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Tommy John FAQ: Dr. Andrews answers frequent questions related to Tommy John surgery

Tommy John FAQ

What is Tommy John surgery?

Tommy John surgery is a reconstruction of the ulnar collateral ligament (UCL) of the elbow. A tendon from elsewhere in the body is used to repair a torn or ruptured UCL. It was first performed by Dr. Frank Jobe in 1974 on Tommy John, a pitcher for the Los Angeles Dodgers.

Does an athlete require an actual elbow injury to undergo the surgery?

Yes. 51% of high school athletes incorrectly believe that Tommy John surgery should be performed on players with an elbow injury to enhance performance (Ahmad et al.). However, the only approved medical reason for Tommy John surgery is a torn or ruptured ulnar collateral ligament. The procedure should not be performed in the absence of an injury.

How many pitchers undergo Tommy John surgery per year?

While no comprehensive database exists, studies on large groups suggest that the number of Tommy John surgeries has risen steadily since the 1990s throughout the U.S. Historically, 15-20 Major League pitchers have undergone Tommy John surgery per year but that number has increased to more than 30 per year since 2010. A 2012-13 survey of active players found that 25 percent of Major League pitchers and 15 percent of Minor League pitchers had undergone Tommy John surgery at some point in their careers.

Are pitchers having the surgery at a younger age?

Yes. Youth and high school age pitchers made up a negligible fraction of Tommy John surgeries at the American Sports Medicine Institute in the mid-1990s, but 25 percent of their Tommy John surgeries by the mid-2000s. A study of national insurance records showed that between 2007 and 2011, the number of Tommy John surgeries increased about 4 percent each year overall, but 9 percent per year among high school age pitchers. More than 50 percent of all Tommy John surgeries in that study were on 15- to 19-year-olds.

What factors influence the likelihood of an arm injury?

There are a number of factors that contribute to the likelihood of having Tommy John surgery or another arm injury. The single most important factor is daily, weekly and annual overuse.

Other factors include lack of rest, pitching while fatigued, poor mechanics, playing catcher when not pitching, playing on multiple teams at the same time, pitching multiple days in a row and throwing at maximum effort.

Understanding the role of pitch types and the likelihood of injury is complicated. Some studies suggest that more curveballs and sliders may be related to injury risk in adolescents, while another study suggests that more fastballs is related to injury risk in MLB pitchers.

How often are pitchers able to return to play baseball after Tommy John surgery?

Overall, Tommy John surgery has a high rate of return to play, particularly relative to other common procedures for pitchers. Most studies have concluded that 70-80% of pitchers return to their previous level of competition following surgery assuming that they follow rehab protocols. However, the rate and time of return to play vary according to the individual and there are many other issues that may complicate the success rate of the surgery.

How long does it take to return to competitive throwing following surgery?

The average pitcher returns to game action 12-16 months following surgery but that time varies greatly by individual. In a recent study by Erickson et al., Major League pitchers returned in as little as 11 months and as many as 30 months. The player's return also depends on when the surgery is performed in the context of the baseball season as well as the severity of the injury. Players, parents and coaches should remember that each injury is unique and has its own timeline for recovery.

Does Tommy John surgery improve performance?

No. 35% of parents incorrectly believe that overall pitching performance would be enhanced following surgery (Ahmad et al.). While there are notable instances of players improving following surgery, the most optimistic expectation for a pitcher undergoing Tommy John surgery is that the procedure allows the player to return to his previous level of performance. In fact, two recent studies have shown that players returning from Tommy John surgery tend to follow the typical aging pattern for players without surgery.

Does Tommy John surgery improve pitching speed?

No. 53% of college athletes incorrectly believe that pitching speed would improve following Tommy John surgery (Ahmad et al.). Similar to overall performance, players do not throw harder after Tommy John surgery than they did before the procedure. Most doctors have concluded that in cases where pitchers who have thrown harder post-surgery, it was predominantly due to the quality of their rehabilitation and improved strength and conditioning.

How often do pitchers suffer another arm injury after having Tommy John surgery?

A subsequent arm injury is common among pitchers who have had Tommy John surgery. More than half of Major League pitchers who underwent Tommy John surgery from 1999 to 2011 went on the Disabled List with an arm injury after returning from surgery. Another recent study from the American Sports Medicine Institute (ASMI) concluded that 19% of Tommy John patients will have a subsequent elbow surgery and 25% will have shoulder surgery.

Can someone have Tommy John surgery twice?

Yes. There have been several studies recently on pitchers who have to undergo a second Tommy John surgery, often called a UCL Revision. Although still relatively uncommon, there seems to be an increase in the number of revisions over the past five years. Previous studies have shown only 2-4 percent of pitchers had revisions but more recent studies indicate an increase in that rate to 10-12 percent in Major League pitchers. The rehabilitation takes longer and the success rate of return to pitching is not as good as with the first Tommy John surgery.

Would lowering or eliminating the mound reduce the stress on the elbow and reduce the number of UCL injuries?

It's unclear. Most studies have concluded that there is little difference in stress between pitching on the mound and throwing from flat ground but other studies have shown significant differences. Overall, amount of pitching, pitching mechanics and rest have been shown to be much more important factors than mound height.

Are players who throw harder more susceptible to UCL injuries?

There is evidence that players who throw harder are more susceptible to UCL injuries, ostensibly because the increased velocity correlates with force in the elbow. Many studies have shown that players who throw harder are more likely to spend time on the Disabled List or miss time due to surgery. Pitchers who throw harder should be especially cognizant of the recommendations on pitch counts, rest and fatigue.

The relationship between velocity and injury is complicated. Increased velocity is also associated with improved performance such that players with higher velocity have longer careers and also perform better. Therefore, it would be unrealistic to recommend that pitchers simply not throw as hard. However, varying speeds might improve a pitcher's effectiveness and conceivably also reduce injury risk.

Does long-toss reduce the number of arm injuries?

While there are many advocates on both sides of this issue, it is important for the player not to exceed the distance at which he feels comfortable and which does not change his biomechanics. One recent study concluded an appropriate long-toss distance is typically 120 feet for college pitchers, but certain pitchers may be capable of throwing from longer distances while still maintain proper biomechanics and throwing the ball on a relatively horizontal trajectory.