Increase in Tommy John surgeries among major leaguers may be rooted in youth ball


Former Dodgers pitcher Tommy John attends a memorial service for orthopedic surgeon Frank Jobe, who performed the first elbow ligament replacement surgery on John in 1974. (Damian Dovarganes/Associated Press)

The young pitchers arriving in Major League Baseball these days, as a group, throw harder than any generation before them. They have more overall mound experience, in many cases having played baseball year-round as adolescents and teenagers. They are, for the most part, more fundamentally sound in their pitching motions, thanks to the rising availability of biomechanical analysis.

But these young pitchers are also ripping their elbow ligaments to shreds in unprecedented numbers — numbers that have prompted leading medical experts to use the word “epidemic” to describe the recent rash of elbow surgeries among big league pitchers.

“It may not be an epidemic in the strictest scientific sense. It could be a blip on the radar,” said Glenn Fleisig, research director of the American Sports Medicine Institute in Birmingham, Ala., and the leading authority on pitching biomechanics. “But those of us who track this issue, we fear it is an epidemic. It certainly looks like more than a blip on the radar.”

On Wednesday, Oakland Athletics right-hander A.J. Griffin, 26, became the 17th major league pitcher to undergo ligament-replacement surgery — more commonly known as Tommy John surgery — on his pitching elbow since the start of spring training. Barely one month into the season, that’s already more than the sport averaged over a full season from 2000 to 2011, according to research at baseballheatmaps.com.

The list of 2014 victims includes former all-stars (Arizona’s Patrick Corbin, Tampa Bay’s Matt Moore, San Diego’s Josh Johnson), closers (the New York Mets’ Bobby Parnell) and three members of the Atlanta Braves’ projected pitching staff (Kris Medlen, Brandon Beachy and Cory Gearrin). For six pitchers, the surgery was a “revision” — a second Tommy John surgery on the same elbow.


How Tommy John surgery works

The average age of these 17 pitchers is 27½, and that list doesn’t include top prospects such as Baltimore’s Dylan Bundy (21), Pittsburgh’s Jameson Taillon (22) and Tampa Bay’s Taylor Guerrieri (21), who all had Tommy John surgery within the past year.

The trend is confounding and in some ways counterintuitive. Doctors and researchers understand the biomechanics of pitching better than ever, and teams are investing more money and manpower and using stricter pitch-counts in an effort to keep their pitchers healthy.

But instead of seeing a reduction in serious elbow injuries, the sport is seeing a rise.

“We probably haven’t made a dent in it,” said James Andrews, one of the leading sports orthopedists in the country. “It’s frustrating, to say the least.”

For years, the industry has focused on mechanics — streamlining deliveries to be as efficient as possible — and on conservative development, such as limiting pitch counts and innings, as a means of preserving and protecting pitchers’ arms.

But this latest rash of elbow surgeries has caused baseball to question whether some trends that on the surface look like signs of progress — such as the specialization in youth sports that has many kids playing baseball year-round and the advances in biomechanics and strength training that have made it possible for young pitchers to throw harder than ever — might themselves be the biggest part of the problem.

“We’ve been serving a dual purpose, which is to help these players both maximize performance and maximize safety. We’ve been operating on the theory that those go hand in hand,” ASMI’s Fleisig said. “You optimize performance and you stay [healthy]. Now there is concern that optimizing performance comes with increased injury risk. . . .

“Through mechanics and strength training and nutrition, we’ve trained baseball pitchers, as an industry, to where they’re optimized. You’re using the muscles correctly — but your ligaments and tendons are hanging on for dear life.”

Surgery not a quick fix

The first Tommy John surgery — in which the ulnar collateral ligament is replaced by a tendon from elsewhere in the body or from a cadaver — was performed in 1974 on a 31-year-old Los Angeles Dodgers pitcher named, as one might guess, Tommy John. At the time, the surgeon, Frank Jobe, figured John had only a 1-in-100 chance of making a successful return to the big leagues. John, though, not only returned (in 1976) but made three more all-star teams, won 164 additional games and pitched until he was 46.

Today the surgery is so widespread it is estimated that more than a quarter of all big league pitchers have had it at least once. It is also reliable: A 2009 study of 179 major league pitchers with UCL reconstructions found that 97.2 percent returned to pitch professionally, including 83 percent who made it back to the majors.

But the procedure is perceived to be so fail-safe pitchers are asking for it even before doctors can lay out non-surgical options — such as rest and careful rehabilitation — according to some of those doctors. This happens from the youth level all the way to the big leagues, often propelled by the false belief the surgery can actually improve their velocity.

“I even had a young patient come in with his parents and say, ‘We want to have the surgery,’ ” said Wiemi Douoguih, team orthopedist for the Washington Nationals. “I said, ‘Yeah? When did his arm start hurting?’ And they said, ‘Oh, it doesn’t hurt. We just heard you can throw faster if you have Tommy John surgery.’ ”

Andrews said he has talked major league general managers out of ordering surgery for their young pitchers before other options are exhausted. “They say, ‘Please go ahead and do it. We want to get it done now, as opposed to waiting,’ ” Andrews said. “There’s a myth that there’s a 100 percent success rate and pitchers come back throwing harder. It’s not true. If pitchers come back throwing harder, it’s not because of the ligament. It’s because of the rehab and the core-strength training.”

Some in the industry believe the obsession with velocity is itself a big factor in the rising number of elbow surgeries. Since PITCHf/x data first became available in 2008, the average fastball velocity in Major League Baseball has risen from 90.9 mph that year to 92 mph in 2013. Some teams have entire bullpens full of pitchers who throw 95-plus, and the 100-mph barrier, once considered the rarest of thresholds, is reached or exceeded on a near-nightly basis.

And it may not be a coincidence that as velocity has risen, so has the incidence of blown-out elbows. More velocity equals more torque, which equals more strain on the ligament.

“We’ve got more guys than ever throwing 97 to 100 [mph], but one of the issues may be that we’re simply not meant to throw that fast,” said the Nationals’ Douoguih, who performed Stephen Strasburg’s elbow reconstruction in 2010 along with the late Lewis Yocum. “It’s like I tell my knee-replacement patients: That metal and plastic is going to wear out a lot faster if you’re 300 pounds than if you’re 150.”

Time off is essential

It is becoming clear, however, that the problems showing up in the elbows of big league pitchers and top minor league prospects did not start when they turned pro. Increasingly, the industry is focusing on amateur baseball, all the way down to Little League, as the root of the problem. Simply put: Kids are pitching way too much.

“When I was a kid, we played different sports. When winter came, you put away the [baseball] glove and picked it back up in the spring,” said Brendan Sullivan, 39, a former All-Met pitcher for St. Albans who spent five seasons in the San Diego Padres’ farm system and who now runs Headfirst Camps, which operates baseball showcases for 1,500 high school players nationwide.

“But now they’re playing year-round,” Sullivan said, “and pitchers aren’t getting the blocks of eight or 12 weeks off, where they’re not throwing. I see it in the D.C. area. They’re playing regularly from March 1 through the fall. And in the offseason — quote-unquote — when the weather isn’t good enough here, they’re playing all over the place: showcases, tournaments, college camps. And on top of it all, a lot of them are getting private instruction in indoor facilities.”

Perhaps not surprisingly, Sullivan has noted an exponential jump in the number of high school-age pitchers in his camps having UCL-replacement surgery.

“I don’t have hard numbers, but 10 years ago, if someone at a showcase camp said they had Tommy John surgery, I would have fallen out of my chair,” he said. “It wasn’t something that was happening or even talked about. But now, not only are we seeing guys withdrawing from camp and having the surgery, in many cases we’re seeing guys who have already had the surgery and are back on the mound. It’s just part of the conversation now.”

Andrews cited a “five- to seven-fold increase” in the incidence of Tommy John surgeries among adolescent and teenage pitchers in his practice since 2000. His first word of advice to any young pitcher: “Don’t pitch year-round. Take at least two months off and preferably three or four.”

In 2011, Fleisig, the ASMI research director, published a 10-year study of youth pitchers that showed those who threw more than 100 innings in a given year were 3½ times more likely to require elbow surgery than those who threw fewer than 100 innings.

“We’re not saying by any means that kids shouldn’t pitch,” Fleisig said. “What we’re saying is more is not always better. Kids should play baseball, and they should pitch. But they shouldn’t always play baseball, and they shouldn’t always pitch.”

Some industry insiders believe MLB should be focusing on youth baseball — rather than, or in addition to, biomechanical analysis and innings limits on professional pitchers — in an effort to reduce the problem where it originates.

“We have got to get a stop sign on this,” Scott Boras, the sport’s most prominent agent, said of the year-round youth baseball circuits, often run by for-profit corporations. “We need youth baseball standards [for limiting pitchers’ usages] certified by Major League Baseball. We need to get a panel. We need to have physicians on it. We need Major League Baseball to support this, and then we need to get these standards out to all [youth] coaches.”

Boras added, “The more talented you are, the more risk the youth system brings you” — and the underlying root of the problem could very well be the economics of the sport.

Millions of dollars are at stake for top pitching prospects, and the best ways to attract the attention of professional scouts — by throwing hard and by showcasing your talents in year-round, top-level tournaments and camps — might also be the same factors that get you hurt.

“The almighty dollar is driving this,” Andrews said. “Kids are trying to throw harder and harder and trying to get themselves noticed by Major League Baseball teams. And that’s a difficult thing to convince people to stop doing.”

James Wagner contributed to this report.

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Dave Sheinin has been covering baseball and writing features and enterprise stories for The Washington Post since 1999.
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