Why Tommy John's Surgery is Rising Among Young Athletes - And What To Do About It

Tommy John’s surgery, named after the Los Angeles Dodgers pitcher who was the first to receive it, has a reputation as the professional athletes’ surgery. But that’s changing. Recent research found that teenage athletes now account for more Tommy John’s surgeries than pros.

That’s significant, since the surgery requires at least a year of extensive rehabilitation before the athlete can return to competition. We sat down with Dr. Khurram Pervaiz, a shoulder and hand surgery specialist in our Orthopaedic Associates of Central Maryland care center, to discuss the surgery and specific tips for young pitchers to avoid injury.

Is Tommy John’s surgery the only option for players with this injury?

Not necessarily. Actually, my approach is pretty conservative. Because this is a common procedure, many athletes know about it and want to go straight to surgery, but I try to convince them to try conservative management first. For example, if the patient has minor injuries to the throwing ligament – the ulnar collateral ligament – then we try rehab and activity modification. But if the patient has a complete ligament tear, the surgery is usually appropriate. They won’t be able to return to throwing or pitching unless the ligament is fully reconstructed.

However, the surgery does have some risks. Although research studies and my own experience demonstrate good outcomes from this surgery, it’s not 100% guaranteed that the patient can perform at the same level. Studies suggest that 15-20% of patients never return to throwing at the same capacity. And, there is a small risk of nerve injury because the ligament sits right next to the ulnar nerve. The decision to do this surgery should not be taken lightly,

What should athletes expect from the surgery?

With this surgery, we are reconstructing the ulnar collateral ligament on the inside of the elbow, near the funny bone. We use a graft to build a new ligament, because there is no way to repair a completely torn ligament. It has to be reconstructed. Sometimes the graft will be from the patient’s wrist, or sometimes it’s a tendon graft from a donor. It’s a very safe procedure that only takes an hour and can be done in an outpatient setting. The patient should wear a splint for one to two weeks, and then we switch them into a full elbow brace that allows motion in the elbow. That’s when they start therapy.

What kind of therapy is required?

It’s typically a year-long rehabilitation process. For the first month, the focus is on getting mobility back and letting the ligament heal. For the first three months, the patient is doing strengthening exercises. Then they can move into a more rigorous strengthening program, followed by an interval throwing program. That program allows the patient to slowly build up their pitching until they are back to throwing as hard as they can.

Are there any risks in performing this on a teenage athlete?

It’s the same concern you would have in repairing an ACL tear on a young teenager. Young athletes are still growing and still have open growth plates in their elbow. You want to ensure the athlete reaches skeletal maturity before you think about reconstructing the ligament.

What do you think is contributing to the rising need for Tommy John’s surgery among teenage pitchers?

There has been a lot of research on this, and there are a couple of factors that may be contributing to this spike in injury. Young athletes are tearing this ligament more frequently because they are playing competitive baseball at a younger age. They are playing on multiple teams at the same time, such as the school team and one or two traveling teams. And with indoor baseball, the sport can continue year-round, which means they can’t truly rest the ligament.

How can young athletes remain competitive but avoid injury?

Studies have found that pitching past the point of fatigue is the number one cause of injuries for teen athletes. In fact, fatigued pitchers are 36 times more likely to need surgery than healthy ones. In light of this research, a few years ago the American Sports Medicine Institute released guidelines for how many pitches young athletes can throw, how many games they can play, and the required adequate rest between throwing sessions. For example, according to the guidelines, a 13-year-old player should only throw 75 pitches a game and 125 a week. It’s also crucial that players get two to three months of complete rest. That means they shouldn’t engage in other sports that exercise the same ligament, like javelin throwing or competitive swimming. Following these guidelines is the best thing a young athlete can do to protect their arm.

It’s also critically important for parents to be aware of these guidelines and know how many pitches their athlete is throwing. Although most coaches try to follow these guidelines, if the athlete is playing on multiple teams, it’s up to the parents to monitor their play from game to game.

Dr. Khurram Pervaiz is a dual fellowship trained orthopaedic surgeon in the Orthopaedic Associates of Central Maryland care center in Catonsville, Columbia and Eldersburg, Maryland. He specializes in shoulder, elbow and hand surgery and has done extensive research on shoulder replacement surgery, wrist biomechanics, limited wrist fusion, carpal tunnel syndrome and total elbow replacement. He is also a reviewer for The Journal of Shoulder and Elbow Surgery and serves on several committees for the American Society for Surgery of the Hand. Dr. Pervaiz was fellowship trained at the Cleveland Clinic and Florida Orthopedic Institute and completed his residency at the Medical College of Virginia.