Tommy John Surgery
Roddy McGee, D.O.
“And here’s the 2-2 delivery….the ball’s in the dirt and the runner will advance to second base without a throw.”
“The pitcher is grabbing at his right elbow, walking around the mound, and he seems to be grimacing…and now he’s signaling to the dugout. Here comes the manager and the trainer. Something went wrong on that last pitch and I think he’s going to be coming out of the game…”
The scenario described above has become a more frequent occurrence in baseball at the big league, college, and even high school level. Anyone with knowledge of the game immediately thinks one thing when observing such a situation – “Tommy John”. Like few other medical conditions and even other sports injuries, baseball players and fans know immediately when they hear the diagnosis what the treatment will be and what the return to play expectations are – an indication of how frequently the injury occurs, the high profile nature of the players involved, and the media attention it has received over the past 3 decades. In the recent past, it was acknowleged that one out of 9 big league pitchers has undergone the surgery. However, that figure has dramatically increased. 124 of the 360 pitchers that started 2013 on a big league roster have had the surgery at least once. It’s become an accepted occupational hazard.
Throwers, and especially pitchers, frequently injure the Ulnar Collateral Ligament (UCL), because of the tremendous forces across the medial, or inside part, of the elbow and the high number of times this is repeated over the course of their seasons. Elements that lead to UCL injuries are flawed mechanics, weaknesses along the athlete’s kinetic chain (hips, core, rotator cuff), and especially regularly throwing after the point of fatigue (one of the reasons so much attention is now paid to pitch counts).
The part of the pitchers delivery when the highest stress occurs is during the point when the arm is back (called “late cocking”) and then starts to come forward (called “early acceleration”).
Specific mechanical flaws have been shown to correlate with an increased risk of injury. If a pitcher’s foot lands in an open position (right handed pitcher’s foot pointing more towards the left handed batter’s box), his hips will rotate too soon, putting him at higher risk for injuries to the elbow and shoulder. The position of the shoulder and elbow at the time of foot contact has been shown to correlate with injury as well (90 degrees of abduction –elbow even with shoulder - and about 60 degrees of external rotation at foot contact is desired) “Leading with the elbow” specifically has been linked to pitchers with UCL injuries. This occurs when there is too much external rotation at foot contact and too much shoulder horizontal adduction (arm too far forward). Finally, the timing between rotation of the hips and the shoulders has to be right – “opening up early” or if the timing between the two is off leads to decreases in velocity and increased risk for injury. When should they occur? The peak of pelvis rotation should be about 1/3 of the time between foot contact and ball release and shoulder rotation peak should occur at about the halfway point of those two.
Fatigue is a significant factor when it comes to injury in pitchers. So, how much is too much? At the adolescent level, kids will increase their risk for needing surgery at some point if they throw greater than 75-80 pitches per game (4 x as likely to need surgery) and greater than 600 pitches in a season. Also, if they pitch more than 8 months out of the year they are at increased risk (5 x more likely to need surgery). K ids who said they sometimes pitch after feeling fatigue were 4 times more likely to need surgery, but if they regularly pitched after feeling fatigue they were 36 times (!) more likely.
What are signs of fatigue? Decreased velocity, more pitches out of the strike zone, and taking extra time between pitches can all be signs, and in the younger age group especially, this should be closely monitored. You can click here for a link to American Sports Medicine Institute’s position statement on youth pitchers - this includes pitch count recommendations as well as rest time between games pitched for youth, adolescent and higher level pitchers.
When a pitcher is experiencing elbow pain, its important that they be evaluated by a physician familiar with these injuries. Suspicion of a UCL injury is based on the player’s history, physical exam. Clues can be seen on plain x-ray, but often times these can appear normal. When a tear is suspected, an MRI of the elbow done after dye is injected into the elbow joint (called an arthrogram).
Initially, depending on the severity of the injury, pitchers with UCL injuries are taken through a trial of non-operative treatment. This includes a minimum of 6 weeks off from throwing, a directed physical therapy protocol, and then an interval throwing program to get them back to their level of competition. A recent study from Kerlan-Jobe shows promise in doing a PRP injection to help facilitate healing. If the patient fails conservative treatment and wishes to continue as a thrower, UCL reconstruction (“Tommy John” surgery) has been shown to be safe and effective at helping people return to baseball.
The surgery involves taking a tendon from the forearm (Palmaris longus) or thigh (gracillis) and securing it to the attachments of the ligament on the humerus and ulna. Various methods of fixation are used and have been shown to be effective. Our current technique is the Modified Jobe technique, described by Andrews. This involves weaving the tendon in a figure-of-8 fashion through bone tunnels drilled in the ulna and humerus. The native ligament is incorporated into the new reconstructed ligament. If the patient has ulnar nerve symptoms (numbness and tingling in the ring finger and small finger), an ulnar nerve transposition is done.
After surgery, the patient uses an elbow brace that limits their motion as the wound is healing and the graft is incorporating into the tunnels. Physical therapy begins and is initially focused on pain relief, decreasing swelling and regaining motion. The goal is to regain motion over the first 4-7 weeks. After that, strengthening begins and we focus on not only elbow flexion and extension but also scapular stabilization, rotator cuff strengthening, as well as lower body strengthening.
We begin an interval throwing program to gradually bring the players back to their competitive level. This usually starts around 3-4 months post op. The total return time after UCL reconstruction averages from 12-18 months.
The rate of success of the surgery has been reported to be as high as 90%. This information should be evaluated carefully however – in some of the reports on surgical outcomes, the number of patients lost to follow up was as high as 30%, so the true success rate could be much less than 9 out of 10. Also, no matter how well the surgery is done, some pitchers won’t progress in baseball because they simply aren’t talented enough.
Several factors go into determing how well a patient does. They include an appropriate surgical technique, compliance with the therapy program, correction of any mechanical flaws (which can be aided with use of a biomechanical evaluation with high speed video cameras), and even psychological factors. Limiting the number of pitches and innings in the first year back from the surgery may have a correlation with longer term success and reducing the risk for a repeat injury.
Some pitchers have been noted to have an increase in velocity following the surgery. This can be misleading. The surgery itself does not make someone’s arm stronger. The pitcher may have had a decline in velocity over time as a result of a failing ligament. Also a focused therapy and training program over a year’s time with rest from throwing can help with small gains. Finally, improvements in mechanics can help to maximize velocity.
Improvements in recognizing the injury and in treatment methods and surgical techniques have led to a substantial increase in the number of players undergoing the surgery. The keys to prevention have been outlined in this article – proper mechanics, an appropriate workload, and proper training and preparation. Despite all of these, a high number of pitchers are at risk for injuring the UCL. When the injury occurs, non-operative and operative treatments are available to help get them back in the game.