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How to Reduce Your Child’s Need for Tommy John Surgery

The Legacy of Tommy John: Increasing Youth Baseball Injuries?

Wiemi A Douoguih, M.D.
Medical Director MedStar Sports Medicine
Washington Region

Medical Director,

In 1974 Tommy John was a power pitcher for the Los Angeles Dodgers. By the middle of the season he had raced out to a personal best 13-3 record and was considered by some to be a favorite for the CY Young award. On July 17th, 1974 John was on the mound facing the Montreal Expos. Tommy attempted to throw a sinker to Hal Breeden in the top of the fourth inning, but the pitch went into the stands. He attempted one more pitch and, although it reached the catcher’s mitt, things didn’t feel right. So, he stepped off the mound and headed for the dugout. Dr. Frank Jobe, Orthopaedic surgeon for the Los Angeles Dodgers, was sitting in the stands at the time Tommy threw the first pitch and knew something was seriously wrong. After Dr. Jobe watched John grab his elbow and walk off the mound he headed straight to the training room to meet him. Dr. Jobe performed a thorough physical exam and was convinced John had torn his ulnar collateral ligament. Prior to 1974 the diagnosis of a torn ulnar collateral ligament had never been made. Dr. Jobe who had lived through the final years of Sandy Koufax’ career during which Koufax pitched with chronic elbow pain, was convinced that John had torn the ligament that we now know serves as the primary stabilizer of the thrower’s elbow.

Dr. Jobe placed Tommy’s arm in a cast and prescribed a six week period of rest. After coming out of the cast Tommy began a throwing program, but each time he reached 75% effort the elbow began to hurt and he had to stop throwing. At this point Dr. Jobe knew that nothing short of a miracle would allow Tommy to return to pitching. Dr. Jobe had been devising such a miracle over the previous several years. He just didn’t know if it would work. He had long thought the ulnar collateral ligament of the elbow was the structure injured when a thrower “blew out his arm”. However, there were no MRI’s in 1974 to assist him with the diagnosis. He had been working on a procedure in the lab to reconstruct the injured ligament; but he’d never done it on a live human. When he proposed the experimental procedure to Tommy John he gave him a 1 in 100 chance of success! While these were ridiculous odds by today’s standards, in 1974 Tommy John knew he really didn’t have any other options if he wanted to try to pitch again.

On September 25th, 1974 Dr. Jobe performed the first ever ulnar collateral ligament reconstruction on Tommy John. He transferred a tendon from John’s forearm (called the palmaris longus tendon) and weaved it around the torn ligament three times before sewing it into the native ligament. 1 year and 1 day after the fateful surgery Tommy threw a live bullpen. He felt tentative and wondered if would ever pitch again at the major league level. However, with each passing month Tommy’s arm grew stronger. In fact, he began to tell people that it felt stronger than ever had before the surgery. The following year he finished the season 10-10. Tommy’s initial concerns and Dr. Jobe’s ominous prediction turned out to be unfounded. Tommy went on to pitch 14 seasons, at the major league level. He recorded 164 more wins and made three World Series appearances. The procedure that was given a 1/100 chance of success now bears the name of the courageous pitcher who took a chance on the brilliant, innovative head physician for the Los Angeles Dodgers.

Dr. Jobe passed away earlier this year, leaving behind him a legacy of reborn pitchers brought back from the proverbial dead. In fact, one-third of all major league pitchers in 2013 had undergone the “Tommy John” procedure. With success rates reported as high as 97.2% after Tommy John surgery, Dr. Jobe’s groundbreaking surgery has revolutionized the way players, coaches and executives think about injury in baseball.5 Unfortunately, having found a miraculous cure for a problem that in the past meant the death knell of the overhead thrower may have created another problem altogether. The start of the millennium saw an increase in year round baseball, overlapping seasons and showcases. A reckless mentality began to permeate youth baseball.

In 2002, Lyman studied a cohort of youth baseball players over the course of a little league season.1 Four hundred and seventy-six young (ages 9 to 14 years) baseball pitchers were followed for one season. They noted that half of the subjects experienced elbow or shoulder pain during the season. The curveball was associated with a 52% increased risk of shoulder pain and the slider was associated with an 86% increased risk of elbow pain. There was a significant association between the number of pitches thrown in a game and during the season and the rate of elbow pain and shoulder pain. As a result of their findings they recommended limiting volume of pitches and avoidance of curve ball and slider until after the age of fourteen. While shoulder and elbow pain were concerning in this young cohort the link between pain and surgery had not yet been established. In 2004 Petty reported on a cohort of high school throwers undergoing UCL reconstruction surgery noting a 50% increase in the number of Tommy John surgeries over a ten year period.2 While 74% were able to return to play, those undergoing UCL reconstruction averaged 3 major risk factors including: year-round throwing, seasonal overuse, event overuse, throwing velocity more than 80 mph, throwing breaking pitches before age 14, and inadequate warm-ups. In fact 67% reported throwing breaking pitches before the age of 14.

Mounting evidence lead the Medical Baseball Safety Advisory Committee in 2006 to make recommendations regarding pitch counts and types of pitches to be thrown for specific age groups, in an effort to reduce the injury incidence in youth baseball players. By the end of the decade it seemed that progress was being made in terms understanding of factors responsible for injury. But it’s one thing to know the rules and another to enforce them. In 2012 Fazarale conducted a survey of youth baseball coaches to assess their understanding and implementation of the Medical Baseball Safety Advisory Committee’s recommendations for youth pitchers.7 The findings were alarming. Coaches correctly answered only 43% of questions regarding pitch count and rest periods. 73% reported that they followed the recommendations, while only 53% felt that other coaches in the league abided by the recommendations. 35% percent of coaches stated that their pitchers reported shoulder or elbow pain during the season, and 19% reported that one of their pitchers pitched a game with a sore or fatigued arm during the season. Interestingly, no coaches reported any pitching-related injuries among their players requiring surgery. Yang, in March of 2014 reported on the results of a nationwide survey of 754 youth pitchers.8 43.4% of all pitchers reported that they pitched on consecutive days, 30.7% pitched on multiple teams with overlapping seasons, and 19.0% pitched multiple games a day during the 12 months before the study. Each of these factors statistically increased the risk of throwing arm pain. 70% of pitchers threw off-speed pitches which was also associated with a statistically higher incidence of arm pain. Pitching with arm pain or fatigue resulted in a nearly 8 fold increase in injury to the throwing arm.

Nearly 40 years have passed since Tommy John under went fateful surgery to reconstruct the ligament in his elbow. Tommy John’s 14 years in the league after surgery seems to be an anomaly, as one recent study showed that the average return to play after UCL reconstructive surgery was only 3.5 years.9 Although much has been learned about baseball injuries during this time, it’s critical that the lessons learned be applied in a way that will help young players achieve their goals while staying out of the doctor’s office.

At MedStar Sports Medicine we are adamant that young players follow the guidelines set forth by the Medical Baseball Safety Advisory Committee for pitch counts, proper rest and avoidance of modifiable risk factors. In general, we recommend a four month rest from throwing each year. Young players should avoid pitching back to back games, pitching multiple games on the same day and playing in overlapping seasons. Pitching sliders and curve balls should be avoided until after the age of 14. Players should also avoid playing pitcher and catcher. Finally, we encourage players to play other sports so that their bodies will develop other muscle groups that may aid in preventing baseball injuries. Following these guidelines does not guarantee that a player will not get injured. But these recommendations are supported by a growing body of evidence that too much throwing can be harmful.

While our surgeons have had tremendous success returning elite youth and professional baseball players to the field of play, our focus is on prevention. Our approach to the overhead thrower includes performing cutting edge research, educational seminars tailored to coaches and parents, and throwers’ screening programs. Further information can be found on our website: medstarsportshealth.org. More information on pitch counts and injury prevention can be found at the ASMI website 4.

References:

  1. Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002;30:463-468.
  2. Petty DH, Andrews JR, Fleisig GS, Cain EL. Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors. Am J Sports Med. 2004;32(5):1158-1164
  3. Nissen CW, Westwell M, Ounpuu S, Patel M, Solornito M, Tate J. A biomechanical comparison of the fastball and curveball in adolescent baseball pitchers. Am J Sports Med. 2009;37:1492-
  4. American Institute of Sports Medicine. Position statement for youth baseball pitchers. Published 2012. Updated April 2013.
  5. Erickson BJ, Gupta AK, Harris JD, Bush-Joseph C, Bach BR, Abrams GD, San Juan AM, Cole BJ, Romeo AA. Rate of return to pitching and performance after Tommy John surgery in Major League Baseball pitchers. AM J Sports Med. 2014 Mar;42(3):536-43.
  6. Douoguih WA, Dolce DL, Lincoln A, Dunn R. Early Cocking Phase Mechanics and Associated Risk in Starting Professional Baseball Players. Presented at MLBTPA meeting Orlando, December 2013.
  7. Fazarale JJ, Magnussen RA, Pedroza AD, Kaeding CC. Knowledge of and compliance with pitch count recommendations: a survey of youth baseball coaches. Sports Health. 2012;4(3):202-204.
  8. Jingzhen Yang, Barton J. Mann, Joseph H. Guettler, Jeffrey R. Dugas, James J. Irrgang, Glenn S. Fleisig and John P. Risk Prone Pitching Activities and Injuries: Findings from a National Sample. Am J Sports Med published online March 13, 2014 DOI: 10.1177/0363546514524699
  9. Osbahr DC, Cain EL, Raines BT, Fortenbaugh D, Dugas JR, Andrews JR. Long-Term Outcomes After Ulnar Collateral Ligament Reconstruction in Competitive Baseball Players. 2013 O’Donoghue award Am J Sports Medicine 2014, Apr 4 (ePub ahead of print).

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