Tommy John Surgery

Back in 1974 Tommy John underwent surgery that would save his career and change the face of baseball. Forever known as Tommy John surgery, when a player jacks up their elbow they have the procedure that bares the lefties name. This piece will talk about the surgery, an alternative possibility, who has had the surgery and what the prospects are for hurlers returning from the procedure.

WHAT CAUSES THE INJURY THAT LEADS TO SURGERY?

There is no definitively established reason as to why some players end up needing the surgery while others do not. Some possibilities that can be considered would include (a) the physical structure of the player (i.e. their genetics), (b) throwing mechanics (c) wear and tear, i.e. heavy or long-term usage, (d) extreme exertion while throwing, i.e. throwing at 100 percent, (e) throwing too many pitchers at a young age, (f) year-round training and throwing. All of these factors likely have some bearing on whether or not a player ends up having to make an appointment to have his arm repaired.

Noted surgeon Dr. James Andrews has noticed a trend towards even younger arms needing the surgery with high school pitchers inundating him with surgical requests. His guess is that hurlers are so big and strong, and throw with such velocity while at a young age, that they simply overpower the elbow ligament, leading to tears (if they throw over 85 mph as a teenager they are especially at risk). He sees the biggest risk factor as year-round baseball with no time off for recovery.

Some youthful athletes believe the procedure should just be done either (a) because they fear it will eventually be required or (b) because they believe they will be able to throw harder when they return. No doctor would perform an unnecessary procedure. There's also always the possibility that the surgery doesn't work. Just ask Ryan Madson, Kris Medlen or Zack Wheeler.

Another reason some decide they need the procedure is because they falsely believe they will throw harder. The procedure does not directly lead to an increase in velocity. “But Ray, guys throw harder after the procedure.” The most likely reason for this is overall conditioning. Pitchers are diligently trained through the process as they strengthen all parts of their body. Something can be said for the new ligament helping the arm to be stronger, but it's most likely any increased velocity is the result of overall physical training.

THE SURGERICAL PROCEDURE

When the ulnar collateral ligament is damaged Tommy John surgery is often indicated to resolve the issue. A tendon is most frequently harvested from the wrist, but there are times when the tendon is taken from the forearm, hip or hamstring of the patient (some people don’t have the extra tendon in their forearm that is often harvested – they just weren’t born with it). In rare instances the tendon is taken from a cadaver.

The operation is a simple procedure that can take anywhere from an hour to an hour an a half. The surgeon drills two holes in the ulna and humerus. A graft of the tendon is passed through the holes and weaved into a figure eight pattern. The ulnar nerve is often relocated so as to avoid any irritation in the future.

THE PATH TO RECOVERY

The recovery period continues to decrease as medical procedures, and training regimens, improve. Generally speaking, athletes can return in under a year from the surgery, but for pitchers it's best to guesstimate 12-18 months for a return to action though it often takes up to two full years before the arm fully responds (relievers can on occasion undershoot the lower end estimate for obvious reasons – they don’t have to stress their arms for 100 pitches).

THE INCREASING VOLUME OF PROCEDURES

According to Jon Roegele (more on him below), the procedure has certainly seen an uptick the last handful of season with 2015 being a virtual epidemic of immense proportions.

2005: 49

2006: 47

2007: 58

2008: 41

2009: 57

2010: 63

2011: 50

2012: 87

2013: 63

2014: 92

2015: 128

2016: 84

Some salient facts.

(1) Over the last 12 years there have been between 41 and 128 Tommy John procedures per season, a pretty massive spread that speaks to the uncertainty of player health.

(2) The average number of procedures per year over the last 12 years is 68.3.

(3) The average number of procedures the last three years has climbed to 101, a massive increase over the previous decades results.  

THE LIST

Tommy John surgery has been going on since the 1970’s, and no one in the world has a more complete database about the procedure than Jon Roegele (you can follow him on Twitter @MLBPlayerAnalys). There are about a gazillion players who have had the surgery since 1974, and the list grows on a nearly weekly basis. Up to more than 1,300 players is the list in total. You can read all about the procedure, when it occurred, who the surgeon was etc. on Jon’s Tommy John list.

DOES IT WORK?

Last March Jon wrote about the effects of the surgery. Here’s a synopsis of what was found.

1 – The American Journal of Sports Medicine reviewed three survey’s that claimed success rates of 83, 80 and 79 percent.

2 – Jon’s database, through March 2015, reported a success rate of 78 percent.

3 – Let me state it differently. About one in five pitchers who has Tommy John surgery never pitches in the big leagues again.

4 – Pitchers who had the procedure from 1974-1999 returned to pitch for longer periods of time than the hurlers who have had the procedure in the 21^st century.

5 – Median means the exact midpoint of a set of numbers. That means there are as many below as above the baseline that is set. Amongst all the pitchers that had the procedure from 2000-09 the median for games pitched was about 60 outings for a total of about 100 innings. Straight away... amongst every arm that had the procedure over the first decade of the 21^st century, the median was 100 innings (as many guys below 100 frames as above it).

Here are the median totals for hurlers, from 1974 to 2009, based upon the age the player was at the point he had the surgery.

6 – Here is a table speaking to return times to the big leagues from the procedure for those that had the surgery from 1974 to 2009.

Success rates are much lower than most have been led to believe.

TOMMY JOHN REPLACEMENT?

Tommy John surgery... the three most dreaded words for a pitcher in baseball. When the elbow goes, the UCL in particular, pitchers are forced to go under the knife in a procedure that was pioneered on the former lefty hurler in 1974. The surgery usually requires 12-16 months to return from meaning that an entire season, at best, is lost if a hurler has the procedure.

There might be an option on the table that could cut that timeline in half.

Dr. George Paletta performed this new procedure on Seth Maness, and the hope is that Maness will be ready for Opening Day... 7.5 months after surgery (Mitch Harris also had the procedure in 2016). This alternative procedure needs a new name, it’s called “primary repair” right now, and that is going to help it to lose the PR game before the thing even gets off the ground. The new procedure repairs the existing ligament, versus Tommy John surgery which replaces the ligament. “It is a repair and buttressing of the existing ligament at the bone, not Tommy John’s reconstruction of the ligament.” According to Dr. Paletta, he has performed 50 procedures and there has yet to be a single setback that required another surgery. Dr. Jeffery Dugas, who is a managing partner at Dr. James Andrews clinic, has reportedly performed about 150 such procedures since August of 2013 and none of those arms had to have the procedure redone or been forced to undergo Tommy John surgery.

That’s the potentially great news with primary repair. However, a caveat. Not all players are candidates for the procedure. “The integrity of the tissue is essential, and sometimes a big-league pitcher’s aged and worn ligament can be as solid as wet toilet paper. The location of the tear is also an indicator for “primary repair.” A rupture in the middle of the ligament requires Tommy John. But if the tear is at either end of the ligament, where it attaches to a bone, then the “primary repair” is possible.”

If primary repair works we could be looking at a whole new avenue to repair injured hurlers arms with a drastically reduced timeline as well.

2014 TOMMY JOHN SURGERY RECIPIENTS

Miguel Sano (March 12^th) – Yes, fielders can have the procedure too, don’t forget that.

Patrick Corbin (March 25^th) – Was a failure in 2016 (5.15 ERA, 1.56 WHIP) which is shocking given how impressive he was in 2015 (3.60 ERA, 1.27 WHIP over 16 starts). It’s not always a straight line to success, especially when health issues are tossed into the mix.

Jameson Taillon (April 9^th) – Was marvelous last season, remarkably so, especially since he missed 2015 with hernia surgery. Oddly, the extra year off and further physical complications likely helped his arm out immensely.

Matt Moore (April 22^nd) – A success story. Threw 63 innings in 2015 before tossing a career best 198.1 last season. Unlike many who have the procedure, he’s been able to limit the walks way more effectively after the surgery than he had prior to going under the knife.

Ivan Nova (April 29^th) – Posted a 5.07 ERA over 17 starts in 2015 and no one cared. He had an impressive run with the Pirates last season though, and like Moore he was able to find the strike zone more frequently (he knocked a full batter off his BB/9 rate last season).

A.J. Griffin (April 30^th) – He didn’t thrown a big league pitch in 2014 or 2015. Last year he had a 5.07 ERA, 1.36 WHIP and 2.33 K/BB ratio over 23 ineffective starts.

Martin Perez (May 19^th) – Perez is the same guy he was prior to surgery, and that is a boring nothing.

Matt Wieters (June 17^th) – Just like Sano, he’s obviously fully recovered now though it took longer than expected with the catcher.

Bronson Arroyo (July 15^th) – Still hoping to continue his career at 40 years of age. The hair, the music, the leg kick.

Tyler Chatwood (July 23^rd) – Didn’t throw a pitch in ’15 but he was impressive last year for the Rockies especially on the road where the sinker baller posted a remarkable 1.69 ERA.

Tyler Skaggs (August 13^th) – Had about 602 setbacks, I counted. He made 10 starts last season for the Angels with a 4.17 ERA and 1.49 WHIP. At least he had 50 strikeouts in 49.2 innings.

2015 TOMMY JOHN SURGERY RECIPIENTS

These hurlers should be full ready to go at the start of the 2017 season.

Yu Darvish (March 17^th) – The 30 year old righty had a few setbacks last season (neck and shoulder) but he made 17 starts lasing 100.1 innings. The heater was still there (11.84 K/9).

Zack Wheeler (March 25^th) – Seriously, how many setbacks did he endure last year? If you know the answer you must have a computer like memory cause the setbacks were seemingly coming on a bi-weekly basis for the former elite talent. At this point we don’t even know if he will be a starting pitcher or reliever. From March 25^th of 2015 until March 25^th of 2017 – two full years – he will have thrown zero big league innings. Moreover, after not throwing a professional pitch in 2015 he threw all of one inning in 2016. This is the cautionary tale with pitcher’s returning from the surgery.

Brandon McCarthy (April 30^th) – Seemingly always hurt, he’s made 10 outings since the procedure with awful results (4.95 ERA, 1.38 WHIP, 5.85 BB/9).

Homer Bailey (May 8^th) – Could never get right last year and ended up making six ineffectual starts in a completely lost season (6.65 ERA, 1.83 WHIP, .452 BABIP).

Adam Ottavino (May 7^th) – Returned triumphantly with seven saves, four holds, and a 0.93 WHIP over 34 outings last year.

Alex Cobb (May 14^th) – We kept waiting for it to happen last season... and it never did. Cobb made five starts and looked nothing like the performer he was prior to the surgery.

Greg Holland (October 2^nd) – Was barely hitting 90-91 mph on the gun in his showcase for clubs this offseason. Hopes to continue to build velocity as he moves further from surgery.

Lance Lynn (November 10^th) – There was talk he might see the field at the end of last season. The 29 year old righty, from 2012-15, averaged 15 wins, a 3.38 ERA, 1.31 WHIP and a 8.64 K/9.

2016 TOMMY JOHN SURGERY RECIPIENTS

Remember, we usually expect a return to be in the 12-16 month range under ideal circumstances. That means a best-case scenario for most arms on this list would be a successful run in the second half.

Jarrod Parker (March 17^th)

Manny Parra (April 8^th)

Felix Doubront (April 12^th)

Marco Gonzales (April 15^th)

Robbie Erlin (May 17^th)

Andrew Heaney (July 1^st)

Nathan Eovaldi (August 19^th)