Tommy John Surgery
Ross Hauser MD
It is now past the mid-point of the current baseball season and those pitchers who have had Tommy John Surgery has revealed this surgery may not be as successful as hoped–so much so that recently Sports Illustrated ran a story on the new reality for Tommy John Surgery: “Why 2-3 Tommy John surgeries could be new reality for some pitchers.”
Some baseball people have begun to question whether the surgery is actually bad for pitchers. In fact, many in the medical community are saying those who had great success with Tommy John Surgery may owe their “coming back stronger,” “more velocity,” simply to the rehabilitation process, these pitchers were forced to take a year or two off, it gave time to heal.
Below are some stunning statistics in regards to Tommy John Surgery. If you are reading this article as a baseball enthusiasts, please allow me to explain to the non-baseball audience this most famous of baseball related surgical procedures.
The surgical procedure is named for the iconic baseball player, then Los Angeles Dodger Tommy John. In this procedure – a surgical graft procedure – the ulnar collateral ligament is replaced with a tendon from elsewhere in the body (often from the forearm, hamstring, hip, knee, or foot of the patient). The procedure is common among collegiate and professional athletes in several sports, most notably baseball.
It is the only procedure now that can repair a complete rupture of the UCL ligament. This article will talk about rehab after this operation and alternatives to this surgery in partial tears. Surgery for partial tears has reached an epidemic with limited results as reported below.
The Tommy John Surgery Epidemic
Let’s start looking at the numbers and make some connections.
In this new paper from June 2016, the title of the research presentation says it all: “Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review.”
Here we have doctors from the New York University Hospital for Joint Diseases saying some remarkable things which confirm the research listed below.
“Medial ulnar collateral ligament injuries of the elbow that require surgical management are uncommon. There is growing evidence, however, suggesting that the incidence of UCL reconstruction procedures is rapidly increasing.” In other words elbow injuries are common and usually do not require surgery. Then , the researchers ask, Why are so many (a disproportionate number) of people getting surgery? – i.e., Tommy John Surgery.
They also noted that there was disproportionate numbers for patients between 15 and 19 years old. Prime baseball years for those with professional aspiration.1
Why the disproportionate number of surgeries: Because parents believe that the surgery will allow their sons to pitch better – this thinking has been cautioned against in many research findings we will now discuss.
Researchers from Columbia University in New York published their findings suggesting that perhaps the surgery is over-performed and that patient expectations of surgery is not what the surgery does. Listen to what they said:
“Reconstruction of the elbow ulnar collateral ligament, known as Tommy John surgery, is being performed with increasing frequency. . .
- The public’s perception of Tommy John surgery may be incorrect with regard to the indications, operative technique, risks, recovery time, and benefits obtained from the procedure.” 2
They developed a questionnaire to measure an individual’s perception of Tommy John surgery. 189 players, 15 coaches, and 31 parents completed questionnaires. Data were calculated and statistical analysis was performed.
- An incredible 30% of coaches, 37% of parents, 51% of high school athletes, and 26% of collegiate athletes believed that Tommy John surgery should be performed on players without elbow injury to enhance performance.
- Thirty-one percent of coaches, 28% of players, and 25% of parents did not believe number of pitches thrown to be a risk factor, and 38% of coaches, 29% of players, and 25% of parents did not relate pitch type (eg, curve balls) with risk of injury.
- Many players (28%) and coaches (20%) believed that performance would be enhanced beyond pre-injury level.
- Individuals underestimated the time required to return to competition. Twenty-four percent of players, 20% of coaches, and 44% of parents believed that return would occur in less than nine months.
Here is what the researchers concluded:
“This study is the first of its kind to investigate public perception of Tommy John surgery and has identified an alarming percent of players, coaches, and parents with misperceptions. Efforts should be made in our communities to better educate players, coaches, and parents regarding elbow ulnar collateral ligament injury in youth baseball players.”2
In other words, the perceptions of Tommy John surgery are very troubling.
The media’s role – glamorizing a surgery – spreading misconceptions
Researchers say that these misconceptions can be traced to media coverage. “The prevalence of medial ulnar collateral ligament (UCL) reconstruction is increasing in professional athletes and the delivery of baseball news by the media exerts a powerful influence on public opinion of the injury and surgery.”
These researchers then asked 516 members of the media a series of questions about the procedure.
- 45% did not know if an athlete needed an elbow injury as a prerequisite for UCL reconstruction and 25% believed the primary indication was performance enhancement.
- eighty percent recognized that pitching speed is typically reduced following surgery, but the remaining 20% felt that velocities actually increased compared with pre-injury velocities.
- Return to play: fifty-two percent overestimated the ability of pitchers to return to back to professional baseball and 51.2% believed return would occur in 12 or less months.
- Overuse injuries: less than half (48.4%) believed the use of pitch counts to be important in the prevention of UCL injury and 33.2% felt that throwing injuries were not preventable in adolescent baseball.3
Why would these players, parents and coaches believe this? Misconception of the surgery and how it is reported. There are studies that suggest incredible recoveries from the surgery. “Ulnar collateral ligament reconstruction with subcutaneous ulnar nerve transposition was found to be effective in correcting valgus elbow instability in the overhead athlete and allowed most athletes (83%) to return to previous or higher level of competition in less than 1 year.”4
How can you argue with surgical results like that? One doctor did. The doctor who invented the “Tommy John” procedure, Frank Jobe, M.D.
Dr. Jobe suggested that these results or increases in performance are generally due to two factors. The athlete’s increased awareness of training and conditioning and secondly – with increasing pitch load, pitchers velocity decreasing as the ligament becomes worn, frayed, lax. Following the procedure, and the months of down time, the procedure produces favorable results because they have a new “UCL”
The first is pitchers’ increased attention to conditioning. The second is that in many cases it can take several years for the UCL to deteriorate. Over these years the pitcher’s velocity will gradually decrease. As a result, it is likely that the procedure simply allows the pitcher to throw at the velocity he could before his UCL started to degrade.5
Realistic findings in the success of Tommy John Surgery and Return to Play
Major League pitchers who undergo more than one Tommy John surgery have a low rate of return to MLB play and have shortened careers after return.
Pitchers who returned to the MLB level maintained performance in several statistics such as earned run average and walks/hits per innings pitched; however, pitchers returned with a significantly decreased workload.6
Pitchers have a high prevalence of UCL reconstruction in professional baseball, with 25% of major league pitchers and 15% of minor league pitchers having a history of the surgery. 7
Appearing in January 2015 in the American Journal of Orthopedics, Brandon J. Erickson, MD wrote an editorial called the The Epidemic of Tommy John Surgery: The Role of the Orthopedic Surgeon. In this editorial Dr. Erickson discussed the realities of the surgery and rehabilitation period for young athletes and compared them to Major League Baseball pitchers.
Dr. Erickson cited that major leaguers even with an endless supply of rehabilitation facilities, trainers, etc, do not return to pitching competitively and consistently in the majors for more than 15 months after UCL reconstruction. The time commitment and rehabilitation required for these patients is staggering.
This is a reality lost on the parents of these children.
As mentioned above, some parents believe this surgery will help their child throw faster, longer, and more accurately. See below we are going to discuss the role of rest and reconstructive injection techniques.
Dr. Erickson’s editorial is in agreement with numerous research studies.
Recently doctors presented their findings on Major League pitchers who had the procedure: (Research presented March 11, 2014 at the American Academy of Orthopaedic Surgeons Annual Meeting).
- There have been 215 ulnar collateral reconstructions performed on Major League Baseball pitchers.
- There is a significant proportion of players (18%) who do not resume major league career.
- For those that return, a high proportion return to the disabled list, both for arm conditions (in general) and specifically for elbow pain (47% and 23%, respectively).
- Moreover, many performance statistics showed a decline following surgery, most notably in ERA, WHIP, opposing batting average, innings pitched, percentage of fastballs thrown and fastball velocity.”8
In January 2016 investigators revealed the following – Tommy John surgery problems are being underreported
- “The rate of revision Tommy John surgery is substantially higher than previously reported.
- For MLB pitchers, return to play after revision surgery is much lower than after primary reconstruction.
- The overall durability of MLB pitchers after revision (2nd surgery) ulnar collateral ligament reconstruction decreases significantly “9
Alternative to Tommy John Surgery
In recent research doctors tested a less invasive type procedure for reconstruction of the lateral ulnar collateral ligament of the elbow. Part of the reason was that patients continued experiencing elbow instability after the UCL reconstruction procedure. Their findings said conclusively more anatomic reconstruction techniques (different surgical techniques) did not reduce the risk of recurrent instability any better than the standard and conventional surgical procedure.10
In July of 2015 doctors utilized a “patch” of dermal allograft (skin/soft tissue processed from donor), and platelet rich plasma (PRP), and mesenchymal stem cells (MSCs) which had been shown to successfully improve healing in the rotator cuff and wrapped the reconstructed UCL in it as a “bandaid.” They found the patient has demonstrated excellent progress and has returned to activity.11
Doctors at the University of California San Francisco Medical Center say excellent data supporting recommendations to prevent elbow injuries (osteochondritis dissecans [OCD] and ulnar collateral ligament [UCL] injuries), such as pitch count and pitch type in baseball, but anatomic risk factors have not been thoroughly examined. Doctors looking at elbow pain in adolescent pitchers should look for clues in significant anatomical differences (such as inward or varus stress) in the pitching elbow injuries between UCL and OCD to help make the correct diagnosis.13
Stem Cell Therapy, Prolotherapy for elbow instability, and Platelet Rich Plasma Therapy are treatments that rebuild and strengthen ligaments without radical surgery. If the goal is more velocity, then these treatments may provide the ligament strengthen needed. Current research is proving this to be true: growth factor therapies are effective in healing musculoskeletal injuries. A recent article published in the British Journal of Sports Medicine showed favorable results for a specific growth factor therapy, platelet rich plasma (PRP) injections to the elbow.12
This study involved two groups of patients with elbow tendinopathy, or tennis elbow. Each of these patients had gone through unsuccessful physical therapy treatment for tennis elbow. For the therapy used in the study, each group had blood drawn to use as a treatment. One group had the blood injected straight back into the injured joint (autologous blood injection). The second group’s blood was centrifuged to separate the platelet-rich part of the blood that contains growth factors (Platelet Rich Plasma injection). All participants received two injections into the injured elbow spaced one month apart.
The results showed that 72% of the autologous injection group had favorable results while 66% of the PRP group had favorable outcomes. Both groups had low percentages of people who ended up getting surgery, with the PRP group at just 10% (lower than the autologous blood injection group).5
We see the results of PRP superior because we use PRP in conjunction with Prolotherapy. As noted in previous articles PRP is not a single injection to a single site and hope for the best? The above research performed exactly that, a single injection, delivered twice at a month interval. In our opinion that is not the way PRP should be administered. One of the basic tenets of why PRP would not be as successful as hoped is that joint instability usually does not come from a single lesion and therefore fixing a single lesion was not fixing the pain. The pitcher considering Tommy John surgery should consider an aggressive Platelet Rich Plasma treatment in conjunction with Prolotherapy.
But do professional pitchers and baseball team management have the patience to see these treatments through?
The likely answer is no. Teams have millions invested in players and they need to get that player on the field. Let’s look at a recent story from Major League Baseball reported by CBS News
Andrew Heaney headed for Tommy John surgery after stem-cell treatment fails
Heaney was hoping the stem-cell treatment would allow him to rehab his torn elbow ligament and avoid surgery
Heaney, as well as rotation-mate Garrett Richards, had been hoping to avoid surgery by using a stem-cell treatment alternative.
Dr. Steve Yoon at the Kerlan-Jobe Clinic in Los Angeles performed the stem-cell treatment on Heaney (and Richards), but admitted the therapy is somewhat experimental.
“The gist of it is we don’t fully understand how all of it works on a cellular level and how it works when you inject this material into an injured area,” Yoon said. “But anecdotally, meaning through experience over the years, we’ve seen good things happen with these type of ejections, with this type of material.”
Both Heaney and Richards only had partial tears of the elbow ligament, which is why they attempted to rehab the injury and avoid Tommy John surgery. A full tear is beyond repair. That automatically means Tommy John surgery. The timing of the surgery likely means Heaney will miss the entire 2017 season in addition to the remainder of 2016.
A few players have successful rehabbed partial tears, but they are in the minority. Most notably, Yankees ace Masahiro Tanaka. A pitcher by the way who has thrived on EXTRA rest.
Do clubs have the patience? Heaney received the injection May 16th – the club announced Tommy John Surgery June 30th. Reported by the Los Angeles Times, Heaney was on the mend after the first injection, an ultrasound showed healing. A second ultrasound 4 weeks later showed the healing had plateaued. Perhaps at this point a second treatment could have been considered.
References for this article
1 Mahure SA, Mollon B, Shamah SD, Kwon YW, Rokito AS. Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review. J Shoulder Elbow Surg. 2016 Jun;25(6):1005-12. doi: 10.1016/j.jse.2016.02.036.
2. Ahmad CS, Grantham WJ, Greiwe RM. Public perceptions of Tommy John surgery. Phys Sportsmed. 2012 May;40(2):64-72.
3. Conte SA, Hodgins JL, ElAttrache NS, Patterson-Flynn N, Ahmad CS. Media perceptions of Tommy John surgery. Phys Sportsmed. 2015 Nov;43(4):375-80. doi: 10.1080/00913847.2015.1077098. Epub 2015 Aug 26.
4. Cain EL Jr, Andrews JR, Dugas JR, Wilk KE, McMichael CS, et al.Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010 Dec;38(12):2426-34. Epub 2010 Oct 7.
5. Keri, Jonah (2007-09-13). “Interview With Dr. Frank Jobe”. ESPN.com.
6. Performance Metrics Before and After Tommy John Surgery in 160 Professional Pitchers
7. Liu JN, Garcia GH, Conte S, ElAttrache N, Altchek DW, Dines JS. Outcomes in revision Tommy John surgery in Major League Baseball pitchers. J Shoulder Elbow Surg. 2016 Jan;25(1):90-7. doi: 10.1016/j.jse.2015.08.040.
8. Marshall NE, Keller RA, Lynch JR, Bey MJ, Moutzouros V. Pitching performance and longevity after revision ulnar collateral ligament reconstruction in major league baseball pitchers. Am J Sports Med. 2015 May;43(5):1051-6. doi: 10.1177/0363546515579636. Epub 2015 Apr 10.
9. Conte SA, Fleisig GS, Dines JS, Wilk KE, Aune KT, Patterson-Flynn N, ElAttrache N. Prevalence of Ulnar Collateral Ligament Surgery in Professional Baseball Players. Am J Sports Med. 2015 Apr 29. pii: 0363546515580792. [Epub ahead of print]
10. Dargel J1, Boomkamp E, Wegmann K, Eysel P, Müller LP, Hackl M. Reconstruction of the lateral ulnar collateral ligament of the elbow: a comparative biomechanical study. Knee Surg Sports Traumatol Arthrosc. 2015 May 10. [Epub ahead of print]
11. Hoffman JK, Protzman NM, Malhotra AD. Biologic Augmentation of the Ulnar Collateral Ligament in the Elbow of a Professional Baseball Pitcher. Case Rep Orthop. 2015;2015:130157. doi: 10.1155/2015/130157. Epub 2015 Jul 9.
12. Creaney L, Wallace A, Curtis M, Connell D. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med. 2011 Sep;45(12):966-71. Epub 2011 Mar 15.
13. Lau BC, Pandya NK. Radiographic comparison of adolescent athletes with elbow osteochondritis dissecans to ulnar collateral ligament injuries and controls. J Shoulder Elbow Surg. 2017 Jan 10.[Epub ahead of print]