How to Avoid Tommy John Surgery: The 3 risk factors for injury

If you are a baseball pitcher, player, or just a fan of America’s greatest pastime, then chances are the phrase “Tommy John Surgery” makes your heart skip a beat and a knot in the pit of your stomach. This infamous injury has plagued many of the great pitchers in baseball: John Smoltz, Tim Hudson, John Lackey, Jason Vargas, Greg Holland, and Stephen Strasburg.  Although modifications in the Tommy John surgery have improved outcomes over the years, it still has the potential to be a career ending injury in overhead throwing athletes. Recent research looking at injury trends in the MLB found that since 2001, more than 75 pitchers in the MLB have required Tommy John surgery, which is 1 in every 9 pitchers!! With elbow injuries on the rise in the MLB and the incidence of Tommy John surgeries increasing annually, it is worth a look on what causes this injury and if there is anything we can do to prevent it!


Who is Tommy John, and Why Does He Need Surgery?

Tommy John Surgery is the common name for a surgical reconstruction of the medial ulnar collateral ligament (MUCL) in the elbow. The procedure was named after the baseball pitcher who first underwent this reconstructive surgery in 1974. The MUCL is located on the inside part of the elbow and attaches from the medial epicondyle of the humerus to the medial coronoid process of the ulna providing stability against valgus or inside-out forces on the elbow complex. This valgus or lateral strain on the elbow occurs with repetitive overhead throwing and as much as 64 Newton-meters of valgus force can occur during a single pitch. Considering the MUCL can only withstand about 33 Newton-meters of torque, we can assume that the muscle activity around the elbow helps dissipate the valgus stress during pitching, but a considerable amount of stress is still placed on this ligament throughout multiple innings pitched.

Occasionally, the valgus stress on the elbow during pitching is too much for the muscles to handle and the MUCL ruptures requiring surgery. The Tommy John surgery consists of replacing the MUCL with a tendon graft from somewhere else in a player’s body, most often the palmaris longus in the forearm. The tendon graft is removed and sutured to the bone using anchors. Success rates for MUCL reconstruction vary from 63-97% depending on technique and have a complication rate of about 10%. However, the mean recovery time for a pitcher to return to MLB play is 20.5 months and only 75% of players feel like they return to the same level of play or better. This begs the question what puts an athlete at risk for this injury?

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Who’s at Risk for a Tommy John Surgery?

There are 3 factors that place excessive force on the medial ulnar collateral ligament and put players at risk for developing a Tommy John injury:

  1. Carrying Angle of Elbow
  2. Pitch Count and Speed
  3. Biomechanics of Pitching

Carrying angle of the elbow is the angle between the mechanical axis of the upper arm and lower forearm when the arms are at your side and facing forward. Normal range is 5-10 degrees in males and 13-15 degrees in females, and children often have larger carrying angles which decrease as they age and mature. This larger angle in children may be a reason for higher injury rates in younger athletes, but is most likely multi-factorial in nature. A larger carrying angle creates more valgus stress on the elbow, which increases during overhead throwing. The elbow carrying angle is usually due to bony alignment in adults, which would be an unmodifiable risk factor, but can also be due to ligamentous laxity or soft tissue restrictions.

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The risk factors of pitch count and speed are a little ambiguous in the literature, but it has been shown that repetitive throwing causes micro-trauma in the MUCL, and it makes sense that excessive throwing with short recovery time places the MUCL at risk for injury. In younger baseball players, high pitch counts, more innings pitched per game, and throwing for more than 8 months out of the year have been correlated with an increased risk for elbow injuries. However, there has been no significant relationship between high pitch count and elbow injury in elite level baseball pitchers. A recent study looked at the pitch characteristics of 114 MLB pitchers who underwent MUCL reconstruction between 2002 and 2015. The study found that pitchers who required Tommy John surgery threw pitches with higher velocity regardless of the type of pitch (fastball, curve ball, change up, slider, or split-finger) and the frequency with which each pitch was thrown had no correlation. This makes sense as greater forces need to be generated in order to throw faster, which places more strain on the muscles and ligaments of the elbow. But what is interesting is that the type of pitch thrown was not correlated with an increased frequency of elbow injury.  

And finally one of the most complex risk factors to understand is pitching biomechanics. Certain motions that occur at the trunk, shoulder, and elbow during the six phases of throwing produce more stress on the medial elbow and increase the chance for ligament injury. Due to the complex nature of throwing mechanics, this will be the topic of next week’s blog in this three part series on avoiding Tommy John surgery. So stay tuned for more information on pitching biomechanics and exercises to improve mechanics and reduce the risk of MCUL injury!!

If you are suffering from elbow pain while throwing or have any questions about recovery from a throwing injury, come check out our state of the art facility in order to analyze your issue. You can also call our clinic 408-784-7167 or check out our website

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