A study performed by the Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University, NY called, Public perceptions of Tommy John surgery, identified an alarming percent of players, coaches, and parents who have a misperception of the surgery.
The results from the study showed that 30% of coaches, 37% of parents, 51% of high school athletes, and 26% of collegiate athletes believed that Tommy John surgery should be performed on players without elbow injury to enhance performance. It also showed that 30% of coaches, 28% of players, and 25% of parents did not believe number of pitches thrown to be a risk factor. Many players (28%) and coaches (20%) believed that performance would be enhanced beyond pre-injury level and the final results showed that 24% of players, 20% of coaches, and 44% of parents believed that return would occur in < 9 months. You can find the entire study here: http://www.ncbi.nlm.nih.gov/pubmed/22759607
After receiving tons of requests to put together an article on ulnar collateral ligament (UCL) tears, surgery and rehab and after reading the results from this study above, I quickly realized I needed to do a service to the baseball community and help educate those on the truth about this trending elbow surgery called, Tommy John Surgery.
Tommy John Surgery
It is called Tommy John Surgery because Tommy John was the first pitcher in Major League Baseball in 1974 to have the UCL reconstruction. Dr. Frank Jobe, current advisor to the LA Dodgers, was the soon to be legendary doctor who performed the surgery, which at the time gave Tommy John only a 1% chance of playing again. Before this surgery UCL tears ended careers. Tommy John not only got back to playing at the Major League Level but he broke records. The success rate today is considerably higher and couple this with the proof of performance enhancement, these are the reasons Tommy John Surgery or UCL reconstruction has become so popular.
Does Tommy John Surgery Enhance Performance?
In a recent study performed by the American Sports Medicine Institute (ASMI) called, Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up holds the answer. Here is the conclusion from the study:
Ulnar collateral ligament reconstruction with subcutaneous ulnar nerve transposition was found to be effective in correcting valgus elbow instability in the overhead athlete and allowed most athletes (83%) to return to previous or higher level of competition in less than 1 year.
Read the entire study here: http://www.ncbi.nlm.nih.gov/pubmed/20929932
Yes, ASMI who revolutionized the procedure has proof that Tommy John Surgery can enhance performance, but not in all cases as suggested in the case study above.
The recent HBO hit story on the comeback of Steve Delabar post elbow surgery, I believe, proves the performance enhancement of this surgery. His entire elbow was destroyed, wired and screwed back together to stabilize the joint. I have not discovered the details of the surgery, but it would make sense that if the bones needed to be wired and screwed back together again then the ligaments where long gone. His pitching velocity increase post surgery was 5-6 mph. This is proof that following reconstruction of the UCL and the joint, the pitcher will have a better chance of performance enhancement if he implements a pitching velocity training program like Steve Delabar did post surgery.
Why are UCL Tears so Common?
Science proves that the valgus load applied to the elbow of most pitchers during external rotation exceeds the amount of stress the ligament can withstand before tearing. A study performed by the Biomechanics Lab at Penn State University called, Biomechanics of the elbow during baseball pitching used cadavers to test to see what amount of stress the UCL could hold before tearing. The average valgus load it could handle was 120 Nm, which occurred near the time of maximum shoulder external rotation during a baseball throw. This load was enough to tear the cadaver ligament. You can read the entire case study here: http://www.ncbi.nlm.nih.gov/pubmed/8343786
The study suggests that the triceps, wrist flexorpronator, and anconeus activity during peak valgus stress helps to support the UCL and stabilize the joint. This is why strengthening these muscles in a strength and conditioning program is critical for injury prevention.
Reason for Most UCL Tears
ASMI put together another study to help determine the reason UCL tears where occurring to hopefully discover the link to this ever growing problem. The case study is called, Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors, the results discovered two important factors in the reason for most UCL tears. Here are the results from the study:
Patients averaged 3 potential risk factors, and 85% demonstrated at least one overuse category. Of the pitchers, the average self-reported fastball velocity was 83 mph, and 67% threw breaking pitches before age 14.
Read the entire study here: http://www.ncbi.nlm.nih.gov/pubmed/15262637
It is safe to say that if a pitcher throws harder than 83 mph then he should be on a pitch count, along with learning a different pitch other than a curveball.
Another study called, Dynamic stability of the elbow: electromyographic analysis of the flexor pronator group and the extensor group in pitchers with valgus instability found a decreased activity of the pronator teres and FCU in pitchers with UCL insufficiency. The study suggest that injury of the flexor pronator mass occurs before or at the same time the UCL is damaged, therefore strengthening this musculature will help stabilize the joint and reduce the chance of injury. You can read the entire study here: http://www.ncbi.nlm.nih.gov/pubmed/8933456
How to Prevent UCL Damage?
It first starts with a pitch count following the ASMI Position Statement for Youth Baseball Pitchers, then follow this with a strength and conditioning program to strengthen the forearm, rotator cuff, and shoulder/scapular area.
When it comes to the pitching mechanics to reduce the stress applied to the joint a recent bio-mechanical analysis has found that coupling of shoulder internal rotation and forearm pronation forms the physiological basis of varus acceleration to minimise valgus elbow load. You can learn more about this analysis here: http://www.ncbi.nlm.nih.gov/pubmed/10824641
My recent article called, Research Proving Pronation Supports Pitching Velocity While Preventing Injury goes into more detail on the specific mechanical movements that will further reduce this elbow stress.
Reason for Having Tommy John Surgery
Many pitchers think that pain is the only reason for having surgery but the other key symptoms that are associated with the pain are what determines if the surgery is needed.
Langer, Fadale, and Hulstyn put together this research called, Evolution of the treatment options of ulnar collateral ligament injuries of the elbow. Here is the results of their research on the signs and symptoms of UCL injuries.
Clinical presentation of UCL injury involves medial elbow pain, typically chronic and episodic more often than acute. Symptoms of instability are seldom reported by patients. However, for 85% of the time, pain is associated with the acceleration phase of throwing after an inadequate warm up period.
Patients may report a previous history of pain and subsequent corticosteroid injection. A “pop” may be heard or felt if the injury is acute. On the contrary, if the injury is chronic, pitchers report diminished accuracy, velocity, control, stamina, and/or strength.
You can read the entire paper here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465120/
I will never forget the day I was in the stands during one of my college baseball games clocking our pitchers on my off day. The pitcher was my roommate and best friend. He was a lefty who threw in the mid to upper 80's. In about the 4th inning he threw a pitch and I heard a pop. He looked concerned that something just happened but didn't look in much pain. This was a very different reaction I experience when I torn my rotator cuff two seasons before. I did notice though the next few pitches he threw his pitching velocity had drop a good 10 mph. The coach took him out at this point.
I remember he was having pain during this point in the year but it wasn't anything that he hadn't experienced before. I believe a pitcher will know he has the symptoms of UCL damage when he has pain and his pitching velocity and control takes a downward turn.
More Facts about Tommy John Surgery
These remaining facts of UCL reconstruction come from the research just mentioned above by Langer, Fadale, and Hulstyn.
Today, UCL reconstruction is no longer considered experimental; the most commonly quoted success rate is 85%. Surgical success is defined as the ability of afflicted athletes to return to a preinjury level of play for at least one year.
Recent statistical data reveal that more than 75 pitchers who have appeared in the major leagues since 2001 have had this surgery—that is, about one in nine (Dodd; USA TODAY, 2003).
A recent retrospective cohort study of the period 1988–2003 revealed that not only has there been a dramatic overall increase, but an approximately 50% increase in UCL reconstruction in high school players (aged 15–19) in recent years.
UCL injury has become a substantial problem in youth pitchers. About 150 reconstructions are carried out a year at the ASMI. According to recent information, 20% are major league pitchers, 20–25% are minor league throwers, and 60% are collegiate and high school athletes.
What concerns me after reading the last excerpt here is the fact that youth pitchers are having more arm surgeries than professional pitchers. This is more proof that the ignorance associated with the conventional wisdom of this game has caused an epidemic of pitcher injuries. I highly recommend that you read my latest article called, Research Proves Why Conventional Wisdom Is Ruining Pitchers Today. It covers this serious problem with the lack of education of these conventional coaches and instructors in hopes that you, your son or your player will not fall victim to this epidemic.
Rehabilitation Following Tommy John Surgery
Here is the rehabilitation protocol as describe by Dr. James R. Andrews of ASMI and colleagues from their latest report posted on the US National Library of Medicine website called, Current Concepts in Rehabilitation Following Ulnar Collateral Ligament Reconstruction.
The total arm-strengthening concept should be followed during rehabilitation after UCL reconstruction. Emphasizing proximal scapular stabilization early in the rehabilitation program and continuing this emphasis using a low-resistance, high-repetition program restores the necessary proximal stabilization to promote an optimal return to uncompensated throwing. This includes scapular stabilization via manual resistance to elicit serratus anterior and trapezius/rhomboid muscle activation without compromising the repair.
Rotator cuff strengthening can commence in the first few weeks following UCL surgery. The resistance is applied proximal to the elbow to prevent and/or minimize stresses across the elbow. Prone extension and horizontal abduction are used to recruit the posterior rotator cuff and scapular stabilizers.
Resistance exercise is progressed with range of motion (ROM). From isometric exercises in the immediate postoperative phase, progression including light- resistance isotonic exercises occurs at week 4 for the wrist and forearm. Progression to the full Throwers Ten Program (click to enlarge picture) is targeted by week 6. Additional progressive resistance exercises are incorporated at week 8 to week 9 to develop dynamic stabilization of the medial elbow. Weeks 6 to 12 emphasize stretching, ROM, and strengthening exercises for the glenohumeral joint, scapula, core, and legs.
Here is their recommendations for rehabilitation if the technique used during surgery was the docking procedure.
The rehabilitation program following the docking procedure is similar to the modified Jobe procedure. The most significant differences involve the restoration of elbow ROM: Immediately following surgery, the patient is limited to 30° to 90° for 4 weeks. From 4 to 6 weeks, their ROM is increased to 15° to 115°. The goal is to restore full elbow ROM at 6 to 12 weeks. The strengthening program following the docking procedure is similar to the modified Jobe procedure: Wrist, hand, and elbow ROM and isometrics are permitted immediately following surgery. Shoulder isometrics are not permitted until 4 weeks, postoperatively; isotonic strengthening for shoulder and arm, at 8 weeks; and plyometrics, at 12 weeks. Interval throwing begins at 4 months, postoperatively, and progresses to off-the-mound throwing with a return to competition at 9 to 12 months, postoperatively.
They also stress the important of plyometric training on the upper extremities for rehabilitation. This is a key part of their rehabilitation protocol as described below.
For overhead athletes, plyometric drills can be an extremely beneficial form of functional exercise for training the elbow using a weighted medicine ball during the later stages of this phase.
Plyometric exercises are initially performed with 2 hands at 12 weeks post injury: a chest pass, a side-to-side throw, and an overhead soccer throw. Plyometrics progress to 1-hand activities at 14 weeks: 90/90 throws (Figure 6), external and internal rotation throws at 0° of abduction (Figures 7 and and8),8), and wall dribbles. Plyometric drills for the forearm musculature include wrist flexion flips (Figure 9), snaps, and extension grips.
Finally here is their advice on returning to throwing activities for the pitcher post surgery and rehab.
An athlete is allowed to begin the return-to-activity phase of rehabilitation upon achieving full ROM, no pain or tenderness, satisfactory isokinetic strength, and a good clinical examination. An interval throwing program is allowed at 16 weeks. The “off the mound” program requires 6 to 8 weeks to normalize pitching mechanics and to reestablish ball velocity and accuracy. In most cases, throwing from a mound is allowed 6 to 8 weeks following the initiation of an interval throwing program. A return to competitive throwing is expected at approximately 9 months following surgery.
Read the entire report here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445125/
I am not a doctor, but based on my expertise I would highly advise any pitcher post Tommy John Surgery to use a total body training program, like the Fusion System in the 3X Pitching Velocity Program, following week 12 for at least 8 weeks to establish the necessary lower body and core strength needed before any mound pitching. The reason is based on the latest research below:
In previous work, Kibler and Chandler calculated that a 20% decrease in kinetic energy delivered from the hip and trunk to the arm requires a 34% increase in the rotational velocity of the shoulder to impart the same amount of force to the hand.
Source of reference: Kibler WB, Chandler J. Baseball and tennis. In: Griffin LY, editor. , ed. Rehabilitation of the Injured Knee. St. Louis, MO: Mosby; 1995:219-226.
The biggest challenge of any surgery is the loss of lean muscle mass post surgery, especially in the legs and core. This coupled with the injury that caused the surgery in the first place is the reason many athletes quit the game following surgery all together. Not only will a pitcher post arm surgery have a significant loss of joint integrity in the elbow and shoulder that was operated on, but the loss in leg and core strength as well will put even more stress on the arm when the pitcher begins his post surgery throwing program. I would not step on a mound until my legs and core where as strong as they were before the surgery. Failure to build the adequate amount of strength in the legs, core, shoulder and elbow could cause the pitcher to reinjury the joint.
Reinjury Post Tommy John Surgery
Not many pitchers reinjury the UCL post Tommy John Surgery, but I am a big believer in the fact that if you do not change the mechanics that caused the injury then you have a good chance it will happen again or you will not get any better. A study performed at the Kerlan Jobe Orthopaedic Clinic, Los Angeles, California, called, Revision surgery for failed elbow medial collateral ligament reconstruction showed that the return rate of pitchers post revision surgery for the UCL is much lower than the success rate of the initial surgery. Here are the results from the study:
Average time to revision was 36 months. The technique used in the revision was the Jobe technique in 11 cases, DANE TJ in 3, and primary repair in 1. Thirty-three percent (5/15 excellent) returned to their previous level of play for at least 1 season. Additionally, there were 4 good, 2 fair, and 4 poor results. The ligament repair had a good outcome. Forty percent (6/15) of patients had complications, 1 of whom required a subsequent surgery (lysis of adhesions). One subject experienced a retear of the medial collateral ligament.
Read the entire case study here: http://www.ncbi.nlm.nih.gov/pubmed/18443277
This study should convince every pitcher that you have one chance to get this right.
UCL Reconstruction in Review
What we have learned from all this research is that UCL damage can be prevented with strength and conditioning, pitch counts and proper pitching mechanics. We have also learned that there are a lot of misconception behind the famous Tommy John Surgery; not everyone survives it or comes out at a higher level. More than likely the reason for the performance enhancement is the improved pitching mechanics and the improved strength and conditioning.
At all cost, surgery should always be avoided due to its unnatural abuse to the body. Being a victim of shoulder surgery myself, I speak to those who have not been through this procedure and advise you to take caution before jumping into it. If you need any support pre or post surgery due to an arm injury or pain, please contact me and I will do my best to help you through this challenging hurdle in your pitching career.