The Tommy John Epidemic

Tommy John surgery has become an epidemic in youth baseball. There has been a 9.2% increase each year in Tommy John surgery between 2007-2011. 15-19 year olds accounted for the largest population (56.7%) and 20-24 years were second at 22.2%. This makes sense because there are a greater number of athletes that play high school baseball compared to college. However, the rate continues to grow each year which is a concern.

In a 2012 study, researchers found that there was a relationship with pitch velocity and medial elbow adduction moments. This means that the higher the velocity, the greater the stress on the inner portion of the elbow. A result, youth pitchers that throw faster may be at an increased risk for injury.

It was recommended that coaches need to take into account velocity when considering work volume. For example, a pitcher that throws 100 pitches at 90 mph places significantly more stress on their elbow compared to a pitcher throwing 80 mph. Regardless of age, the harder a pitcher throws, the greater the stress.

The Mechanism of Injury:

Tommy John surgery repairs a torn Ulnar Collateral Ligament (UCL), which is on the inside part of the elbow. The ligament provides stability to resist valgus force, which means that it provides stability in the late cocking phase of cocking. This is the phase of throwing when there is excessive ligament tension on the UCL.

The UCL most often becomes gradually torn over a time, the ligament is stretched and degradation occurs due to the repetitive nature of throwing. One pitch can be the straw that breaks the camel’s back. The tear is often felt as a ‘pop’ and pitchers are often unable to continue throwing afterwards.

After the tear, it is common to see swelling and bruising after 24 hours located near the inner elbow and upper forearm. The athlete is not able to throw at full speed and accurately. The athlete may also experience decrease in elbow range of motion, numbness or tingling in the hands, weakness throughout the arm, and loss of grip strength.

An MRI is used to identify the location and severity of the UCL, which is important for determining if the athlete needs reconstruction surgery, repair surgery, or conservative care.

The Surgery:

Tommy John is named after the first athlete that had this UCL reconstruction surgery performed. He successfully returned to professional baseball and went on to win 164 more games.

The first Tommy John procedure was performed in 1974 by Dr. Frank Jobe. The procedure is a surgical graft procedure that involves replacing the UCL with a tendon from somewhere else in the body or an allograft from a deceased donor.

There is a 3-4 inch incision made on the inside of the elbow. Holes are then drilled on the ulnar and humerus bones so that the harvest tendon can be woven in a figure-8 pattern through the holes and anchored. The source of the grafts can be from the palmaris tendon, the patellar tendon, hamstring, or a toe extensor. The ulnar nerve is relocated to prevent scar tissue from compressing the nerve.

The athlete leaves the hospital in a splint to protect the repair for the first week and then after that week the athlete is given a brace to wear for the next 6 weeks.

The Recovery:

There are typically 4 phases of recovery following Tommy John surgery.

Phase 1: Immediate Post-Op Phase (0-3 weeks)

The goal is to protect healing tissue, decrease pain and inflammation, protect the graft, and prevent muscle atrophy. The athlete will wear a splint with the elbow bent to 90 degrees the first week and then will progress to wearing an elbow brace. The exercises consist of gentle elbow and wrist ROM, wrist and elbow isometrics, cryotherapy for pain & swelling, and then in week 3 shoulder exercises are added. After week 3, we are looking to increase range of motion by 5 degrees of extension and 10 degrees of flexion each week.

Phase 2: Intermediate Phase (Week 4-8)

The goal of this phase is to continue to improve range of motion and regain and improve muscular strength. Light resistance exercises are added using resistance tubing and light dumbbells for the shoulder.

Phase 3: Advanced Strengthening (Week 8-14 Weeks)

The goal of this face phase is to increase strength, power, and endurance, maintain full elbow ROM, and start to incorporate sport specific activities. Eccentric elbow exercise and plyometric exercises are starting to be incorporated. Plyometrics are two handed only at this point.

Phase 4: Return to Activity (Week 14-23)

The goal of this is to start to incorporate sport specific exercises. Plyometrics have progressed from two hands to one hand. At week 16, Phase I of the throwing program may begin, which focuses on long toss. There are multiple steps and it gradually increased from 45 ft up to 180 ft. The throwing program typically occurs every other day for 3x per week.

If Phase I was successfully completed, Phase II may begin which involves throwing off the mound. Stage 1 involves fastballs only and the intensity starts at 50% and will ramp up to 75%. State 2 involves throwing bottom practice at 75%. Stage 3 is when breaking balls are introduced. A radar gun is used to measure percent effort.

At post-op week 30-32 (~ 8 months), competitive throwing can begin.

Research Articles:

American Orthopaedic Society for Sports Medicine. "Tommy John surgeries increasing for youth athletes." ScienceDaily. ScienceDaily, 12 July 2015. <www.sciencedaily.com/releases/2015/07/150712203819.htm>.

Hurd, Wendy J et al. “Pitch velocity is a predictor of medial elbow distraction forces in the uninjured high school-aged baseball pitcher.” Sports health vol. 4,5 (2012): 415-8. doi:10.1177/1941738112439695