Tommy John’s Elbow

What is the first thing you think of when you hear the name Tommy John? It may depend on when you were born. If you are of a certain vintage, the name may have dual meaning. It may conjure up memories of the man who holds seventh spot on the all-time wins list for left-handed pitchers in the Major Leagues. Hear that name in a sentence nowadays with the name of your favourite pitcher, and it most likely means their season is finished. If you are a baseball fan born in the 1980’s or later, you may know very little about Tommy John the man; the all-star left-handed pitcher who was given a remarkable second chance. At the time, the technique that would save John’s career was practically experimental, but it would turn out to be revolutionary. Today the name Tommy John is the nickname for a surgical procedure called “ulnar collateral ligament reconstruction” (not quite as easy to say, or remember). Just as the name carries dual meaning, it also carries a sense of bitter sweetness; it usually means a player has sustained a season-ending injury, but that player, like John, can be given that second chance. Tommy John was a four-time all-star, once before his surgery, and three times after that. He would go on to play 26 professional seasons, tying a record at the time for most seasons played (later to be surpassed by Nolan Ryan). He would collect 288 career wins, just shy of the prestigious 300 club. Truly, his was a sensational career, miraculous even given the circumstances. Today, the surgery, although career-prolonging, has become all too common, not only at the professional level, but also with much younger athletes. Ideas surrounding how to handle young pitchers, and control pitch and inning counts, as well as how to manage the dreaded “elbow soreness” have become important topics of conversation that swirl around the baseball world at every level of competition.

Before we go much further, let’s take a look at what the ulnar collateral ligament (UCL) is, and why it is important for pitchers. The UCL is a thick, triangular ligament on the inside of the elbow joint. It connects the inside forearm bone (ulna) to the upper arm bone (humerus), and prevents them from gapping apart during throwing movements. Without this ligament it would be difficult for a pitcher to transfer the momentum of the wind-up from their legs, to their trunk, through their arm, to the wrist and hand where the ball is released. The result of a poorly performing UCL would be a loss in velocity for a pitcher.

Ulnar Collateral Ligament (UCL)

Interestingly knuckleballer R.A. Dickey does not have an UCL in his right throwing arm. None. He was either born without one, or tore it very early in his pitching career without really noticing. Either way, Dickey was nearly forced to retire because of this discovery. He was a first round pick and was initially given a bonus offer of $810,000 from the Texas Rangers, when a team doctor noticed the strange angle at which Dickey was holding his right elbow in a photograph. Based on this observation, the doctor suggested further investigation of Dickey’s elbow. This is what led to the startling revelation that the UCL simply wasn’t there. Unfortunately for Dickey, this led the Rangers to withdraw their offer, and give him a new, much smaller one of only $75,000. This turn of events devastated Dickey initially, but amazingly, he reinvented himself. He converted to a knuckleballer, working his way back to the Major Leagues, and would go on to win the National League Cy Young award in 2012 with the New York Mets. Dickey’s story is truly amazing, but is more of the exception than the rule.

For pitchers, the UCL often becomes the vulnerable point in their biomechanical chain, their chink in the armour if you will. The UCL usually becomes injured, not with one single throw, but as a result of repeated micro-trauma after many throws. Sometimes there are inefficiencies in a pitcher’s wind-up; a core or hip muscle weakness, a lack of mobility in their hips, shoulders, or upper back. These issues may cause them to attempt to throw harder with their arm instead of generating more force from their lower body. Another possibility is the pitcher is simply throwing too many pitches. Too much load on the UCL without sufficient rest, to the point where the stress becomes additive, and the ligament begins to fail. Maybe the initial elbow soreness is ignored, and the pitcher continues to throw through the pain. Either way, there is a limit to the amount of stress the ligament can withstand, and it will eventually tear with too much loading.

So now we get to the part where Mr. Tommy John’s famous surgery comes into play. The year was 1974, and John, a member of the Los Angeles Dodgers, turned to orthopaedic surgeon Frank Jobe as a last hope to save his career. Since the technique was considered experimental, Dr. Jobe estimated the chances of it being a success at 1 in 100. Not exactly promising. But John had nothing to lose, so under the knife he went. Dr. Jobe made a small 3 or 4 inch incision on the inside of John’s elbow. Holes were drilled in the inside forearm bone (ulna), and upper arm bone (humerus) to accommodate the new ligament (graft). The new ligament is usually made from a tendon that is harvested from elsewhere in the patient’s body. Often it is from a muscle in the forearm of the same elbow that is being operated on, or from the opposite forearm. Usually the tendon of choice comes from a muscle called the palmaris longus. It is on the inside of your forearm, and has a long, thin, tendon. Once the tendon is harvested, it is woven in a figure 8 pattern through the holes that were drilled in the ulna and humerus, and anchored in place to form the new ligament. Another important factor here is that a nerve has to be relocated. There is a nerve that runs on the inside of your elbow called the ulnar nerve. It is the reason we have a “funny bone” around the inside of our elbow. The nerve is fairly close to the surface, so if you happen to bump the inside your elbow on something, it can directly contact the ulnar nerve, and briefly send numbness or tingling down into the forearm. As mentioned, this nerve must be relocated during the Tommy John procedure. The reason being, it is too close to the newly constructed ligament, and there is concern that it could be damaged during the procedure, or that subsequent scar tissue could interfere with its function. Following surgery, the elbow is immobilized with a splint for about a week, then a brace for about another 5 weeks to protect the new ligament. The rehabilitation process is very gradual, and it can be a good year or longer before the player is throwing with anywhere near their pre-injury velocity or pitch count. After the brace is removed, the player can gradually start to strengthen their elbow over the course of the next 4 months, as long as they don’t over-stress the new ligament. At the 4 month mark, the player can start to toss the ball without winding up. Then at 6 months they can start to throw with a small wind-up. At 7 months, they can throw off the mound, and at 9 months, provided they have full strength and range of motion and no pain, they may be able to return to competition, but won’t necessarily be pitching with pre-injury velocity. The new ligament is very delicate in the early going, thus the very conservative approach to returning to action.

The fact that this procedure is available, and that it can save a pitcher’s career is truly amazing, a marvel of modern medicine. It has become a staple, fortunately or unfortunately, in the current landscape of both amateur and professional baseball for fans and players. And although it exists as a safety net of sorts, it does not negate some unsettling trends that have come to light in the baseball world at large. For example a survey found that 50% of high school baseball players, and more than 25% of players, coaches, and media members believed that Tommy John surgery actually increased the strength of a healthy player’s elbow. This is completely false, but it is a very real belief that exists. To the point where there is the potential for a healthy young pitcher to consider having completely unnecessary surgery, and go through the rigorous rehab process mentioned earlier, because they think it will give them some sort of advantage. One would hope that surgeons would apply simple logic and restraint in these cases, but you get the idea.

Another trend which is a concern in the sporting world in general is athletes specializing to one sport, and often one position within that sport, at earlier and earlier ages, often playing throughout most if not the entire calendar year in one form or another. In terms of pitching, this results in an obvious increased risk of overuse injury to the UCL. The sheer volume of loading for the ligament increases in general if the athlete is only playing baseball, and doing so almost non-stop. Again, this is a trend that is not unique to baseball. Athletes, for one reason or another, are choosing to focus on one sport very early on. Perhaps there is a belief that this will increase chances at success, and lead to future opportunities, including scholarships, and even the chance to play professionally. For very young athletes however, one would have to assume that some if not all of the pressure to make such choices comes from parents or coaches. Playing multiple sports has the potential to contribute to a young player’s overall athleticism, and generally distribute load to various body parts, reducing the risk for overuse injury.

It is inevitable that a certain percentage of young pitchers will develop elbow soreness at some point in their careers if they throw enough pitches. However, upon detection of this soreness, crucial decisions must be made, by both players, coaches, and training staff. Often throwers are encouraged to more or less ignore their elbow soreness, and continue to throw despite the pain. This pain should be taken as the first warning sign that the UCL has sustained too much loading, and needs a rest. It may also indicate that a health care specialist should look at other movement inefficiencies the pitcher may be displaying. Either way, the player should have their elbow properly assessed, and they should undergo a proper throwing rehabilitation protocol depending on the results of the evaluation. As well, load on the injured elbow should be properly managed when it is time to start throwing again, and pitch counts should be instituted to help control this load. To date, the biggest risk factor for sustaining injury to the UCL that has been identified is too high of a pitch count. High pitch counts, and players that pitch almost year round have the biggest risk of injuring their UCL. Things like type of pitches have been studied as well, (i.e. throwing curveballs versus fastballs, etc.), but there is not enough evidence to conclusively say that one type of pitch carries a higher risk of injury than another.

Pitching at the Major League level is an ever-evolving practice, and something that is fascinating to consider. The average velocity of a starting pitcher’s fastball in 2018 was 92.8 mph, compared to between 88 and 89 mph in 2002. The reason for this dramatic increase most likely has to do with strength and conditioning practices, including working with weighted balls, and very specific training regiments. There is a distinct importance placed on being able to throw hard, with control. Hitters and pitchers are always looking for a competitive advantage. As pitchers get stronger and faster, it is important to remember that the UCL is a ligament. A ligament that covers the elbow joint, an area of the body that is subject to a significant amount of torque during a pitcher’s delivery. Just look at a picture of a pitcher just before they release the ball, and take note of what position their throwing arm is in, in particular, the elbow. Now again consider that the UCL is a ligament, a passive structure that can’t be directly strengthened. The fact that pitchers are throwing the ball with more force than ever before is most likely why careers, and innings pitched are getting shorter. As the performance of the average MLB starter hits a peak, the longevity of their career seems to be dropping off. We have gone from four to five man rotations, the leader in innings pitched will maybe hit 215-220 innings per season, where in the 1970’s the leader would be over 300, and over 260 in the mid 1990’s. Some teams are even moving away from traditional starting pitcher roles, using more of a bullpen approach right from the start of the game, where each pitcher will only throw a couple of innings. We will most likely never see another pitcher win 300 career games. All of this illustrates the importance of respecting a player’s pitch count in order to manage load on their arm. The UCL will not always necessarily be the weak link in the chain for every single pitcher, they certainly sustain other types of injury, but it is impossible to avoid stressing this ligament if you repeatedly throw a baseball hard. Teams may put either inning or pitch limits on a young prospect as they enter the MLB, or on a player returning from significant injury such as Tommy John surgery. Often these limits are determined at the start of the season, and once a pitcher hits the threshold, they are shut down for the year, whether they are experiencing elbow pain or not, or whether their team is in contention for the post season or not. Such was the case with Stephen Strasburg in 2012, when the Washington Nationals decided to shut their young star pitcher down after a pre-determined number of innings for precaution, despite being in contention for the playoffs. Difficult decisions like this have to be made, with the health and longevity of the athlete in mind.
The name Tommy John has come to represent more than an all-star MLB pitcher, and quite frankly even more than a career-saving surgical technique. When we unpack the implications of why players, both amateur and professional, are having the surgery as often as they currently are, it speaks to the current state of baseball culture. It reveals positive trends in terms of how teams and players are adapting to the reality that is competitive pitching, and putting thought into the longevity of a pitching career. It also sheds light on some of the misguided attitudes towards what the surgery can do for a player’s arm, and brings some focus to the larger discussion of the young one-sport athlete. Certainly at the time Mr. John turned to Dr. Jobe, his main thought was to prolong his own playing career. There would simply be no way he could anticipate the impact it would have on pitchers, or on the sport of baseball as a whole.


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