In the summer of 1974, it seemed like Tommy John’s career was over. The baseball pitcher, playing at the time for the Los Angeles Dodgers, couldn’t finish a game because of extreme pain in his elbow. Ice and rest did nothing, so that fall, he underwent the surgery that would come to bear his name—Tommy John surgery.
During the procedure, John’s ulnar collateral ligament, in his elbow, was reconstructed with a tendon from his hand. This kind of ligament transfer had previously been done in the ankle to help polio patients but had not been tried in the elbow or for athletes.
Less than two years later, John returned to baseball; he would go on to play for another 14 seasons, pitching more winning games post-surgery than he did pre-surgery.
Since then, thousands of baseball pitchers of all ages have had Tommy John surgery. We talked to UNC Health orthopedic surgeon R. Alexander Creighton, MD, about the procedure.
Ulnar Collateral Ligament Injuries
Your elbow is made up of three bones: the humerus, in the upper arm, and the ulna and radius, both in the lower arm. The ulnar collateral ligament (UCL) connects the humerus to the ulna, providing stability on the inside of the elbow.
When you throw something overhand, particularly with great force, you put stress on your entire elbow, and it puts the UCL under more strain than other everyday activities. Over time, the ligament can become stretched and eventually tear.
“It’s common for people to hear a pop after a throw and feel immediate pain,” Dr. Creighton says of a tear. “It may have been a gradual process of sustaining microdamage and smaller injuries, and then one throw can be the straw that breaks the camel’s back.”
Dr. Creighton says the injury is most common in baseball pitchers but it can happen to anyone who repeatedly throws overhand, including football quarterbacks, javelin throwers, softball players and soccer goalkeepers. It is also possible to tear your UCL through a traumatic event, such as falling on an outstretched arm.
In addition to hearing a pop and feeling pain, someone with a UCL injury may experience stiffness, weakness or swelling of the elbow, and numbness or tingling in their fingers. The injury is diagnosed with a physical exam and imaging (X-ray and MRI).
If the tear to the ligament is small, Dr. Creighton says that rest and physical therapy can sometimes be sufficient for healing, but severe injuries will necessitate surgery if the athlete wants to continue overhand throwing.
Tommy John Surgery and Recovery
During Tommy John surgery, the UCL is reconstructed using other tissue from the body. Most commonly, the palmaris longus tendon, which is located in the forearm, is harvested via small incisions. This tendon helps with flexing your wrist, but it’s fairly weak and its absence doesn’t affect wrist function. Indeed, some people are born without a palmaris longus tendon—Dr. Creighton says about 10 percent of people don’t have one—so a ligament from the knee or tissue from a cadaver also can be used.
The surgeon opens the elbow, drills holes through the humerus and ulna, and threads the new ligament through them. The tissue is secured with screws.
“The guardrails for where the ligament is placed are very consistent, but we do work close to a major nerve of the elbow,” Dr. Creighton says, so nerve damage or irritation is a potential complication of the surgery.
It’s also important to be aware that the recovery process is lengthy.
“Following a reconstruction, it will be nine months to a year before an athlete can return to their sport,” Dr. Creighton says. “Rehab is a huge part of the recovery process, and the patient has to do their part.”
Dr. Creighton says that after a period of healing, athletes work on regaining their range of motion, and then focus on rebuilding strength.
“Pitching is not just the arm; it’s about how you flex your shoulder and how you rotate your trunk and core to create force for the throw,” Dr. Creighton says. “During rehab, you have to work on the whole body.”
That concentrated period of rehab can help young pitchers return to their sport feeling stronger than before.
“With younger patients, if you give them a year off, they’re going to continue to grow and become stronger and more flexible,” Dr. Creighton says. “With that growth and development, they tend to become better at their craft, including velocity when pitching.”
Still, a reconstructed UCL isn’t a bionic arm—the injury can happen again if pitchers don’t take precautions.
Precautions for Young Pitchers
For young pitchers, it’s important to take time off from throwing. Major League Baseball has issued guidelines that set limits for how many pitches should be thrown per game, and how many days of rest are needed afterward. For example, a 13-year-old pitcher should take two days of rest after throwing 36 to 50 pitches in a game.
“When you’re a skilled young athlete, you get asked to play on a lot of different teams, so you might be playing all year-round,” Dr. Creighton says. “That amount of throwing is too much. You need to rest the arm with some time off or cross-train with participation in other sports.”
Coaches may take the pitcher off the mound but still place them at a position where they’re repeatedly throwing the ball, such as shortstop or center field. Instead of changing positions, young players need to take an offseason. It can be helpful to remember that professional pitchers take frequent rest days.
Additionally, players should cross-train so that they build strength throughout their body, which can help to encourage good form while pitching. Players should work with their coaches or a trainer to ensure they have proper pitching technique.
Even with good form, though, pitchers should be aware that they risk overuse injuries, particularly as they begin to throw harder and faster.
“Elite pitchers have a financial incentive to throw harder, because they can potentially get a scholarship for college or play professional baseball,” Dr. Creighton says. “They throw harder at the risk of their ligament not holding up.”
Concerned about sports injuries? Talk to your doctor, or find one near you.