Saturday, February 6, 2016

Can we explain the increase in Tommy John surgeries?

Tommy John Surgery... the three words every baseball pitcher dreads hearing.

Can we explain the increase in Tommy John surgeries?


Tommy John Surgery… the three words every baseball pitcher dreads hearing.

It indicates a long tedious road of rehabilitation and valuable time away from the game. The rehabilitation following surgery generally takes 12 months to return to pitching and 18 for a full recovery. There are also usually 2-3 months prior to surgery where most pitchers follow conservative care attempting to avoid surgery.  All told, it may be 2 years from initial injury until you are pitching ‘normally’ again.    

Tommy John surgery, or Ulnar Collateral Ligament (UCL) reconstruction, was pioneered in 1974 by Dr. Frank Jobe.  As many baseball fans are aware, Tommy John was the first player to have this surgery.  He had more wins after surgery than prior to surgery and pitched 15 more years in the majors. Countless others have had their careers revived following UCL reconstruction and have gone on to pitch long healthy careers.  The success rate of UCL reconstruction is about 90 percent, meaning 1 in 10 players will NOT return to their previous level following surgery.

With that in mind, conservative care—including no throwing, rehabilitation, and a re-evaluation of mechanics should be followed with partial UCL tears. Many individuals falsely believe that all ligament sprains/partial tears should be fixed surgically; some parents have even requested ligament reconstruction to PREVENT an injury. 

Many pitchers have had long healthy careers without surgery following a partial UCL tear. The keys to conservative care are:

1) Fix the problem that led to the injury (mechanics, shoulder weakness, poor movement patterns/ movement dysfunction)

2) Patience to allow adequate time for the ligament to heal. Often times this requires 6-8 weeks of no throwing, followed by a 6-8 week long-toss program, and then 4-6 weeks of bullpens before pitching in a game. If at the end of the 16+ week period the pitcher continues to have pain, surgery may be considered.  I have seen too many players rush the rest period, have continued pain, and wind up with surgery that may have been avoided.

The surgery has become more routine, but as the name ‘reconstruction’ suggests, it is anything but simple. The procedure, which takes about one hour, requires a sports medicine surgeon (who specializes in elbow injuries) to recreate the ligament on the medial or inside of your elbow using a tendon from your forearm.

The surgeon drills holes above and below the medial elbow and creates a figure-8 pattern with the tendon.  Once completed, your ligament is reconstructed. The surgery also often entails moving your ulnar nerve (funny bone), removal of bone chips, and/or cleaning parts of your elbow.  This website describes the anatomy and surgical procedure in detail.

This season in MLB, UCL reconstruction has reached epidemic proportions.  As of May 31, 19 pitchers in MLB alone have had their ligament reconstructed. This is the most to date in the history of baseball and is on pace to shatter the season record of 35 in 2012. Although this increase may be a coincidence or a simply an anomaly, the number of UCL reconstructions has increased dramatically over the past 10+ years among all age groups. This statistic cannot be ignored; adolescents are tearing their UCL at alarming rates with younger baseball pitchers requiring this surgery. The question is simple: what is causing an increase in UCL injuries?  The answer is not so simple, but there are certainly risk factors that appear to increase a pitcher’s likelihood of injury. 

One of the more likely causes is sport specialization at an early age. As I mentioned in my previous post, The dangers in sports specialization, I believe children should play multiple sports and should not be restricted to one sport at a young age. This is most true when it comes to pitching in baseball. Many pitchers pitch from a mound year round. They rarely take a break from throwing or pitching and thus never recover. Furthermore, many young pitchers throw too many pitches per game and week. As they fatigue, their hips, core, and scapula (shoulder blade) muscles become weaker and perform less work; this increases the stress and force on the elbow. 

Fatigue leads to poor mechanics, which is the second major cause of injury. With poor mechanics, the UCL of the elbow undergoes increased stress, which over time can lead to a tear or sprain. It is imperative that pitchers use proper mechanics. Be wary of individuals that guarantee increases in velocity; some of them (hopefully a small minority) are willing to sacrifice long term health for increased velocity. Thirdly, the pitcher most likely has postural and movement deficiencies leading to weakness in his scapula and core; tightness in his shoulder and hip flexors; and overall poor movement patterns. 

The American Sports Medicine Institute and Dr. James Andrews released a position statement in May on UCL injuries.  Among other things, they state that UCL injuries in MLB are likely due to a cumulative effect starting with pitching as an amateur.  Read the full report here.

When year-round pitching, daily and weekly pitch counts, mechanics, and postural/movement dysfunction are addressed preventatively, the incidence of UCL injury will likely decrease. We know the question; now we need to work on the solutions. Stay tuned to Sports Doc for my next two posts on throwing mechanics and rehabilitation following UCL reconstruction.
Read more Sports Doc for Sports Medicine and Fitness.
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J. Ryan Bair, PT, DPT, SCS Founder and Owner of FLASH Sports Physical Therapy, Board Certified in Sports Physical Therapy
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Desirea D. Caucci, PT, DPT, OCS Co-owner of Conshohocken Physical Therapy, Board Certified Orthopedic Clinical Specialist
Michael G. Ciccotti, M.D. Head Team Physician for Phillies & St. Joe's; Rothman Institute
Julie Coté, PT, MPT, OCS, COMT Magee Rehabilitation Hospital
Peter F. DeLuca, M.D. Head Team Physician for Eagles, Head Orthopedic Surgeon for Flyers; Rothman Institute
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Joel H. Fish, Ph.D. Director of The Center For Sport Psychology; Sports Psychology Consultant for 76ers & Flyers
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Justin Shaginaw, MPT, ATC Athletic Trainer for US Soccer Federation; Aria 3B Orthopaedic Institute
Thomas Trojian MD, CAQSM, FACSM Chief of the Division of Sports Medicine at Drexel University
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