In the demanding arena of sports, particularly in baseball, an injury to the ulnar collateral ligament (UCL) in the elbow can be a career-altering event for pitchers. Tommy John surgery, formally known as UCL reconstruction, has emerged as a revolutionary procedure, transforming potential career endings into temporary setbacks.
This surgery, named after Tommy John, the first Major League Baseball pitcher to undergo it in 1974, offers hope and a second chance for athletes to return to their sport. Since its inception, over a thousand professional pitchers have benefited from this procedure. Remarkably, by 2023, over 35% of active major-league pitchers had undergone Tommy John surgery, marking a significant 29% increase since 2016. This highlights the surgery’s growing prevalence and importance in modern baseball.
Tommy John Surgery: A Landmark Innovation in Baseball
“The sheer number of individuals who have undergone this procedure, the countless pitching careers it has salvaged, is staggering. We are now in an era where Tommy John surgery is increasingly common,” notes Dr. Vasilios Moutzouros, an orthopaedic surgeon and chief of sports medicine at Henry Ford Health. “Without this surgical solution, one can only speculate about the current state of baseball.”
Dr. Moutzouros emphasizes the profound impact of this surgery: “It has redefined a sport, a feat achieved by very few surgical procedures or medical innovations.”
Delving into the Tommy John Surgery Procedure
“Tommy John surgery is essentially a reconstruction. It involves creating a new ulnar collateral ligament in the elbow,” explains Dr. Moutzouros. He clarifies that this surgery addresses the UCL, located on the medial, or inner, side of the elbow, which is commonly injured in pitchers due to repetitive stress. “Over time, pitchers often injure this ligament, leading to stretching or complete tears that necessitate reconstruction.”
Dr. Eric C Makhni, a sports medicine orthopaedic surgeon at Henry Ford Health, elaborates on the surgical technique: “In any ligament reconstruction, we utilize a graft—a ligament or tendon—from another part of the patient’s body.” He adds, “Frequently, we harvest a tendon from the wrist, known as the palmaris longus, or a hamstring tendon. This graft is then meticulously woven into tunnels drilled into the bones where the original UCL was situated. We secure it with sutures, effectively recreating the damaged ligament.”
Dr. Moutzouros points out the complexity of the surgery: “It’s not a straightforward procedure because the elbow is an exceptionally intricate joint to operate on.”
The Link Between Pitch Velocity and UCL Injuries
Research has increasingly highlighted the correlation between pitch velocity and the risk of UCL injuries. “Our research group has extensively studied this area, conducting motion analyses and utilizing wearable sensors to assess elbow torque,” says Dr. Makhni. “A consistent finding across our studies is the critical role of velocity.”
“The harder you throw, the greater the torque and stress exerted on the elbow. This has been consistently validated in various studies,” Dr. Makhni explains. “The highest risk is observed in young athletes who throw with excessive force.”
Dr. Moutzouros adds context to the biomechanics of throwing: “The human body isn’t naturally designed to repeatedly throw a baseball at 100 miles per hour. This inherent limitation distinguishes elite pitchers from those who cannot achieve such velocities, and also contributes to injury risk.”
Rising Prevalence of Tommy John Surgery Among Young Athletes
While Tommy John surgery is prominently associated with professional baseball, there’s an alarming trend of increasing surgeries among younger, school-aged athletes. Research indicates that by 2014, a significant 67.4% of UCL reconstruction surgeries were performed on athletes aged 16–20, and some even younger, in Little League.
Dr. Makhni identifies several contributing factors: “One major factor is the emphasis on throwing harder at younger ages. Additionally, young athletes who pitch and then play catcher on their ‘off’ days, or those who pitch year-round without seasonal breaks, are at increased risk.”
He cautions against single-sport specialization: “In youth sports, we generally advise against focusing on a single sport year-round. Playing the same sport continuously leads to overuse injuries in specific body areas.” He also points to improper training techniques, particularly the use of weighted baseballs.
“Weighted baseballs are a significant concern. It’s one of the first questions I ask young patients,” Dr. Makhni states. “They are marketed to rapidly increase velocity, often with false claims of no injury risk. However, the sports medicine community overwhelmingly recognizes the inherent risks.”
“No sports surgeon specializing in these injuries would advocate for the use of weighted baseballs,” he asserts. “They impose excessive stress on the elbow, directly increasing the risk of injury.”
UCL Injuries Beyond Pitchers: Expanding Patient Profiles
“In recent years, we’ve observed a rise in UCL injuries and subsequent surgeries in athletes who are not pitchers,” notes Dr. Makhni. “I have performed Tommy John surgery on catchers, infielders, and softball players. However, our data and research on return to play for these non-pitching athletes are less extensive.”
Dr. Moutzouros adds, “We also frequently see UCL injuries in football, particularly among defensive and offensive linemen. Interestingly, many football players tend to rehabilitate through these injuries without surgery.” He clarifies, “While UCL injuries are becoming more recognized in football, the incidence is nowhere near the levels seen in baseball.”
Determining the Necessity of Tommy John Surgery
Deciding whether Tommy John surgery is necessary is a nuanced process. Dr. Moutzouros explains, “Several factors are considered, including the duration of symptoms, the precise location of the injury, whether the patient has experienced this before, and if it’s a complete tear. Ultimately, it’s about understanding the patient’s overall situation and, crucially, their goals for throwing.”
He further clarifies, “Some individuals may not intend to continue throwing long-term beyond their current level, perhaps just for their high school team. In such cases, surgery might not be necessary.”
“Surgery is primarily indicated for individuals who are committed to competitive pitching in the future. This is the key takeaway,” Dr. Moutzouros emphasizes. “Tommy John surgery is most appropriate for those who plan to continue playing baseball at a competitive level.”
The Tommy John Surgery Recovery Timeline
“A typical recovery protocol begins with a period of rest and focused work on regaining range of motion. This phase can last up to six weeks, during which players often wear a brace and gradually restore elbow mobility,” outlines Dr. Makhni. “Weeks six to twelve involve more intensive arm strengthening, especially targeting the forearm muscles, and ensuring smooth, fluid motion.”
“Beyond twelve weeks, strengthening exercises intensify, and players may start light ball tossing as early as four months post-surgery,” he continues. “This is where recovery paths diverge based on the surgical approach. For primary UCL repairs, where the original ligament is repaired rather than replaced, athletes may return to pitching sooner compared to UCL reconstruction. Reconstruction requires more time for the grafted ligament to fully integrate and mature into the new UCL.”
Dr. Makhni provides typical return timelines: “Baseball pitchers undergoing a primary repair might return to game situations in approximately seven to ten months. For those undergoing reconstruction, the timeline is typically longer, ranging from nine to sixteen months, with a target of ten to twelve months for full return.”
High Success Rates of Tommy John Surgery
“The outcomes of Tommy John surgery are generally very positive, with a high degree of predictability for athletes returning to competitive throwing,” states Dr. Moutzouros. “Around 90% of individuals successfully return to throwing after the surgery.”
He clarifies common misconceptions about enhanced performance post-surgery: “The level of performance upon return is often debated – whether pitchers regain their pre-injury throwing velocity and accuracy. Data suggests they often do. However, the notion that pitchers consistently throw harder because of the surgery is inaccurate.”
Dr. Moutzouros attributes improved performance to comprehensive rehabilitation and training: “If a pitcher throws harder post-surgery, it’s generally due to successful surgery combined with dedicated rehabilitation and retraining of pitching mechanics. It’s not that the surgery inherently makes them ‘better,’ but rather that the focused recovery process sets them up for success.”
Repeat Tommy John Surgeries and Outcomes
“The outcomes of subsequent Tommy John surgeries, such as second or third procedures, are generally less favorable. They typically involve longer recovery periods and a reduced likelihood of returning to the same level of play,” cautions Dr. Makhni. “Revision surgeries often encounter scar tissue and potential bone fragments, making the procedure and recovery more challenging for the surgeon and patient.”
Despite the challenges, some professional pitchers have defied these odds. Jason Isringhausen and Jonny Venters are notable examples of major-league pitchers who successfully returned to play after undergoing Tommy John surgery three times.
Furthermore, the notion that pitchers cannot achieve elite success post-surgery has been disproven by pitchers like Jacob deGrom and Justin Verlander, who both won Cy Young Awards after undergoing Tommy John surgery.
Preventing UCL Injuries: A Proactive Approach
“Proper warm-up is crucial to prepare the arm for throwing,” emphasizes Dr. Makhni regarding injury prevention. He also raises concerns about pitch clocks potentially rushing pitchers and not allowing adequate recovery between pitches.
Dr. Moutzouros stresses the importance of balanced throwing mechanics: “To maintain arm health, it’s essential to warm up thoroughly and throw with consistent mechanics, avoiding ‘overthrowing’ or abruptly changing throwing style.” He also highlights the importance of cool-down routines.
“Adequate rest, both between pitching sessions and between seasons, is paramount,” adds Dr. Makhni. “We often recommend cross-training – participating in different sports throughout the year to provide the body with varied movement patterns and periods of rest from specific stresses.”
Dr. Moutzouros outlines a typical pitching rhythm: “A structured approach involves alternating active pitching sessions with rest days, light activity days, and bullpen sessions before full game days. This structured approach is why starting pitchers, especially those throwing over 60 pitches per outing, typically require four days of rest between starts.”
“Ultimately, creating an environment where athletes feel safe to communicate arm pain and take necessary breaks is the most important preventive measure,” concludes Dr. Makhni. “While ongoing education is needed, most individuals involved in youth and professional sports are genuinely committed to prioritizing athlete health and responding appropriately to pain and discomfort.”
