Tommy John Surgery: The Realities and Myths of Sports' Most Famous Operation
July 17, 2013
It is not a stretch to say that baseball as we know it would not exist without Tommy John surgery. It is probably the most widely known work of medical magic in sports. And it's never been more widely used than it is today.
This month, the Baseball Hall of Fame will honor the operation's inventor, Dr. Frank Jobe, almost 40 years after he took pioneering steps to fix Tommy John's elbow. But despite the operation's fame, and the fact that the procedure hasn't changed much since 1974, there are still misconceptions and myths about the surgery.
More important, there is still a huge need for the surgery, as little progress has been made in preventing pitchers' elbows from breaking down.
Bleacher Report is highlighting Jobe's Hall of Fame honors with a package of stories about the past, present and future of a surgery as integral to the game's development over the past 50 years as cable TV and international players. While this article focuses on the what and how of the surgery, other articles examine its historic impact, its notable patients and the startling increase in its use.
What Jobe created in 1974 has allowed a large percentage of MLB pitchers to keep pitching, which has been key in maintaining the quality of the game. Without this surgery, a full one-third of pitchers in the major leagues would have had career-ending injuries and been replaced by other, less talented hurlers. This B/R list (also represented in the graphic below) is culled from news reports, and it shows the 124 current major league pitchers who've had the surgery at least once.
If the surgery had disappeared 10 years ago, all of these pitchers would have been replaced by seemingly less effective pitchers. Long relievers would be starting, Triple-A quality would be Double-A quality, and a lot more runs would be scored.
Instead, Tommy John surgery is almost routine. Day after day, in operating rooms in Birmingham, Ala., Pensacola, Fla., Cincinnati and Los Angeles, where it was originated, the simple surgery is not just restoring arms, but keeping the game of baseball viable.
How the Surgery Is Done
While it is occasionally that one bad pitch that overloads the elbow and leads to Tommy John surgery, more often the damage is the product of an insidious process. The amount of pitches, over time, wear and fray the tendon until finally, often without warning, the ulnar collateral ligament fails.
There's not a significant technical difference between what Jobe created and what doctors like renowned sports surgeon Dr. James Andrews use today. When the elbow ligament is damaged, it is replaced with a ligament from elsewhere in the patient's body.
Looking for solutions to sprained elbows in the early '70s, Jobe knew that the palmaris tendon (a small tendon in the wrist) was redundant and was often used in hand reconstructions. He brought his friend Dr. Herbert Stark in to assist with his first surgery, on John, knowing Stark had more experience with such techniques.
Today, the palmaris is often used, though more doctors are going to the thicker and stronger hamstring tendon. With more repeat Tommy John surgeries, having multiple sites to pick from has become a more regular concern for both patient and surgeon.
Once the tendon is harvested, the doctor will have the tendon cleaned and cut to size while he goes back into the elbow. Holes are drilled through the bones of the upper and lower arm, angled to allow the tendon to loop through and be placed in as near an identical position as the damaged ligament. In some cases the doctor will leave the damaged tendon in place, but most dissect it away.
The donor tendon is then looped through two or three times and locked into place. The doctor will then check that the ulnar nerve ("funny bone"), which runs through the same area, is not entrapped. Some doctors will move (transpose) the nerve as a matter of course, while others leave it in place. Nerve entrapment is one of the most common complications of the surgery. Tommy John himself suffered from the issue.
The surgery and pursuant rehabilitation have become as close to routine as can be for any major surgery. The chance of an elbow sprain being a career-ending event is very low. Usually, the injury ends a career only if the pitcher decides to walk away.
The recovery is very predictable, ranging from nine to 12 months, down from the original 12 to 18 months. We still see setbacks during the rehab process, though outright failures of the sort Daniel Hudson from the Diamondbacks had, necessitating a redo of the procedure this summer, are very rare.
Why the Surgery Is Needed
As routine as the surgery has become, figuring out why the injury happens and how to prevent it has been a befuddling problem for baseball and its doctors. More pitchers at all levels are feeling something pop in their elbow. It's a trend that confounds scouts and sports-medicine professionals.
In most cases, the UCL does not fail in a dramatic fashion. It is very seldom one pitch; it's a weakening of the ligament over the course of years until it finally breaks down. There often is evidence that the ligament has had significant sprains on multiple occasions, something the pitcher either knowingly or unknowingly pitched through.
Researchers like Dr. Glenn Fleisig at the American Sports Medicine Institute in Birmingham, Ala., know what can cause a ligament failure. Fleisig has a cadaver lab, where disembodied arms are rigged up to test both overuse injuries and traumatic failures.
The disconnect between the cadavers at ASMI and actual pitchers is that we don't know exactly what the pitchers are doing to their arms. Which forces that cause damage in the lab are in action on the mound?
Biomechanical evaluations could help teams and doctors figure out which pitchers are exerting the forces that could cause them trouble. But only about half the teams in MLB do any sort of those evaluations. Only two teams do these evaluations on all of their pitchers.
That lack of use has left us with little real-world data, despite study after study showing the value of this data.
Dr. Bill Raasch, the team physician for the Milwaukee Brewers, has been studying biomechanics for years in his lab at Froedtert Hospital in Milwaukee. Milwaukee is one of two teams that takes biomechanical studies of each of its pitchers.
The other is Baltimore. Led by pitching guru Rick Peterson, best known for his work with the "Moneyball"-era Oakland A's and especially for his work with Tim Hudson and Barry Zito, Peterson is an advocate of a holistic approach to pitching that includes biomechanical evaluations. (Peterson is co-owner of a company that does biomechanical evaluations for amateur pitchers.)
Technological advances could lead to more effective and widespread use of biomechanical studies. Newer methods do away with the awkward markers needed by most systems. There is even a push to use less-complex approaches, such as Microsoft's Kinect camera system. Many believe a rumored slow-mo camera in the next iPhone could offer a revolution in tracking pitching mechanics.
The Pitch-Count Problem
One often noted possibility for reducing arm injuries is pitch limits.
The advent of the pitch-count era has not seen the expected drop in injuries. In fact, things have gone the opposite way. Over the last five years, pitching arm injuries have increased by almost 30 percent, according to my MLB injury database.
This result hasn't changed the near-universal use of pitch and innings limits. Even teams trying new things—or rather, old things—like the Texas Rangers, who said they wanted to increase how deep their starters go into games, have achieved no real change in overall pitch count and no real change in injury rate.
One factor to consider as a cause is the increased average velocity around baseball. Pitchers appear to be throwing harder, with speed guns more regularly ringing up the magic number of 100 mph and no-name pitchers hitting the once-astounding 97 mph number. All it takes is a quick look through the data collected by Pitchf/x to see how many pitchers are throwing fastballs in the upper 90s. (FanGraphs has that data broken down by pitcher, but no list of average velocity or follow-up on who has thrown the fastest pitch in 2013.)
In some ways, this might be the result of Jobe's own innovations. He invented a series of exercises designed to strengthen the shoulder. The near universal use of these "Thrower's 10" has strengthened shoulders and reduced the number of rotator-cuff strains. Stronger arms and reduced shoulder injuries may have created an increase in elbow injuries.
(While this is a logical stretch, it would be the lesser of two evils if true. Elbow surgery has a far higher rate of success—more than 90 percent in most modern studies—than shoulder surgery.)
The increase in the number of surgeries is astounding. While a complete record of Tommy John surgeries is unavailable and even the surgeons themselves do not have records—Andrews couldn't even remember who the first player he performed the surgery on was!—we can see that there was a massive increase in the 1990s.
Jobe waited almost three years before performing the second Tommy John surgery on a baseball player (the patient was Brent Strom, who is now a pitching coach). It wasn't until 1996 that there were more than 10 players having the surgery in a calendar year. In 2010, it was 44, and that's just major-league players.
In terms of dollars lost, pitching injuries have increased by 700 percent over the last decade, reaching more than half a billion dollars lost per season. Tommy John surgery and the resultant rehab represents a majority of that money spent at the major league level.
The numbers are high for high school, college and minor-league pitchers, too. That it's needed at all on middle school pitchers is mind-boggling, but the procedure has been done on those as young as 13. Andrews was doing as many as 150 UCL surgeries back in 2003, and that number stayed about the same from 2004-07. The pace has not slowed since then.
Jobe has an answer to the question, "Why?"
"Overuse," he said simply during our recent interview. "It’s a little bit surprising [that Tommy John is still frequent]. I think it can be prevented, we can monitor how much they throw, make sure their mechanics are perfect. I think that people like Jim Andrews still work on some exercises that will determine how many pitches are suitable."
Andrews funded the research that led to Little League adopting pitch-count rules five years ago, a radical step that has caused some backlash. The battle to keep the numbers down is well-researched, but in most cases it does not look to have made a significant dent in the incidence of this surgery.
The question then—why are there more Tommy John surgeries now than at any point since the surgery was created?—remains. I asked an all-star roster of doctors, those quoted in this article and more. Not one had a satisfying answer.
At least medical science is better at diagnosing the elbow injury.
Fans might disagree, seeing teams send players out for six weeks of rehab only to have the player end up on a surgeon's table, but that's a necessary part of the process. We have progressed to the point where high-powered MRI machines are giving excellent views of the ligament, and the rollout of high-resolution ultrasound machines could allow doctors and trainers to see the ligament over the course of time.
Myths of a Miracle
The prevalence of Tommy John surgery has given rise to some misconceptions.
Jobe feels strongly that Tommy John surgery should never be performed on a prophylactic basis.
"The surgery doesn't make anyone better," Jobe told me in a 2009 interview and reiterated in our recent conversation.
"It doesn't make someone faster or, well, anything," Cincinnati Reds surgeon Dr. Tim Kremchek said.
While coaches and parents will often ask surgeons whether surgery will help their player turn into a major leaguer, it doesn't work that way.
Tommy John surgery is a transplant, in much the same way that a heart or liver transplant works. The transplanted ligament is not stronger than the original, healthy ligament was, nor is the arm different in any way.
A comparison to LASIK surgery might be more apt. It returns a patient to normal function, but it doesn't make him or her a super-pitcher.
"It restores. That's it," Jobe said.
A pitcher has a maximum velocity that he is capable of, a combination of mechanical force and efficiency. Pitchers are seldom in perfect condition, so being near the maximum is sufficient for most, and any change is very difficult to notice.
Moreover, the onset of UCL damage often comes slowly and imperceptibly. A pitcher who could be throwing 90 is suddenly throwing 88, then 87...and soon, few remember his capability was 90. When he comes back from Tommy John surgery and is throwing 90, it appears faster than before, but only in comparison to his injured state rather than his healthy state.
The complex, technical rehab is also a big help in seemingly improving a pitcher. Most have never had this much rest on their arms as they have in the weeks after surgery. By the time they get back on the mound, they have six months of rest plus closely monitored strengthening. And they often work on their mechanics during their time off.
Fit and rested, it's no wonder that many feel better than they did and can often, at least for a time, show an increase in velocity and movement.
In most cases, these gains don't hold long. While Pitchf/x data does not go back far enough to give an extended sample, there does not appear to be a lasting change in velocity for someone who has come back from the surgery and rehab.
Despite this, there is still a loud group that thinks Tommy John surgery is something akin to sorcery. I once heard an MLB executive say in 2008 that he was tired of having so many pitcher injuries. Instead of saying something logical next, he said he was thinking he would send all his new draftees to have Tommy John surgery to "get it out of the way."
Tom Candiotti, one of Jobe's early patients, observed this sentiment back in 2003, using the same words to describe it.
There's also the idea that it's a shrug-your-shoulders routine. Former manager Jim Tracy compared the surgery in 2010 to "taking your car to Jiffy Lube."
"There is still a profound ignorance, even inside baseball [about the surgery]," Kremchek said. "We're victims of the success. All the way down to Little League we're seeing the effects of all the things we're not doing and all the things we're overdoing."
Advances in Treatment
When I asked doctors about why Tommy John surgery is more needed than ever, the prevailing answer was they didn't know and they didn't have the right data to find out. Baseball made a leap forward when Jobe figured out how to save Tommy John's career, but the sport is falling behind now.
As explained earlier, the technique used today by all the top surgeons is essentially the same as what Jobe did the first time.
"Either he was way ahead of his time or we're behind ours," Kremchek said.
The slight alterations used by Dr. David Altchek and a few others, called a docking technique, are minor variants in where holes are drilled and how the donor tendon is placed.
That's not to say that new techniques are not being worked on. Specialized tools have been created to make the operation easier and quicker for the surgeon.
In the future, we are likely to see some advances that will seem futuristic.
The first big change is the use of biological augmentation. Currently, several doctors such as Andrews and Dodgers team doctor Neal ElAttrache are using PRP (platelet rich plasma) injections as a matter of course during initial diagnosis and in surgery. While the efficacy of PRP remains unknown and the research spotty, Andrews believes that there's some upside and no downside to its use.
It's quite possible that more advanced matter, such as growth factors or healing substances, could be introduced that could increase the strength of the donor tendon and the anchor sites. This of course comes with performance-enhancing concerns. Because of European regulations, they are a bit ahead in this field and have used advanced biologics in arm surgeries, but it is not clear if any of these have been Tommy John reconstructions.
(Yes, athletes in other sports do get Tommy John surgery. There have been several cases in American football, but most of the others come in arm-overhead sports, including field events, lacrosse and gymnastics. Jobe's second Tommy John surgery was on an Eastern European javelin thrower, though he does not recall the athlete's name. It's a great sports mystery!)
Another advance that could come into play in the next decade is the use of exografts. Instead of using a donor tendon from the body of the patient, doctors are experimenting with the use of engineered substances.
One possibility is engineered human tissue, which suffers from an "ick" factor. Tissue is taken out and strengthened using a variety of techniques, some as simple as braiding or curing in a solution that hardens the fibers.
Scientists and doctors are also experimenting with nonbiologic transplants. The tendon could be replaced by a cord of Kevlar or other strong fibers. This kind of replacement is often used in veterinary medicine but has been used in some nonathletic human cases.
The failure rate is still higher than when using a donor tendon, and many worry about the lack of flex in these super-strong fibers. For a pitcher, a Kevlar UCL might seem like an advantage, but we don't know for sure.
Advances in stem cells, genetics, proteomics and more could make the process a lot less like what Jobe created and more like regrowing a tendon.
The funny thing here is that finding that first athlete to try something is always the tough part. No one actually wants a surgery or surgical technique named after him, it seems.
It is not hyperbole to say that baseball as we know it, especially at the major league level, could not exist without Tommy John surgery. With the rapid increase in the surgeries at the major league level and increasing need at lower levels, the work of Jobe and the doctors and therapists that followed him is going to be needed more than ever.
Baseball's slow pace of change has created a climate of revision rather than prevention, where Jobe's operation has become so successful that it's not considered a failure of the system.
Perhaps the ultimate honor for Jobe would be that his operation was not so needed any more.
This article is part of a package of multimedia stories about Tommy John surgery. Click these links for more:
Will Carroll has been writing about sports injuries for 12 years. His work has appeared at SI.com and ESPN.com. His book "Saving the Pitcher" was published in 2004.
Tyler Brooke, Stacey Gotsoulias and Joel Henard provided invaluable research assistance for this project. All interviews and research done firsthand, unless otherwise indicated.