UTK Special: The Tommy John Process

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Chris Sale is heading for Tommy John surgery. He’s far from alone in a club that has gone from ten in 1990 to thousands from pros to Little League. The Red Sox ace is heading into a process that will take months, but has great outcomes. While we see the pitcher injured and then re-emerge, few understand the process. Let me walk you through it:

The pitcher grabs his elbow and looks to the dugout. While this injury did not likely happen on this field, on this mound, it is at this moment where the process of rebuilding him begins. Ulnar collateral reconstruction, commonly known as Tommy John surgery after the first patient to have it, was first done in 1974. By 1985, when a pitcher named Nolan Ryan had the surgery recommended to him, it had only been done a single-digit amount of times and he rejected it as “experimental.”

Today, the surgery is done thousands of times, on younger and younger pitchers. Despite it’s success and ubiquity, few understand the process if they haven’t gone through it. Today, I’m going to walk you through what happens so that you understand the process is a lot more than what you see.

THE INJURY

We see pitchers grab their elbow, often in serious pain, but UCL sprains are very seldom traumatic injuries. That is, they seldom happen with one overtax of the ligament, the way we often see with ACL sprains. A player twists his knee while running or gets hit during a cut and the ligament gives. While there may be an element of teardown in those, UCL sprains are almost all chronic injuries. This can be seen on imaging, but is more apparent during the surgery.

“It looks like a bomb went off sometimes,” said one team physician who asked to be off the record so he could discuss specific cases. “Usually it’s a fraying. I’ve heard you use the rope analogy and that’s good, but it’s much more forceful than people think.” The UCL is under tension during the delivery and given current studies, done on cadavers, it is stressed past its true breaking point by a standard pitching delivery.

We know that pitchers don’t break down on every single pitch so there’s a protection system beyond the ligament itself, likely involving muscles and tendons. Most of the focus has been on the flexor mass, the system in the forearm just distal to the elbow that often takes on chronic damage as well.

“When it finally snaps,” explained the team physician, “the pain is from the surrounding area. The ulnar nerve is occasionally hit. The elbow ‘opens up’ because the structure has given way, which can cause tightness and guarding. It’s just not a good situation.”

Pitchers regularly say that there’s a sharp pain, then a dull pain. In almost all cases, the UCL sprain is not complete. It’s not a “full tear” or rupture. Instead, it’s a significant sprain that takes a chunk out of the ligament. If the tearing goes through roughly a third of the ligament’s thickness, the ligament has lost enough structural integrity to need replacement. Below that, there’s rehab, though the success rate is mixed.

THE VISIT

“When they walk in my office, most of them already know,” said the team physician. “If I haven’t seen them at the field or if it’s a minor leaguer coming in, they’re not coming to town just to say hi. They know it’s serious.”

The doctor will usually have the player, a family member, and a team representative at the initial contact. He’ll explain the process and what they think it is. An MRI is ordered or called up if it was done on site. The doctor will also take the player through a series of motions and manual tests to give him an idea of the function and pain level.

“There’s been a couple days in most cases,” he said. “Injury. MRI the next day. Travel to see me. Sometimes its as much as a week, but it’s calmed down a bit. Some of those guys have flipped the switch to surgery and rehab, some stay a bit in denial. I’ve told guys I know needed surgery to take a week and try to throw again. It’s not going to work, but they need to know for themselves.”

The MRI is normally the confirmation rather than the diagnosis. When the picture is brought up on screen and the player and their support can see it, there’s seldom surprise or worry. “Tommy John as a result is understood in baseball,” said the doctor. “You come in on one side and a year later, you’re pitching again. You’re not better, but no one sees what comes in between. If they saw that, they wouldn’t be as nonchalant about it and no parent would be asking.”

THE SURGERY

The surgery itself is fairly simple and more than forty years since Dr. Frank Jobe stood over the table and came up with the surgery on the spot, it hasn’t changed much. There’s a couple holes, a harvested tendon that’s either looped, docked, or anchored in place to replace the now-removed congenital ligament. The tools look like something from Home Depot - a drill, a jig, some plastic anchors. The surgery itself is routine and takes about half an hour, including harvesting the tendon and preparing it.

There’s some debate and technique within the orthopedic community about the surgery. Two loops or three, or the location of the harvest, hamstring or wrist. New techniques such as InternalBrace aren’t widely adopted yet, though the success in a certain population certainly holds hope for the future. Some doctors move the ulnar nerve as a routine, some don’t. The basics of the operation are standard and accepted, because it works at a near ninety percent rate.

The patient is brought in to surgery, prepped, cut, repaired and stitched in under an hour. There are seldom any complications or surprises in the process. Many surgeons allow family or others to observe the procedure. The cuts are small and there’s very little blood or gore. In the times I’ve been in the observation room,

In essence, the surgery is the simplest part of the process. It’s not difficult and it’s hardly an exclusive club of surgeons that perform it, thought at the major league level, only a handful of doctors are trusted enough to perform it. At lower levels, there’s usually a number of surgeons in major cities that do it, though experience and results vary. There have been no published studies of the results of these surgeries, which leads to most recommendations going to the ones who you already know - Andrews, ElAttrache, Kremchek, Altchek, and Meister.

THE REHAB

The key to the entire process is not the surgery, but the rehab. As I said above, the surgery itself is relatively standardized. The same is not even close to true for the rehab process. The protocols sometimes go back to the original surgery itself. If you ever wondered why there’s a 120-foot limit on much of the process, it goes back to Dr. Jobe’s original progression and the distance he had available.

The most used is called the Andrews protocol, but was actually created by Dr. Kevin Wilk. The heart of this rehab protocol was created in the mid-80s. The “west coast” and “Meister” protocols are variants off this original, with all three evolving in ways with new equipment and knowledge, but they’re still recognizable if you were, say, Jimmy Key back in the mid-80s or last year.

You can see a nine month progression from Dr. Tim Kremchek at this link. (https://www.beaconortho.com/blog/tommy-john-rehabilitation/)

One of the biggest changes of the last few years is in the days and weeks immediately following surgery. Previously, players were casted or braced with their arms immobile for weeks which was thought to allow the anchors to set into the bone. Instead, it was allowing scar tissue to build up and muscles to break down. Over the last decade, new braces that allow for increased earlier motion have made results better.

The player will spend months going through various exercises, making sure there’s limited loss of range of motion and strength even while there is no activity. A player can keep up his cardio and some weightlifting as well in this phase. He - and I say he because the vast majority of Tommy John patients are male - will progress to plyocare routines and light throwing within three months, pushing out to

The length of the process is still problematic. The standard recovery is often stated to be eighteen months, but that is largely based on Tommy John himself. John had an entrapped nerve, causing a second surgery and a timing setback. There’s a great deal of research that shows that the transplanted tendon is stable within months, even without something like the InternalBrace.

THE RETURN

Once the medical portion of the rehab is done, the shift goes to function - in this case, throwing. The player will already be throwing at distance, but will continue to extend this ahead of getting back on the mound.

Just as with the evolution of the rehab protocol, there have been some changes over the last few years to the functional portion of the rehab, but not as much as you think. This is probably going to change given the rapid changes in general pitching work, such as plyocare and connection work.

There’s also much less hesitancy to let rehabbing players go out to distance or get on a mound, even early in the process. Data has allowed for some changes to this and knowing what adds stress to the process should allow for more iteration and evolution. Torque based protocols have been worked, but will require closer monitoring and acceptance of wearable technology in the game.

The final stages are pretty much the same, with a progression from throwing bullpens to live batting practice to simulated games. The shift to game action at the minor leagues or spring training, depending on the calendar and need, is a noted milestone, but seldom is much more than the normal ramp-up that players see regularly when healthy.

Remember as well that the calendar is a major factor in how things happen. Players often are told not to come back at the end of the season and have a “normal off-season.” This makes it look like it took an extra six months to return when the player could have been pitching in games at a much earlier point.

Doctors and rehab professionals I spoke with for this piece all believe that the latter phases of the rehab could be speeded up, perhaps as quickly as six months with a standard Tommy John and significantly less with an InternalBrace. The problem is the success.

“The success rate is anywhere from 80 to 90 percent right?” asked the team physician. “The actual success rate is higher. A high school kid walks away or an older guy decides he’s going to retire and that guy doesn’t return. To speed things up would require accepting a higher failure rate and no one seems willing to do that.”

I believe that the shift would have to be to in-season or start-of-season rehabs. An early season injury - where most UCL injuries happen, prior to May 1 - would need to be able to return by September. For a February or March injury, this would be on the extreme low end. For a May injury, making sure they could be back in nine months would give them the “normal off-season” as well. These are possible, but we’ll need more research and a willingness to experiment.

SUMMARY

You’ll see many pitchers stepping back on the mound and the announcer saying “here he is, back from rehab. Last time we saw him, he walked off with the doctor and now, there’s the pitch, strike one.” You’ll know more about what went on in between. That hard slog, jokingly referred to as the boring phase, the mundane phase, and the painful phase, do often pay off with a full return to sport.

I always wonder what Dr. Jobe thought as he stitched Tommy John back up, creating that all-too-familiar circular scar on the elbow. They may be the second most important stitches in the game.