Texas Rangers

Tommy John surgery now common, but as confounding as ever


It has become cliché, baseball’s “Tommy John epidemic,” but the renowned ligament-replacement surgery has become just about as prevalent as a fan eating a hot dog at the ballpark.

That’s a problem for fans and franchises, which have emotional and financial investments in pitchers signed to contracts that dwarf the economies of some Third World countries.

News that a pitcher is suffering from tightness in his forearm seemingly always leads to the procedure invented by Dr. Frank Jobe and used on his first patient, Los Angeles Dodgers pitcher Tommy John in 1974.

More than 1,000 major-leaguers had Tommy John surgery performed as of 2013 — mostly, but not all of them pitchers — a figure that has soared in recent years. Since the beginning of January 2014, more than 100 major league or minor league pitchers have had Tommy John surgery, including Yu Darvish of the Texas Rangers earlier this month.

Between 1974 and 1995, 12 major-leaguers had the surgery. Jobe had performed only about 50 total between 1974 and the late 1980s.

Though Jobe’s procedure was revolutionary — he took the UCL in John’s right arm and put it in his left, pitching arm — the reasons for the surgery are simple: The art of pitching includes a lot of stress never designed for the ulnar collateral ligament, which over time frays and/or tears from years of overuse and oftentimes exacerbated by what doctors call flaws in the kinetic chain.

The kinetic chain comprises all the links in the physiological infrastructure from head to toe resulting, in this case, in a thrown baseball. Mechanics are a big part of that.

“Times have obviously changed quite a bit,” Rangers right-hander Yovani Gallardo said. “Baseball is a little bit different now. There are a lot of things going on. We have pitch counts now, and I think there’s a reason for that.

“You never know. It’s one of those things. Yu, for example, he’s a hard worker. He puts a lot of work in the gym preparing himself for each and every game. It’s sometimes one of those things you can’t explain. It’s just one of those injuries in baseball.”

One reason for the dramatic increase in occurrences is doctors are better able to diagnose the injury and have perfected the procedure to the point that it’s routine. In the early days of the onset of Jobe’s discovery, many players did what they could to avoid the surgery, simply because there were so many things not known.

Players were trying anything they could to extend their careers because the general perception though much of the 1980s was that the ability to come back from the surgery was limited.

After John’s surgery, Jobe didn’t do another one for two years so that he could study and try to determine the procedure’s long-term effectiveness.

That has evolved, as well. Most come back and some better than they were before, though the data reveal a mixed bag. Some believe evidence suggests pitchers don’t come back as good as they were before the surgery.

But a critical evaluation of that data should include the assumption that completely healthy pitchers will also show a decline in performance as they age, according to Dr. John Conway, medical director of the Texas Health Ben Hogan Sports Medicine program at Texas Health Harris Methodist Hospital Fort Worth.

Dr. James Andrews, who operated on Darvish, said in a position paper last year that pitchers should avoid the surgery if possible. It’s a misperception among parents of young pitchers that the surgery can actually be a preemptive measure against ligament tears.

Whether Darvish returns and produces like Tommy John did, time will tell.

John didn’t pitch at all in 1975 but returned to play in 1976 at age 33. He won 20 games the next season, 1977, and again in 1979 and ’80. He pitched until he was 46.

The big determining factors of whether a pitcher can return, said Conway, are genetics, work ethic and mechanics.

“I think it’s one of the best operations I do in my practice,” said Conway, a Rangers team surgeon in the 1990s and into the 2000s, who said he conducts about 100 ligament replacement surgeries a year. “It has one of the most predictable outcomes of every procedure I do.

“I tell my patients, ‘If you be patient and follow what I tell you to do, most will return to play.’ I think that’s a fair statement.”

Doctors today also better understand what contributes to both elbow and shoulder injuries. And they are correctable, said Conway, who has published material on Jobe’s groundbreaking operation.

“Anything along the kinetic chain that gets messed up puts strain on the shoulder and elbow,” Conway said. “It can be as simple has being tight in your hips, weak in your landing leg. Any number of things can contribute to stress on the elbow.”

Some movement patterns increase risk mor eso than other movement patterns, Conway said.

Major league baseball franchises, of course, and most college programs have coaches monitoring technique and mechanics of pitchers and how many pitches they’re throwing.

That’s generally not the case with Little Leaguers, where these problems begin, said Conway.

“I think everybody believes now that a lot of the problems we see are the result of things they did in Little League, middle school and high school. How they got used, misused, overused.”

It’s not uncommon to see youngsters engage in what Andrews said exactly not to do in his position paper.

In yesteryear, most major-leaguers growing up played March through June.

Today, kids are playing competitively year-round on multiple teams.

Some will catch when they’re not pitching, play in the field after pitching the first game of a doubleheader, perhaps even close that game. These are all significant risk factors, Conway said.

“Honestly, I probably would not” allow his son to throw as many pitches he did, said Gallardo, whose youth playing days are stuff of legend.

Conway said the emphasis in children’s baseball should be learning how to pitch, that is, read the hitter, throw the ball where you want it to go. Forget the curveball at that age and throwing it has hard as you can.

“Kinetic chain in the kids is probably where we have the best chance of limiting their risk as they get older,” Conway said. “If they get to minor leagues and they already have a significant amount of wear, it’s not surprising that by the time they get to the big leagues, they’ve had a ligament tear.

“On the other hand, if they get to college or the minor leagues and that ligament hasn’t seen much stress because their kinetic chain works right, their mechanics are good and they’re being smart about the weight training-program, they’re much more successful staying healthy long term.”

12major-leaguers had Tommy John surgery between 1974 and 1995.

100+Major league and minor league pitchers have had Tommy John surgery since the beginning of 2014, including Rangers ace Yu Darvish.

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