC, Cain EL, Raines BT, Fortenbaugh D, Dugas JR, Andrews JR : "Long-term outcomes after ulnar collateral ligament reconstruction in competitive baseball players: minimum ten-year follow-up." Am J Sports Med, 2014; 42(6): 1333-1342.
- Marshall NE, Keller RA, Lynch JR, Bey MJ, Moutzouros V: "Pitching performance and longevity after revision ulnar collateral ligament reconstruction in Major League Baseball pitchers." Am J Sports Med, 2015; 43(4): 1051-1056.
- Kheri J: "The Tommy John epidemic: what's behind the rapid increase of pitchers undergoing elbow surgery?" March 10, 2015: http://grantland.com/the-triangle/tommy-john-epidemic-elbow-surgery-glenn-fleisig-yu-darvish/
- American Sports Medicine Institute: Position Statement for Tommy John Injuries in Baseball Pitchers, July, 2014. http://www.asmi.org/research.php?page=research§ion=TJpositionstatement
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