Everything you need to know about Tommy John Surgery

Podcast Transcript

Music intro –

Speaker 2: 0:11

Hello and welcome to the Bone and Joint Playbook with Dr. John Urse, and “Tips for pain-free aging.” Dr. Urse is a board-certified orthopedic surgeon with over 35 years’ experience in the Dayton, Ohio area. He is also a clinical fellowship- trained surgeon in total joint replacement from Harvard. Today’s topic is “All you need to know about Tommy John Surgery.”. This episode is brought to you by:

Speaker 3: 0:35

Ted’s Authentic Greek Salad Dressing and Marinade. It’s healthy, gluten-free, sugar -and dairy-free, low salt – and most of all – delicious. You can find Ted’s in Dayton, Ohio at Dorothy Lane Markets, Health Foods Unlimited, and Dots Markets. That’s Ted’s Authentic Greek Dressing and Marinade. Thanks, Ted. 

Speaker 4: 0:53

Well, hey folks. This is Terry O’Brien with Tri-Level Productions, and this is another episode of the Bone and Joint Playbook with Dr. John Urse .Hello, Dr. Urse .

Speaker 5: 1:04

Hi Terry How are you?

Speaker 4: 1:06

I’m great! It’s been a while since we’ve been down here.

Speaker 5: 1:08

 This is February of 2023, when baseball pitchers and catchers report for spring training. In all baseball team fans’ hearts, hope springs eternal that their team will win -it -all this year. That may depend on the health of the pitching staff.

Speaker 4: 1:22

You’re a baseball fan. You’ve been playing baseball for how long?

Speaker 5: 1:26

About 50 years, off and on, but the past 22 years in a wood- bat fast- pitch league or two…

Speaker 4: 1:28

 Today’s topic is of one that’s near and dear to your heart because of baseball. What is it?

Speaker 5: 1:34

“All you need to know about Tommy John Surgery”.

Speaker 4: 1:

 I’ve got to ask, what is Tommy John’s surgery and why do they call it that? 

Speaker 5: 1:47

Well, that’s because the first patient to have this surgery was named Tommy John. He was a pitcher for the Los Angeles Dodgers in the 1970s, and he had suddenly lost his ability to throw the ball effectively. His arm was sore at the elbow, and his velocity had decreased. Batters were hitting his pitches better, and he went to a doctor in Los Angeles, Dr. Frank Jobe, a sports medicine specialist.  He told him, “I have an idea how to fix your elbow problem”.

Speaker 4: 2:20

What did they do to fix his problem?

Speaker 5: 2:24

The problem is that you’ve stretched a ligament on the inside of your elbow.  It’s called the Ulnar Collateral Ligament.  We’re going to mercifully abbreviate that ‘UCL’ for the rest of this podcast. The UCL is like a ropey structure that holds the elbow tight on the inside, or little finger side.  A normal elbow just bends and straightens, up and down, much like our knee does. If that ligament gets over-stretched, much like an old rubber band, then it allows the elbow to hinge open awkwardly. That puts a stretch on the funny bone nerve on the inside of the elbow called the Ulnar nerve. Once that happens, the elbow becomes unstable, or wobbly. When a pitcher throws with a stretched out UCL, it hurts or it’s uncomfortable, they lose their velocity. As the conditions worsens, it may cause numbness or tingling in the small or ring fingers due to irritation of that nerve.  The pitchers are now ineffective on the mound, and as their pitch velocity decreases, they and their coaches realize something is wrong. The only people that are happy are the other team’s hitters.

Speaker 4: 3:26

<laugh>. So, is it only a pitcher condition?

Speaker 5: 3:30

No. It happened a few weeks ago in an NFL championship football game . One of the 49er’s quarterbacks got his elbow stretched awkwardly by a tackler, and ripped that inside elbow ligament. Though he was able to finish the game, he couldn’t continue throwing passes, forcing his team to only run the ball in the second half. That’s one reason the Philadelphia Eagles made the Super Bowl. We didn’t know until further imaging and testing from the doctors that a torn UCL was the diagnosis. 

Speaker 4: 4:05

So back in the 1970’s when they did this operation for the first time, was it successful? Could he come back and play baseball again?

Speaker 5: 4:12

It was extremely successful, which surprised the surgeon and the baseball community. This was a career ending injury for any pitcher with this problem.

Speaker 4: 4:23

So up to that point, this injury meant the end of your baseball or throwing career. 

Speaker 5: 4:26

Yes, and if you remember a podcast on the anterior cruciate ligament, or ACL, knee injury to the ACL also ended many athletes’ career. Gayle Sayers and many of the more famous sports players in the seventies and before did not have the opportunity to have a good repair like we do these days for that injury. Now a new ACL graft replaces the useless torn ACL, much like a replacement graft restores the elbow stability in a Tommy John surgery. Having that repair, Tommy John, after a 2- year recovery, return to baseball. He pitched extensively over 12 years, never missing a game pitching due to his ’bionic’ elbow. Plus, he retired as the seventh winningest left-handed pitcher in Major League history. So, after his surgery, he not only was he able to pitch again, he attained his previous velocity and was very effective in resuming his pitching career.

Speaker 4: 5:14

So, one of the questions I asked you earlier, and I was, I think it’d be worth mentioning, is can it improve if I’m pitching 89 miles an hour, can I go 93 miles an hour?

Speaker 5: 5:24

Initially, pitchers that were successfully rehabilitated after the surgery were thought to be pitching faster. A recent study looking at the last decade of baseball from 2010 to 2020 using radar guns found that their pitches are about as fast as they were before the surgery. They’re not any faster, but as we said, they were losing velocity because they were having pain when they threw. And, after this surgery has finished rehab, the velocity is back on four different kinds of pitches. If you’re a baseball pitcher throwing sliders, fast balls, curve balls and changeups, you need to have an idea of how fast that pitch will go because varying a pitch speed and location is one-way pitchers get batters out.

Speaker 4: 6:16

Before we get into the details of what goes on in a Tommy John surgery, how does it occur?  Is it done by throwing the baseball wrong? Does it start with high school kids or kids younger than 14?  Are they throwing wrong?

Speaker 5: 6:34

Well, that’s a great question, Terry.  It’s actually starting at a very young age, whenever kids start pitching. In youth or little league, the best pitcher pretty much finds the coach’s heart, and he gets the mound quite often. <laugh> What we found is “pitch count”, which is how many pitches a pitcher throws in a given game or week, is a huge determinant of whether that elbow is going to get injured later . The second thing is, as you said, the type of pitch they throw. When you throw a curve ball  or a slider, it makes the ball, spin or turn. By doing it, you’re torquing your elbow and wrist, which puts an unnatural force across the elbow at an early age. Again, we’re talking about little leaguers or high schoolers, and these are the kids that are really good in their leagues, but they’re being asked to pitch over and over by either parents or coaches. So there are phone apps developed where you can go on your smartphone and say, “my son’s 10 years old, how many pitches this week? The answer 45. 

Speaker 4: 7:43

They be throwing sliders and curve balls at that age?

Speaker 5: 7:45

 Not at all. Instead, teach your children how to throw knuckle- balls or change-ups, which slow or vary speed.  A curve usually comes in slower, but it moves from a straight line. But, a good knuckle ball moves up or down or side to side. So if you teach young pitchers some off speed pitches without torquing the elbow, avoiding curves, avoiding slider pitches, then those are more protective for the future for that pitcher’s

Speaker 4: 8:21

Arm. What is an average pitch count for a for a high schooler? Just, you

Speaker 5: 8:28

Know, well, it can be a 50-75 pitches normally,  but I had a patient in my office who threw 142 pitches in his junior year game.  A tie score sent the game into extra innings and his coach kept him on the mound. He came to me with shoulder and elbow problems…that’s way too many pitches for anybody.  Even in the pros, 100 pitches are pretty much where you see most pitchers taken out of a game.

Speaker 4: 8:

Speaker 5: 8:56

 When we talk about 45 in a week for a little leaguer, you can see that when a high schooler is throwing 140 pitches, it’s a travesty, really.  It’s way too much stress to the elbow and shoulder. For that reason, we have to start much earlier in their careers in order for them to not have problems later. 

 Since that very first surgery in the 1970’s perhaps one in seven professional baseball pitchers will have a Tommy John surgery in their career. Wow!  And that’s a lot of athletes.  It’s a highly technical surgery, and involves quite a bit of post-operative rehab.

Speaker 4: 9:38

 Before we get into the details of the surgery, how do I know that I’m developing this elbow problem?  You said one may feel tingling in the fingers. Are there other things that maybe are earlier warning signs, that maybe kids out there, parents or coaches should be looking  for?

Speaker 5: 9:52

First, their elbow is going to be painful. It’s going to hurt on the inside, which is the little finger side, not the thumb side of the elbow. You may not get that nerve symptom of tingling until later, when the ligaments really stretched out a lot. Secondly, they will have discomfort throwing, with the effect of losing velocity on their pitches. 

The best way to tell what’s wrong is to get a good examination from your trainer and/or orthopedic surgeon. The definitive diagnosis would be imaging with either an ultrasound or an MRI. Also, there are incomplete or partial tears. With only a partial tear, an earlier podcast mentioned uses of platelet-rich plasma or PRP, right? One recent article in the American Journal of Sports Medicine, from a former physician with the LA Dodgers, Luga Podesta, MD, has shown an ultrasound-guided PRP injection in a partially torn ligament can allow it to heal without surgery. And though it takes a while to heal, the UCL will actually tighten up as you use ultrasound to move the elbow, showing it has tightened the ligament.

Speaker 4: 11:27

I do have one more question about steroids. Can you inject steroids into your elbow to compensate for Tommy John injury?

Speaker 5: 11:37

Depends where you are putting that injection. Steroids or cortisone- type medicines help with pain and inflammation, and can be used for overuse elbow conditions like tennis, bowlers, or golfers elbow.  These areas on either the outside (thumb side) or inside of the elbow can have a cortisone or steroid injection as long as it is not near the UCL ligament. Steroids can weaken a ligament, so they are not a service to that ligament in any way.  And if you’re putting a shot in those areas, actually PRP is probably better than a steroid injection but is a newer technology rarely covered by insurances.

Speaker 4: 12:13

Let’s go into what goes on in a Tommy John surgery. By the way, have you done these Tommy John Surgeries in the past?

Speaker 5: 12:20

 I do not do this surgery. This is a very specialized surgery. Probably less than 1% of orthopedic surgeons will do this specialized procedure. There are pockets of physicians who treat mostly high- level athletes that do this surgery.  They transfer a tendon in your wrist to the inside of the elbow, and weave a figure- of -eight   through some little bone tunnels that recreates a new ligament. It’s much like that ACL surgery we talked about in the knee, where the torn ligament is replaced with a new graft .Thus, the torn UCL or ACL cannot be repaired and are replaced with a strong substitute graft.  

Speaker 4: 13:09

Is it an hour surgery, is it a three -hour surgery?

Speaker 5: 13:12

Well it’s certainly physician dependent.  I would say it’s somewhere between one and two hours. The next most important part is really the protection phase after the surgery.  Then, a guided recovery program allows resumption of a throwing program.  The average non -pitcher let’s say a shortstop, may get back playing within a year, but it can take 12 to 18 months for most pitchers. Oh wow.  

So, to summarize, recall we talked about limiting pitch counts in younger years. The number of pitches per game needs to be monitored, starting at the youngest and up thru higher levels. So if you’re a nine to 14 year old and you threw over 400 pitches, you had a 65% chance that a Tommy John ligament may be injured at a later date.

Speaker 4: 14:05

400 pitches over what period

Speaker 5: 14:06

I believe one season… And then if you were in the 400-600 range of pitches, it would be in a 120% range that you may get an injury to the ligament . Recent in- press studies should have that risk data for us. 

Type of pitches also matter. It’s absolutely more harmful with curve- balls and sliders. The curve ball actually hurts more. The slider actually causes more injury to the ligament. So teaching the young developing pitchers smarter ways to pitch, i.e., change of speed knucklers or palm balls, and limiting their pitching is the key to preventing this as a problem later. Remember, the best pitchers are playing all the way through little league, high school and college. If you then go on to minor or major league baseball, that arm’s been through a lot of pitches.

Speaker 4: 15:07

Yeah. Okay. So, prevention is just basically reducing the amount of pitching per week or per time cycle.  Is there anything else we can do to help prevent it?  If I’m pitching a lot, I can go back and soak it in ice or something to help?

Speaker 5: 15:25

 We always talk about RICE, , which is Rest, Ice, Elevation and Compression sleeve.  The best thing I tell baseball players is to not play baseball year ‘round.  Go play soccer, basketball, golf, and try to use other parts of your body. These kids are on travel teams, then they’re on their school teams, then they’re on another fall travel team and it’s year round abuse to their body parts. No time for healing or rest. Many of the best athletes frequently are multi-sport athletes , and we know the person who was a quarterback, shortstop, and leading point guard in basketball.  or people that give their body a chance to rest and recover between seasons.

 What do you do when it happens? I think you need a diagnosis. We talked about that. As with anything in medicine you have to know if there is any injury to that ligament? Get a good physical exam by a competent health-care provider, and if indicated, consider an MRI or Ultrasound to assess a partial or complete UCL tear. 

Speaker 5: 16:21

If it is cut transversely and the person wants to pitch again at a high level,, they pretty much need to have it repaired. But not everyone needs Tommy John Surgery. I have a injury to my ligament, but it happened when I was pitching in my forties. And so, as I got older, my arm got a little stiffer and it wasn’t really wobbly and I never got mine fixed.  I had some loose bodies in my elbow, and had a clean -out elbow scope thru small incisions.  I didn’t need to have a big reconstruction. I told people the Cincinnati Reds did not need me pitching for them that year. And I have enjoyed playing baseball over 20 years since that minor procedure.

Speaker 4: 17:39

When you said it’s a big surgery, it sounded like the procedure itself didn’t sound that complex, or that didn’t take that long.  You’re in and out, not an inpatient kind of thing. Right.

Speaker 5: 17:49

Well just because the surgery is an in- and -out procedure doesn’t mean it’s a simple surgery. This elbow surgery is very technical.  That’s why a lot of doctors don’t do this surgery. In the world of sports medicine at this elite level, believe it or not, the people who guide most of the direction of where someone goes for these surgeries are the sports agents. When a Jerry McGuire-type agent has a client with a $20 million pitching arm, and you’re getting 10% of that guy’s salary, he is going to the Wizard of Oz. <laugh>That’s because he’s the best guy or girl who can do that surgery, or because he’s done five other clients on your roster of players and he gets people back with a great outcome.

Speaker 4: 18:46

All right, so let’s, let’s spend a little time as we wind us down, to talk about what can they expect. So if I have this done and I’m sitting out for 18 months to two years, which seems like a long time for an athlete, can they expect this new ligament to be good as new?  Will they see any issues with it, and it’ll last for a long time? Or is this something they have to baby and worry about?

Speaker 5: 19:07

Most people never need this done again. However, there are plenty of examples of people who have had two Tommy John surgeries. They’ve had to take a ligament from the other arm or a cadaver source to re- make another ropey stabilizer for the elbow. And there are times where people never get their throwing velocity completely back.  It may depends if was there any injury to the nerve? 

The textbook answer is the people that go through the surgery are pretty happy. They get their velocity back; the numbers prove they do. Recent studies show if they were throwing 94 miles an hour pre-injury, they’re going to throw 94 miles an hour after their recovery time.  That’s what makes the coaches, owners and the agents happy, and ultimately, the player, because he’s going to get back to his former level.

Speaker 4: 20:02

So, what is the age that you should have a Tommy John surgery?

Speaker 5: 20:05

Well, great question. I think that’s a question for the people that do the surgery, but I would say, I know it’s being done in late adolescent years. Wow. Probably late teens.  And then there were, as I said, there were parents and maybe coaches encouraging kids at younger ages because they had that injury and that means they had overdone something at a much earlier age., 

 Funny thing about the surgery is that when ESPN interviewed Dr. Frank Jobe, who pioneered the procedure, about the surgery , he said: “  I probably would’ve called it Sandy Koufax Surgery <laugh> , if I had thought of it 10 years earlier,” <laugh> . And they said, well, well why is that? He said, well,” Sandy Kofax had the same problem that Tommy John had 10 years earlier. I just didn’t have an answer or had not come up with this procedure to fix it, or it would have a different name”.

Speaker 4: 21:02

All right .So this has been a kind of a fascinating one for us because it combined sports as well as some medical information for the listener. Have I left off any question I should have asked?

Speaker 5: 21:12

No, as you said, it’s a really important topic to show where prevention is truly important. Having newer technologies in smartphone apps to track pitch counts, and modifying movement and type of pitches should be highly effective.  I think it’s well worth trying to get hold of this problem at a much earlier age. Unfortunately, we are seeing all the untoward effects of not doing that in the players that are older who are requiring surgery. 

Speaker 4: 22:06

Well, Dr Urse, this has been a fantastic podcast. Hopefully people are going to enjoy listening to this topic. We’ll see you here again pretty soon. Our next podcast is on ‘Robotic Total Hip and Knee Replacement Surgery’ coming up soon, is that correct?

Speaker 5: 22:20

Yes, it is, Terry.  All these podcasts are listed on DrJohnUrse.com

They are also available wherever you listen to podcasts on Apple or Spotify or I-heart.  Feel free to float around the website, leave a review, or some suggestions for future topics.  Thanks again to sponsors at Ted’s Dressing!

Speaker 4: 22:36

All right, Thank you all very much for joining us today on the ‘Bone and Joint Playbook’ with Dr. John Urse, I’m Terry O’Brien. I’ll see you soon.

Speaker 6: 22:44

Thank you for joining us today on this episode of The Bone and Joint Playbook: Tips for pain-free aging.’  Please join us again for another episode. This has been a production of Doctors Unmasked, produced by Terry O’Brien.