Tommy John Surgery – The alternatives to UCL reconstruction surgery
In this article Ross Hauser, MD discusses Tommy John Surgery options.
If you have questions about Tommy John Surgery options, send them in by emailing
If you are reading this article you are likely a baseball pitcher or a parent of one who needs to explore the options in the treatment of a torn or ruptured ulnar collateral ligament in your elbow. You have a great deal of urgency in finding solutions.
Let’s get to some updated research and bullet points:
February 2018, the Journal of shoulder and elbow surgery, doctors at New York University Hospital for Joint Diseases publish these observations:
- Data for 35 Major League Baseball positional players who underwent medial ulnar collateral ligament reconstruction during 31 seasons were obtained.
- Individual statistics for the 2 seasons immediately before injury and the 2 seasons after injury included wins above replacement (WAR), on-base plus slugging (OPS), and isolated power (ISO).
- Of the 35 athletes who underwent surgery, 7 did not return to their preinjury level of competition (return to play rate of 80%).
- In comparing preinjury with postinjury statistics, players exhibited a significant decrease in plate appearances, at-bats, and WAR 2 seasons after injury but did not demonstrate declines in WAR 1 season after injury.
- Compared with matched controls, athletes who underwent MUCL reconstruction did not demonstrate significant decline in statistical performance, including OPS, WAR, and ISO, after return to play from surgery.
- Of all positional players, catchers undergoing surgery demonstrated lowest rates of return to play (56%) along with statistically significant decreases in home run rate, runs batted in, and ISO.(1)
We are going to get to more research below in analyzing data, but one thing that is pointed out in many research studies. These are Major League Baseball players with huge medical staff’s behind them and the latest in healing technology. This is usually not the treatment follow up that a 16 or 17 year old or mid-20s independant or low minor league player gets.
In January 2018, doctors at the Mayo Clinic and the Hospital for Special Surgery in New York published in the Current reviews in musculoskeletal medicine as summary of recent findings:(2)
- Nonoperative options for UCL injuries include guided physical therapy and biologic augmentation with platelet-rich plasma (PRP).
- In some patients, repair of the UCL has shown promising return to sport rates by using modern suture and suture anchor techniques. (There are companies who produce “surgical kits,” which help standardize the surgery and the outcomes. The modern techniques of surgery attempt to improve on the tunnels in the bone that are drilled and the screw fixation of the transplanted tendon.)
- Proximal avulsion injuries (where the ligament has pulled a chip of bone off) have shown the best results after repair.
- Currently, there is growing interest in augmentation of UCL repair with an internal brace.
- (Note the internal brace method is intriguing in its concept especially for a Prolotherapy doctor. Here there is no reconstruction surgery but rather, the damaged ligament is repaired with suturing techniques and the wrapped in a collagen based fiber tape as the internal brace. This sounds like the Prolotherapy concept. Injections instead of suture repair the ligament. The Prolotherapy injections bring repairative collagen to the area and patch, rebuild, and strengthen the ligament. Contact me via email using the form at the bottom of the page to discuss this further).
The summary conclusion of this research presents today’s reality:
- The treatment of UCL injuries involves complex decision making.
- UCL reconstruction remains the gold standard for attritional injuries and complete tears, which occur commonly in professional athletes.
- However, non-reconstructive options have shown promising results for simple avulsion or partial thickness UCL injuries.
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
It is now pre-season for the 2018 baseball season. Pitchers who have had Tommy John Surgery and had results that may not be as successful as hoped face a new reality, multiple surgeries. Sports Illustrated ran a story in 2015 “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 their pitching arms time to heal not only the surgery, but micro tears in the shoulder and wrist.
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 and iconic 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.
The Tommy John Surgery Epidemic
Let’s start looking at the numbers and make some connections.
In a 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.(3)
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.”(4)
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.”(4)
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.(5)
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.”(6)
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.(7)
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.
In a presentation lecture at the American Academy of Orthopaedic Surgeons Annual meeting 2014, presenters suggested that pitchers who returned to the Major League Baseball 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.(8) Study highlights:
- 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.”
In the Journal of Elbow and Shoulder surgery, the Los Angeles Doctors, Dr. Jobe, and doctors at the Hospital of Special Surgery in New York released these 2016 findings:
- Since 1999, 235 MLB pitchers have undergone Tommy John surgeries;
- 31 pitchers (13.2%) underwent revision surgery, and
- 37% underwent revision within 3 years of the index procedure.
- Twenty-six revisions had more than 2 years of follow-up;
- 17 pitchers (65.4%) returned to pitch at least 1 major league game, whereas only 11 (42.3%) returned to pitch 10 or more games.
- Of those who returned to MLB competition, the average length of recovery was 20.76 months. Compared with controls matched for age and position, MLB pitchers undergoing revision surgery had a statistically shorter career after revision surgery (4.9 vs 2.6 seasons, pitched fewer innings, and had fewer total pitches per season.(9)
Appearing 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.
Alternative to Tommy John Surgery
Clearly the best alternative to Tommy John surgery is to avoid the need for the surgery by monitoring pain, elbow instability, and allowing the elbow to heal. For detailed discussion or pre-surgical elbow instability, please read our article on Comprehensive Prolotherapy and PRP tennis elbow injections
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.(10)
The Los Angeles Angels will present a rare opportunity for fans, players and even doctors to see two pitchers in action in 2018, one who refused the Tommy John surgery, one who had it.
- Los Angeles Angel pitcher Garrett Richards is entering the 2018 ready to go, after two years of elbow problems and refusing the Tommy John procedure, Richards signed a one year 7.3 million dollar contract for 2018. Richards had stem cell therapy, see below.
- Los Angeles Angel pitcher Andrew Heaney who had Tommy John surgery in 2016 and returned leate in 2017, agreed to a one year $800,000 contract for the 2018 season.
January 27, 2018 Texas Ranger pitcher Keone Kela hopes stem cell therapy will help him pitch without the need for Tommy John Surgery
(Texas Ranger pitcher Keone) Kela tried stem-cell therapy to help the shoulder. Cells were removed from bone marrow in another part of the body and injected into the shoulder. Bone-marrow cells are used most often for cartilage, ligament and tendon repair.
The treatment is being used more often by pitchers, usually in hopes of avoiding major surgery. Bartolo Colon, in 2010, is the first pitcher known to have had the procedure. It helped Los Angeles Angels starter Garrett Richards avoid Tommy John surgery but did not have the same effect on teammate Andrew Heaney.
Kela said the treatment has helped. He has been throwing on flat ground from about 75 to 90 feet with no difficulty.
“I feel elastic,” Kela said. “The body feels good. The arm feels good. I’m ready to go.”
If you are being recommended to surgery, what is realistic as far as alternatives go?
First step is to determine if there is a complete rupture or disintegration of the ligament or if it is a partial tear/rupture. The next step is to seek out experienced doctors in both surgery and stem cell therapy or Stem Cell Prolotherapy.
Are you a candidate for our non-surgical treatments? Contact us
References for this article
1 Begly JP, Guss MS, Wolfson TS, Mahure SA, Rokito AS, Jazrawi LM. Performance outcomes after medial ulnar collateral ligament reconstruction in Major League Baseball positional players. Journal of shoulder and elbow surgery. 2018 Feb 1;27(2):282-90.[Google Scholar]
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9. 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. [Google Scholar]
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