Stephen Strasburg. Kerry Wood. John Smoltz. Chris Carpenter. Josh Johnson. Tim Hudson. Billy Wagner. Jordan Zimmerman. Joe Nathan. Neftali Feliz.
Prior to 1974, these pitchers’ careers would have been over prematurely. Modern medicine has come to the rescue of many a pitcher though, offering a surgery called ulnar collateral ligament (UCL) reconstruction, commonly called the “Tommy John” surgery.
Tommy John was an All-Star caliber pitcher whose career spanned an amazing 26 years, holding the record for most seasons played until he was eclipsed by none other than Nolan Ryan. He was named to the All-Star team four times, won 288 games, and played in three World Series. Perhaps the most amazing thing about Tommy John though, is that nearly all of his success came after a would-be career ending injury.
John was in the midst of an excellent season pitching for the Los Angeles Dodgers in 1974. He was 13-3 and was leading the Dodgers to their first National League Pennant in eight years. Then, while pitching against the Montreal Expos, John felt something go wrong in his elbow after releasing a sinker. He left the game and was examined by the Dodgers team physcian, Dr. Frank Jobe. Jobe diagnosed an ulnar collateral ligament tear, a diagnosis that often meant the end of a pitching career in those days. The only known treatment was to rest the elbow and hope the ligament healed itself. John’s didn’t.
After several months without improvement, Jobe offered another option to the hurler; undergo a radical new procedure Jobe had thought up after performing similar surgeries on polio patients. Jobe told Tommy John that this surgery had never been tried on an athlete and that he had less than a one in 100 chance of ever pitching again, even if the operation was a success. John figured he had nothing to lose so he accepted Jobe’s offer.
Since then, baseball has never been the same.
The injury that leads to Tommy John surgery is tearing or weakening of the ulnar collateral ligament. This ligament helps hold the elbow together and prevent side to side motion of the joint. Think of it this way, your elbow should only move in one plane, up and down. Now, think of someone holding your arm at your side by placing one hand above your wrist and the other above your elbow. If another person then tries to push your elbow towards your body or pull it away, it should not move. That is because the ulnar collateral ligament is doing its job. If that ligament is weakened or torn, the elbow would be able to move towards and away from the body.
When a pitcher throws a baseball, there is tremendous stress on the elbow. If you think about the pitching motion, the arm starts out behind the torso and as the ball is thrown, the shoulder comes forward while the elbow and wrist lag behind. As the ball is released, the elbow acts as a fulcrum while the lower arm is whipped forward, applying maximum force to the ball. Now, imagine the elbow not being stable during that throwing motion and being able to slide on itself during the throw. This would lead to pain, loss of velocity, and loss of control: symptoms of ulnar collateral ligament damage.
What Dr. Jobe did was to devise a surgery where he took a muscle tendon from the forearm of the non-throwing arm and used that tendon to wrap across where the ulnar collateral ligament was supposed to be. Dr. Jobe drilled holes in two of the bones that make up the elbow, the humerus and the ulna. He then took the tendon and weaved it through the holes in a figure-8 pattern, attaching it with screws to hold it together.
Tommy John went through an extensive rehabilitation program after surgery, but was able to return to pitching in 1976. He posted a 10-10 record and was considered a “medical miracle” by doing so. John wasn’t done yet though. He went on to win 160 of his 288 games after surgery and many say his best pitching years came after the revolutionary procedure.
Baseball has seen a rash of arm injuries in recent years, leaving many to wonder what is different about pitchers today compared to a few decades ago. Teams have instituted pitch count limits, extensive arm strengthening programs, and have even gone so far as to shut pitchers down before the end of the season to avoid excessive wear on their arms. None of these precautions seems to have made much difference. The Washington Nationals famously shut down their ace, Stephen Strasburg, in the heat of a pennant race over fears about the wear on his young arm. Strasburg went on to tear his UCL the very next season and has yet to be the same pitcher.
The only factor that has been proven to be a risk for UCL damage is the number of pitches thrown. This is a repetitive stress injury, so the more times you throw a pitch, the higher your chances of tearing or weakening the ligament. If you think about how young baseball players are developed today, many of them have been pitching since the age of nine or 10. Today, we have select baseball programs starting as early as age eight, where kids are expected to play baseball and baseball only for nine or 10 months of the year. Talk about repetitive stress!
I suspect this system will end up being at least part of the reason why elbow injuries are so common in baseball today. If we want to preserve the arms of our youth, we need to limit the number of pitches they throw as kids and they should not be allowed to throw breaking balls until they are much older, since these pitches put even more stress on their young elbows. If kids got back to playing multiple sports, I suspect we would see less arm injuries as those kids became major league pitchers. Until then, we’ll always have Tommy John.