In baseball, the words “Tommy John surgery” are uttered every day. And with a rash of injuries sidelining stars around the league, we are hearing the phrase more than ever. The number of injuries to pitchers’ ulnar collateral ligaments keeps rising, an epidemic swallowing the sport and leading to changes in the surgical landscape. But it’s no longer as simple as a pitcher tearing his ligament, going under the knife, and returning a little over a year later. Now there are many pitchers undergoing second, or even third, surgeries, known as revisions, with slightly different techniques and recovery times at play. And many players are gravitating towards a newer option, the internal brace procedure, which is adding a dimension to a seemingly familiar landscape. One thing is clear: Tommy John surgery, in its various forms, is going to continue to be an important part of baseball for the foreseeable future.
Advertisement
What is Tommy John surgery, exactly?
The ulnar collateral ligament is located on the inside of the elbow, attaching the upper bone of the arm, the humerus, to a forearm bone, the ulna. When a pitcher suffers an injury to their UCL, they may sometimes choose a conservative treatment plan, often consisting of rest and plasma-rich platelet injections. In many cases, this is simply delaying the inevitable.
“We often try it because there’s really nothing to lose with it,” said Eric Bowman, an orthopedic surgeon and the head team physician for the Vanderbilt Commodores and Triple-A Nashville Sounds. “There’s very little downside to it. It has growth factors and we hope that it provides a healing stimulus. But at least the data we currently have doesn’t really point to it being a huge boost for conservative treatment.”
Especially in the cases of substantive tears to the ligament, a full reconstruction is often required. The procedure we now know as Tommy John surgery originated in 1974, when orthopedic surgeon Frank Jobe performed the procedure on MLB pitcher Tommy John. The surgery involves replacing the existing UCL with a graft usually harvested from either a hamstring tendon, the Palmaris tendon in the forearm or a tendon from a cadaver. Surgeons attach the new tendon by drilling holes in the humerus and the ulna. The graft is then threaded through the two holes and secured by sutures, buttons or screws.
“When players like Sandy Koufax had torn up elbows, they didn’t have a procedure like this,” Bowman said. “When Tommy John was the first one that had it, that was a newer procedure, and all of a sudden we were able to get these players back to playing.”
Why has ‘TJ’ become so common?
At the major-league level, there were 275 pitchers who had Tommy John surgery last season, up from 190 in 2016.
Advertisement
But surgeons in the industry indicate the largest increases in UCL injuries are actually seen at the youth level. Tommy John surgery was once nearly unheard of for high school players. Now it is becoming common. As far back as 2015, one study indicated 56.8 percent of Tommy John procedures are performed in the 15-19 age group.
“I think it’s playing year-round,” said Dr. Brian Schulz, the team physician for the Los Angeles Angels and an orthopedic surgeon at the Cedars-Sinai Kerlan-Jobe Institute. “I think it’s early sport specialization, not taking time off and playing other sports. I think there’s a lot of kids that understand that velocity is a very important factor if they want to be a pitcher, and they’re doing weighted ball programs and velocity enhancement programs at a young age. You’re putting a lot of stress on the inner elbow doing that.”
At the MLB level, debate rages on about the cause of arm injuries. Is it the endless chase for velocity and spin? The adaptation of designer breaking pitches? Overuse stemming from childhood? The pitch clock?
“If you look at the average velo, that has ticked up quite a bit (from 90.5 mph on fastballs in 2008 to 93.9 in 2022),” Schulz said. “That’s probably the biggest risk factor, is the size of the player and the velocity that they throw.”
How does Tommy John impact performance?
Once viewed as a last-chance operation, Tommy John in the 21st century no longer has such a negative stigma. But the idea that all pitchers return from Tommy John as harder-throwing superhumans comes with misconceptions.
“Probably 10 years ago people were coming in and almost wanting it electively for their kids because they thought it would make them throw harder, which is crazy,” said Josh Dines, an orthopedic surgeon at the Hospital for Special Surgery who has also worked with the New York Mets and Los Angeles Dodgers. “And that’s the nicest way I can put it. It’s like assault and battery on your kid.”
Advertisement
Although the rate of athletes returning to play is high, the rate of players returning to the same level of play was “less frequent and took longer, with 67 percent to 87 percent of MLB pitchers returning in about 15 months,” according to a 2020 study. Plenty of pitchers have returned from Tommy John to have successful careers, but the road back can come with bumps. In 2022, Justin Verlander became the first pitcher to win the Cy Young Award in his first season back from a UCL reconstruction. John Smoltz is currently the only pitcher to have had Tommy John and be elected to the Hall of Fame.
Conversely, the 2020 study showed pitchers who had UCL reconstructions had ERAs and WHIPs “equal or better” than controls but also found fastball usage and velocity tend to decrease slightly after surgery. Overall, there is little clinical data to suggest Tommy John directly correlates with enhanced long-term performance.
“In the first four or five months after Tommy John surgery, we’re really not even throwing a baseball,” Dines said. “You’re working on core strength and shoulder rotation and all these other things that when you’re playing baseball often get neglected. But because you have nothing else to do, you’re focusing on them. I think if anything that’s what makes these baseball players better and throw harder.”
How does a UCL revision differ from a reconstruction?
As the number of Tommy John surgeries skyrockets, we are seeing another phenomenon emerge: An increase in UCL revisions, the clinical term for a second (or third) Tommy John surgery. Not long ago, there was a common belief in the game that a Tommy John procedure would all but guarantee a healthy UCL for at least 10 years. That belief, Shulz said, was never actually based on clinical data.
“People will throw around numbers,” Schulz said. “There’s not a lot of data out there that, ‘The average Tommy John lasts this long.’ I think you’re seeing more failures for a couple reasons. One of them is people are having them at a younger age now.”
If a pitcher has Tommy John at age 17 and continues pitching at a high level, it could be natural for a pitcher to need another procedure by age 27. There is also anecdotal concern that increases in velocity and force applied to the UCL could be shortening the lifespan of the Tommy John procedure.
If a player requires a second surgery, the procedure often differs from the first.
Advertisement
“The procedure itself is a little bit more complex,” Bowman said, “because you’re having to work around scar tissue. When you’re going in and it’s sort of a pristine environment you can put things exactly where you want it, and the tissue overall might look fairly normal. When you go in on a revision situation, there’s scar tissue, there is already tunnels and hardware in place. Sometimes you have to navigate that or negotiate that to get the exact reconstruction you want.”
While initial Tommy John procedures across all levels come with a return-to-sport rate of close to 90 percent, the data is murkier when it comes to UCL revisions.
Return-to-play rates hover around 75 percent, Bowman said, but return to previous performance level is closer to 55 percent — think a player who has pitched in the majors but only makes it back to Triple A, or a pitcher who never performs like they did before the second surgery.
The game does, however, boast successful two-time Tommy John pitchers. Texas Rangers starter Nathan Eovaldi had a second Tommy John in 2016 and has pitched in 134 MLB games after the second procedure. Jason Isringhausen, José Rijo and Jonny Venters are on a short list of pitchers to have the procedure three times and return.
The rehab from an original UCL reconstruction now averages 12 to 14 months. The timeline for a revision, Bowman said, tends to be longer.
“In general we go a little bit slower,” Bowman said. “Some of that is because the risks are higher.”
Is internal brace a revolution?
In recent years, a new surgical technique has become increasingly popular. It’s called the internal brace, where an athlete’s existing UCL is reinforced with a tape-like suture that is anchored into the humerus and ulna. The internal brace can serve as a Tommy John alternative for athletes who have not completely torn their UCL. MLB players such as Lucas Giolito and infielder Trevor Story are among those who have recently had the internal brace procedure, but it is more common for amateur players, Bowman said.
Advertisement
“Internal brace is great, and it’s probably going to revolutionize what we do from a Tommy John standpoint,” Bowman said. “We do repairs on younger kids and adolescents, high school, college kids because repairs, basically we try to get the tissue that they have to heal so we don’t have to use grafts, and the recovery time is about half.”
Athletes can typically return to throwing in about six months after an internal brace procedure. Many major-league pitchers, however, may not be good candidates for the surgery.
“The problem when you get toward the majors level is the tissue isn’t as good, so you have to replace the tissue,” Bowman said. “Just putting the internal brace in there or the suture, it can help relieve some of the stress, but the bad tissue just isn’t going to heal very reliably, so that’s when you have to put the graft in.”
Red Sox pitcher Lucas Giolito, who first had Tommy John surgery in 2012, had an internal brace procedure in March rather than a UCL revision.
“The way it’s been explained to me is that the brace has a very high rate of recovery compared to getting a second Tommy John,” Giolito said. “I think a lot of the data and research has shown — at least what’s been told to me — if you get Tommy John, that Tommy John breaks. You get a brace, it’s got really good results. I feel confident in that.”
Some surgeons, including leading physicians Neal ElAttrache and Keith Meister, are now opting to include an internal brace even when using a graft in a typical UCL reconstruction. Shohei Ohtani and Jacob deGrom are among big-name stars who have taken this route. The hope is that the brace can help fortify the new ligament and thus reduce the odds of failure.
“The thinking is an internal brace is like a seat belt,” Schulz said. “Your seat belt is not important unless your car stops really quickly. … So if there’s an excessive force on the ligament, the brace would act as a seatbelt to stop it from completely tearing, or stop it from tearing at all, in theory.”
Advertisement
The idea behind the internal brace in a reconstruction makes sense. Meister told the Dallas Morning-News he has seen a failure rate of about 1 percent among the 300 hybrid surgeries he has performed. But the industry is still gathering data on whether it actually makes a difference.
“Whether it’s in a repair or even now using (the internal brace) in reconstructions and revisions, it’s just to make it as strong as possible,” Dines said, “because we know these athletes are gonna go out and beat it up because they’re gonna try to throw as hard as possible. It just makes me sleep a little better at night.”
You can buy tickets to every MLB game here.
(Top photo of Giolito: Billie Weiss / Boston Red Sox / Getty Images)
