As winter gives way to spring and the smell of fresh-cut grass fills the air, people will emerge from their winter hibernation and begin the trek to baseball and softball parks. The crack of a bat, the pop of a ball hitting a mitt, and the chant of “here, batter, batter” will increasingly be heard as people of all ages turn their focus towards America’s pastime.
And, inevitably, throughout the season, many unfortunate pitchers will undergo one of the most famous procedures in all of sports – Tommy John surgery.
What Is Tommy John Surgery?
Most people who have spent much time around baseball have inevitably heard the words Tommy John injury. When we refer to a Tommy John injury, we are referring to the Ulnar Collateral Ligament or UCL.
Who is Tommy John surgery named after?
Tommy John was a professional baseball player who began his career in the early 1960s and played in the majors until the early 1980s. His career hit a bump in 1974 when he was diagnosed with a UCL tear.
Before 1974, a torn UCL was a career-ending injury to any high level baseball player. Up until that time, there were no good options to repair or reconstruct this ligament.
Mr. John was evaluated by a sports medicine doctor by the name of Dr. Frank Jobe in California. Dr. Jobe ultimately reconstructed Mr. John’s UCL with a new surgical technique, and thus the Tommy John surgery was born. Following the surgery, Mr. John was able to return to a high level of competition and resume his professional baseball career.
UCL Reconstructions Today
Today, over 40 years after the first UCL Reconstruction (Tommy John Surgery), there is almost an epidemic of UCL injuries in Major League Baseball pitchers. Baseballheatmaps.com compiles the MLB’s injury data on their website. According to that information, there were 17 UCL reconstruction operations in 2012, 28 operations in 2013, and 19 operations in 2014. The American Sports Medicine Institute’s position paper on Tommy John injuries states, this rise in professional UCL injuries corresponds to the sharp rise in adolescent UCL injuries that were seen in the late 90s and early 2000s. It is believed by many that a torn UCL in a professional pitcher is often the result of accumulated stress that has worn the ligament out over time. The injuries that are being seen now on a Major League level are likely related to the stresses these athletes underwent when they were in adolescence.
Signs of UCL Tears or Other Injury
From time to time, baseball or softball players may notice some pain on the inside (medial side) of their elbow. This may be a sign of ulnar collateral ligament or UCL injury. The following may also be symptoms of a UCL or Tommy John injury:
• pain with throwing
• decreased velocity
• numbness or tingling in the pinky and ring finger
• tenderness on the inside of the elbow
Some athletes may hear or feel a “pop” during a specific throw, but not every athlete will describe this “Uh oh, I just hurt my elbow” moment.
Is Tommy John Surgery Necessary?
If you are concerned that you or your young athlete may have an injury to their UCL, they should be evaluated by a sports medicine specialist or orthopedic specialist who commonly evaluates the elbow of throwing athletes.
These orthopedists may use magnetic resonance imaging (MRI) to evaluate the integrity of the UCL and rule out any other causes of the elbow pain. From there, the surgeon will decide if tommy john surgery is necessary.
Myths about UCL Tears
There is little debate among sports medicine specialists that Tommy John or UCL injuries are a problem at both the major league and amateur levels of baseball.
However, some myths are floating around ballparks that are worth addressing. Many of these misconceptions are addressed in the American Sports Medicine Institute's (ASMI) recent position statement for Tommy John Injuries.
FACT or MYTH?
Having Tommy John Surgery allows me to throw better and harder than before.
To some, this notion may sound crazy, but surveys and studies have shown that between 25-50% of amateur players, parents, and coaches believe this.
There have been some reports of athletes electively having surgery on a healthy elbow in hopes of increasing ability. Having surgery on a healthy elbow to increase ability is the wrong reason to have surgery.
Many athletes do return to a high level of play after surgery and some may throw harder post- surgery, but this increase in performance is more likely a result of fixing the damaged ligament and exhaustive work with physical therapists, strength coaches, and pitching coaches afterward.
If any athlete spent 6 months of dedicated time to work on mechanics and strengthening their arm, core, and legs there would likely be an increase in performance.
Most studies show that between 10-20% of pitchers don’t make it back to their previous pre-injury ability. The good news is that if you have an injury, 90% of pitchers can return to their previous level of performance.
It is time to have surgery if you have an injury and it is limiting your ability to play. You should not consider surgery on a healthy elbow because you think it will improve your ability to throw harder.
Throwing too many curveballs leads to UCL Tears and Tommy John Surgery.
Lots of research has been done on the biomechanics of pitching and throwing curveballs. That research hasn’t shown a big correlation between curveballs and elbow injury.
This is assuming that the athlete is strong enough and mature enough to throw a curveball with good mechanics. Some youth pitchers may have received proper coaching and may be physically mature enough to throw curveballs, but many don’t fall into this category.
The ASMI recommends that young pitchers and players follow these simple steps to help avoid injury related to curveballs.
- Learn basic throwing
- Learn fastball pitching
- Begin change-up pitching
If we lower the mound we can reduce stress and injury to the elbow.
There is still some debate about this one.
No clear evidence proves that throwing from a mound puts a significantly greater amount of stress on the elbow. The link to elbow injuries is likely more related to the amount of maximum effort throwing (pitching) instead of the mound height.
Lowering the mound height won’t by itself decrease injury if young pitchers are still throwing as hard as they can too often. You can reduce this “max effort throwing” by playing other positions and playing other sports.
I like the way the ASMI puts it. If a child has the goal of becoming a successful adult pitcher, then they should focus on being a young athlete who is a good pitcher, not just a youth pitcher.
Too much pitching leads to Tommy John injuries.
This one is true.
Generally, when an orthopedic surgeon operates on a torn UCL they find a ligament that has been frayed and repetitively injured over time. Elite Sports Medicine + Orthopedics and Nashville, TN orthopedic specialist, Dr. Burton Elrod, describes it like this:
You have seen those cartoons where the character is hanging off the edge of a cliff while hanging on to a rope. While he is hanging there the rope is popping strand, by strand, by strand. Eventually the rope tears.
Repetitive maximal effort throwing can “fray the rope”. In our culture, many players play in the traditional spring season, then play summer ball, then play fall ball, then take lessons, and repeat.
There has been a strong link shown between too much competitive pitching and injury.
How Can Your Prevent UCL Tears?
Ultimately, the goal with pitchers of all levels is to prevent injury to the arm.
Elite Sports Medicine and Orthopedics, Dr. Burton Elrod, who is considered one of the best orthopedic specialists in Nashville, TN and Franklin, TN, explains that with high level athletes (amateur or professional), there is a fine line between maximum performance and injury.
The goal is to maximize your ability and potential while at the same time taking the necessary precautions to avoid injury. The American Sports Medicine Institute has come with recommendations for both professional pitchers and youth baseball pitchers to reduce the risk of Tommy John injury.
The following recommendations are taken directly from the American Sports Medicine Institute’s (ASMI) position paper for youth baseball pitchers:
- Watch and respond to signs of fatigue (such as decreased ball velocity, decreased accuracy, upright trunk during pitching, dropped elbow during pitching, or increased time between pitches). If a youth pitcher complains of fatigue or looks fatigued, let him rest from pitching and throwing.
- No overhead throwing of any kind for at least 2-3 months per year (4 months is preferred). No competitive baseball pitching for at least 4 months per year.
- Do not pitch more than 100 innings in games in any calendar year.
- Follow limits for pitch counts and days rest. (See Below)
- Avoid pitching on multiple teams with overlapping seasons.
- Learn good throwing mechanics as soon as possible. The first steps should be to learn, in order: 1) basic throwing, 2) fastball pitching, 3) change-up pitching.
- Avoid using radar guns.
- A pitcher should not also be a catcher for his team. The pitcher-catcher combination results in many throws and may increase the risk of injury.
- If a pitcher complains of pain in his elbow or shoulder, discontinue pitching until evaluated by a sports medicine physician. Inspire youth pitchers to have fun playing baseball and other sports. Participation and enjoyment of various physical activities will increase the youth’s athleticism and interest in sports.
I find the recommendation to avoid radar guns particularly interesting.
We tend to like statistics in sports. We often ask questions like, how much can they lift, how fast are they, how far than they hit it, how hard can they throw, etc. I am guilty of this too.
Sometimes, I will ask athletes how hard they can throw when they come into our ortho clinic in Nashville, TN. I ask because it is a conversation starter.
The answer to that question will likely not affect the course of treatment or my evaluation of that player. However, by asking the question I have emphasized velocity.
Don't overemphasize velocity.
Velocity should not be a pitcher’s (or a medical provider) number one priority. The number one priority should be placed on getting batters out.
Chris Heston of the San Francisco Giants recently threw a no-hitter against the New York Mets while never topping 91 mph on the radar gun, proving you do not have to throw in the upper 90 mph’s to be an effective pitcher.
In addition, there is a very helpful smartphone app available. Throw Like a Pro: Throw Faster, Stronger, and Safer (by Abracadabra Health) is a $10 app designed by Dr. James Andrews and physical therapist Kevin Wilk. The app includes in-season and off-season strength work, pitch counters, and long toss programs that are in line with the ASMI’s recommendations.
Find an Elbow Doctor if You Are Hurt
One last thing – Let us help! I know that people generally get anxious about going to see a doctor. There is always a fear that an orthopedic doctor may give you bad news or recommend that you stop doing something you enjoy. That is not our goal at Elite Sports Medicine + Orthopedics.
Our mission is to provide unsurpassed orthopedic care to our patients so that they may pursue and maintain more active and healthy lifestyles. We want you or your child to continue participating in the sports and activities you enjoy, but we want that participation to be as safe and injury-free as possible.
Having a torn UCL is no longer career-ending to a professional or aspiring baseball player. The orthopedic specialists at Elite Sports Medicine + Orthopedics have vast experience with this athletic injury and the treatment options.
We would be happy to evaluate your athlete’s elbow pain and provide the corresponding treatment to enable them to return to activity as quickly and safely as possible. You can book an appointment with an elbow specialist in Nashville, TN or Franklin, TN.