Dr. Schulz provides fresh perspectives on why surgeries have become more prevalent, especially among younger athletes.
Link to Article: What Tommy John surgery looks like today: Revision surgeries, internal brace procedures – The Athletic
In baseball, the words “Tommy John surgery” are uttered every day. And with a rash of injuries sidelining stars around the league, we are hearing the phrase more than ever. The number of injuries to pitchers’ ulnar collateral ligaments keeps rising, an epidemic swallowing the sport and leading to changes in the surgical landscape. But it’s no longer as simple as a pitcher tearing his ligament, going under the knife, and returning a little over a year later. Now there are many pitchers undergoing second, or even third, surgeries, known as revisions, with slightly different techniques and recovery times at play. And many players are gravitating towards a newer option, the internal brace procedure, which is adding a dimension to a seemingly familiar landscape. One thing is clear: Tommy John surgery, in its various forms, is going to continue to be an important part of baseball for the foreseeable future.
What is Tommy John surgery, exactly?
The ulnar collateral ligament is located on the inside of the elbow, attaching the upper bone of the arm, the humerus, to a forearm bone, the ulna. When a pitcher suffers an injury to their UCL, they may sometimes choose a conservative treatment plan, often consisting of rest and plasma-rich platelet injections. In many cases, this is simply delaying the inevitable.
“We often try it because there’s really nothing to lose with it,” said Eric Bowman, an orthopedic surgeon and the head team physician for the Vanderbilt Commodores and Triple-A Nashville Sounds. “There’s very little downside to it. It has growth factors and we hope that it provides a healing stimulus. But at least the data we currently have doesn’t really point to it being a huge boost for conservative treatment.”
Especially in the cases of substantive tears to the ligament, a full reconstruction is often required. The procedure we now know as Tommy John surgery originated in 1974, when orthopedic surgeon Frank Jobe performed the procedure on MLB pitcher Tommy John. The surgery involves replacing the existing UCL with a graft usually harvested from either a hamstring tendon, the Palmaris tendon in the forearm or a tendon from a cadaver. Surgeons attach the new tendon by drilling holes in the humerus and the ulna. The graft is then threaded through the two holes and secured by sutures, buttons or screws.
“When players like Sandy Koufax had torn up elbows, they didn’t have a procedure like this,” Bowman said. “When Tommy John was the first one that had it, that was a newer procedure, and all of a sudden we were able to get these players back to playing.”
Why has ‘TJ’ become so common?
At the major-league level, there were 275 pitchers who had Tommy John surgery last season, up from 190 in 2016.
But surgeons in the industry indicate the largest increases in UCL injuries are actually seen at the youth level. Tommy John surgery was once nearly unheard of for high school players. Now it is becoming common. As far back as 2015, one study indicated 56.8 percent of Tommy John procedures are performed in the 15-19 age group.
“I think it’s playing year-round,” said Dr. Brian Schulz, the team physician for the Los Angeles Angels and an orthopedic surgeon at the Cedars-Sinai Kerlan-Jobe Institute. “I think it’s early sport specialization, not taking time off and playing other sports. I think there’s a lot of kids that understand that velocity is a very important factor if they want to be a pitcher, and they’re doing weighted ball programs and velocity enhancement programs at a young age. You’re putting a lot of stress on the inner elbow doing that.”
At the MLB level, debate rages on about the cause of arm injuries. Is it the endless chase for velocity and spin? The adaptation of designer breaking pitches? Overuse stemming from childhood? The pitch clock?
“If you look at the average velo, that has ticked up quite a bit (from 90.5 mph on fastballs in 2008 to 93.9 in 2022),” Schulz said. “That’s probably the biggest risk factor, is the size of the player and the velocity that they throw.”
How does Tommy John impact performance?
Once viewed as a last-chance operation, Tommy John in the 21st century no longer has such a negative stigma. But the idea that all pitchers return from Tommy John as harder-throwing superhumans comes with misconceptions.
“Probably 10 years ago people were coming in and almost wanting it electively for their kids because they thought it would make them throw harder, which is crazy,” said Josh Dines, an orthopedic surgeon at the Hospital for Special Surgery who has also worked with the New York Mets and Los Angeles Dodgers. “And that’s the nicest way I can put it. It’s like assault and battery on your kid.”
Although the rate of athletes returning to play is high, the rate of players returning to the same level of play was “less frequent and took longer, with 67 percent to 87 percent of MLB pitchers returning in about 15 months,” according to a 2020 study. Plenty of pitchers have returned from Tommy John to have successful careers, but the road back can come with bumps. In 2022, Justin Verlander became the first pitcher to win the Cy Young Award in his first season back from a UCL reconstruction. John Smoltz is currently the only pitcher to have had Tommy John and be elected to the Hall of Fame.
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