Tommy John and Elbow Injury Research
Authors: Makhni, EC; Lee, RW; Morrow, ZS; Gualtieri, AP; Gorroochurn, P; Ahmad, CS
Tommy John is absolutely not a simple surgery with a guaranteed success rate. We often only hear of the pitchers who exceed expectations and come back quicker or of the ones that can still play at a high level. We fail to realize the number of players who do not return or only return for a short period of time.
Statistics that stood out:
- 147 pitchers were considered active before undergoing TJ (played >1 MLB game from 1999–2011).
- 29 pitchers (20%) failed to return to MLB competition.
- 19 pitchers (13%) returned but pitched less than 10 innings.
- 99 pitchers (67%) were left who returned to throw 10+ innings in MLB.
- More than 50% of players returned to the DL because of injuries to their throwing arms after returning from surgery.
This study excluded 10 players who had multiple surgeries (21 combined)
Rate of Return to Pitching and Performance after Tommy John Surgery in Major League Baseball Pitchers
Authors: Erickson, BJ; Gupta, AK; Harris, JD; Bush-Joseph, C; Bach, BR; Abrams, GD; San Juan, AM; Cole, BJ; Romeo, AA
For Tommy John studies it is required that you investigate the numbers and do not blindly accept the conclusion. For example, this study concluded “…reconstruction of the UCL allows for a predictable and successful return to professional baseball.” It is simply not that straightforward.
Statistics that stood out:
- 179 active MLB pitchers were considered active from 2010–2013 (7 pitchers were excluded for revision UCL tears, and 37 were excluded because they were <18 months post op).
- 148 (83%) returned to pitch at minimum 1 inning in MLB.
- 26 (14.2%) returned only to the minor leagues.
- 5 (2.8%) never pitched again.
- At the start of the 2013-2014 season (last year of the study), 56 (32%) pitchers were still active in the MLB.
“A player was deemed to have returned to pitching if he pitched in any MLB game after surgery.”
Authors: Jiang, Jimmy; Leland, J
This study looked at MLB pitchers between the 2008-2010 MLB seasons and analysed pitcher velocity pre and post surgery.
- 41 pitchers in total had UCL reconstruction between those years
- 3 were excluded for revision UCL surgery
- 1 retired, 7 never returned to the majors
- 1 fractured a forearm and 1 lacked insufficient prestudy data
- This leaves 28 pitchers available for statistical analysis
- No pitcher returned with a high average velocity compared to before surgery
Velocity of fastball and changeup(s) thrown by pitchers who return to MLB after UCL reconstruction decreased by a small, but statistically significant, values from preinjury to postinjury years. There was not a significant difference in the mean velocity of those pitches when compared to a control group of pitchers without a known UCL injury.
Although the velocity difference was small, there is a much smaller chance of a team signing a pitcher who was 90-92 then had Tommy John and came back 88-90. More can and should be done in training these athletes when coming back from surgery.
Authors: Liu, Joseph; Garcia, Grant; Conte, Stan; El Attrache, Neal; Altchek, David; Dines, Joshua
- Since 1999, 235 pitchers underwent Tommy John, 31 (13.2%) underwent revision surgery
- Of those 31 pitchers, 26 were available for return to play analysis, 17 (65.4%) returned to pitch at least 1 MLB game
- only 11 (42.3%) returned to established play (pitch in 10+ games)
- the number of UCL revision reconstructions per year performed on MLB pitchers from 1999 to 2014 significantly increased to one-third of all Tommy John surgeries in 2014
This study strongly suggests that the risk of having revision surgery after Tommy John surgery may be increasing. This is a trend that will need to be watched closely. More attention should be focused on the rehabilitation and training of athletes coming back from surgery.
Note: the Ulnar Collateral ligament (UCL) can also be referred to as the Medial Ulnar Collateral Ligament.
Authors: Keller, Robert; Steffes, Matthews; Zhuo, David; Bey, Michael; Moutzouros, Vasilios
- 168 Pitchers were included in the study between the years 1982-2010
- Those pitchers pitched in at least 1 major league game before undergoing MUCL surgery
- 87% of pitchers returned to pitch (1 inning) in MLB
- There was a statistically significant decline in pitching performance that improves in the 2nd and 3rd year but not fully to previous levels.
- Pitching performance declined the year before surgery
The last bullet is interested and suggests the fact that Tommy John may be multi-causal. Pitchers may attempt to try and pitch through some sort of injury that over time may get worse or lead to a different injury such as a UCL tear.
Authors: Watson, Jonathon; McQueen, Peter; Hutchinson, Mark
Because of the increase in Tommy John surgery this study wanted to compare the success rates of different techniques of Tommy John. Comparing these techniques would allow patients and surgeons to see if one technique had fewer complications or an improved return-to-play rate.
- Total of 21 studies (7 biomechanical and 14 clinical) met the inclusion criteria.
- This included 1368 patients that underwent surgery
- 239 (17.5%) were high school or recreational athletes
- 585 (42.8%) were college athletes
- 481 (35.2%) were professional athletes
- 63 (4.5%) were not classified into the previously mentioned groups.
- 18.6% (255/1368) had complications with the surgery
In comparing the Jobe technique, modified Jobe technique and docking technique the docking technique resulted in a significantly higher rate of return to play and a lower complication rate. It’s important to note that some techniques may be used because each surgery is different and may have complications so that one technique may be eliminated. The techniques of the surgery are still evolving which should continue resulting in high rates of return and less complications across the board.
Lastly most UCL reviews look at just professional athletes were this study included high school, recreational and college athletes who are going to have very different resources available for rehab than professional athletes.
Authors: Erne, HC; Zouzias, IC; Rosewasser, MP
The Medial Collateral Ligament (MCL) is composed of: the anterior bundle, the posterior bundle, and the oblique bundle (or transverse ligament). It is the anterior bundle (located on the inside of the elbow, closest to the body) that is most vulnerable to valgus stress with the elbow extended. The posterior band is more vulnerable with the elbow flexed.
The highest amount of force on the elbow is seen when pitchers transition from the cocking to acceleration phase of the throwing motion, at maximal external rotation. It is repetitive valgus stress that make pitchers prone to elbow injuries.
When an injury has occurred there is often a decrease in velocity and command along with pain. But not all elbow pain is an MCL injury. If an athlete is experiencing pain they should see a doctor or physical therapist.
Authors: Hurd, Wendy J; Jazayeri, Reza; Mohr, Karen; Limpisvasti, Orr; El Attrache, Neal S; Kaufman, Kenton R.
It’s believed that the cause of medial elbow injuries is excessive ligament tension during the late arm cocking phase. There is also a relationship between pitch velocity and elbow injuries.
This study wanted to look specifically at the relationship between pitch velocity and high medial elbow adduction moments.
The researchers found that the pitchers who had the greatest pitch velocity also have greater medial elbow adduction moments. The joint moments found were biomechanically related to pitch velocity. Therefore youth pitchers who throw at a high velocity may be at increased risk for elbow injury.
It was also recommended that coaches take the velocity of their pitchers into account when measuring workloads in pitches. “The pitcher who throws 100 pitches in a game with an average velocity of 83 MPH would experience a greater volume of work compared with a pitcher throwing 100 pitches with an average velocity of 75 MPH.”
The harder a pitcher throws, at any age, means that there is going to be more stress.
Authors: Ahmad CS; Grantham, WJ; Greiwe RM
Questionnaires about Tommy John surgery were sent and filled out by 189 players, 15 coaches, and 31 parents. The results of the questionnaires show that there is a large gap between the realities and the perception of Tommy John surgery.
51% of high school athletes, 26% of collegiate athletes, 30% of coaches, 37% of parents believe that UCL surgery should be performed on players pre-injury to enhance performance. This has been shown to be false, surgery does not improve performance. Doctors would not perform unnecessary surgery on athletes.
A percentage of all groups believed that pitching control, speed, and performance improved in pitchers post surgery. 74% of high school athletes, 61% of college athletes, 93% of coaches and 92% of parents also believed that arm pain was greatly diminished post Tommy John.
Interestingly enough all groups underestimated the percentages of players that return to their previous level of play post surgery. The highest guess was the high school groups at 67%, while actual return to play rates are around 80%. It was also found that many greatly underestimated the time needed to rehab post surgery.
The misconceptions seemed highest in the younger individuals. Coaches and parent should be better educated on Tommy John surgery and what it can entail. Education will play a big part in helping players, coaches and parents make better decisions to keep pitchers healthy.
Authors: Erickson, Brandon J; Cvetanovich, Gregory L.; Bach, Bernard R; Bush-Joseph, Charles A; Verma, Nikhil N; Romeo, Anthony A.
This study examined whether putting pitchers who were coming back from Tommy John surgery on pitch counts reduced their chance of having a revision UCL surgery.
The study included 154 pitchers who underwent UCL surgery from the year 1974-2015 , and 135 did not require revision UCL surgery. When comparing the two groups of pitchers, no significant difference was found between the number of innings pitched in the season after UCL surgery, number of pitches thrown, number of innings pitched in the pitcher’s career post op, and number of pitches thrown in the pitcher’s career post op. There was also no difference in revision rate between pitchers who pitched more or less than 180 innings in their first full season back from injury.
This study suggests that restricting innings and pitches post surgery doesn’t guarantee that a pitcher will stay healthy. However, this doesn’t mean that pitch counts wouldn’t be successful in keeping pitchers healthy preemptively. A study examining a preemptive reduction in workload and pitchers health would be an interesting compliment.
MLB pitchers are much more physically mature that youth and high school athletes. Studies should also examine the effectiveness of pitch counts on younger athletes over many years of playing.
Authors: Erickson, B; Harris, J; Tetreault, M; Bush-Joseph, C; Cohen, M; Romeo, A
This study wanted to determine whether the proportion of MLB pitchers who underwent UCL surgery and pitched competitively as a youth athlete grew up in a warm or cold weather areas. Rather than temperature, the warm and cool weather area was determined by location relative to the 33rd parallel.
In total, the authors found 247 MLB pitchers who underwent UCL reconstruction with 56.3% of them coming from warm weather areas and 43.7% coming from cold weather areas. Therefore, the researchers concluded that playing in warm weather areas may lead to a higher chance of having tommy john surgery.
This was further examined by Jon Roegele, who keeps track of all professional TJ surgeries, and he recreated the study with different results. The study above seemed to compare all pitchers in MLB history to those who had TJ from when tommy john surgery was first invented in 1974. In comparing pitchers who did or didn’t have TJ from 2009 to 2018, the numbers change, and there is little difference between areas. (Warm 27%, Cool 32%, Total 29%). You can read further on this here.