“It’s crazy that Tommy John surgery will be around long after I’m in the ground.” Tommy John the first baseball player to have the surgery

BIRMINGHAM, ALA.—The young lefty on the operating table hasn’t felt right for eight months.

An amateur pitcher, likely still in his teens, he’s anaesthetized and all but covered by a blue surgery sheet. Only his outstretched pitching arm — fist balled tight with tape and gauze, arm shrink-wrapped in a sterile covering — is visible.

Like thousands of pitchers before him, the young lefty has torn the ulnar collateral ligament, or UCL, in his elbow. He’s come here to get a new one.

At St. Vincent’s hospital, leading sports medicine physician Dr. James Andrews and his team of surgeons repair the shoulders, knees and elbows of high-performance athletes. Some are multi-millionaire professionals, while others, like the young lefty on the table, are chasing multi-million-dollar dreams. (As a condition of being allowed to view the surgery, we weren’t allowed to know the patient’s name or see his face).

In the command centre that overlooks the four operating suites dedicated to sports-related surgeries, a flat-screen TV is tuned to ESPN. As doctors and nurses study charts and scribble notes, a continuous loop of the day’s sports news and highlights plays in the background.

Dr. Lyle Cain, a protégé of Andrews, manoeuvres amid the bloody flesh of the young lefty’s exposed elbow and pulls taut the two ends of a harvested tendon.

“This is where you try to make it tight,” says Cain, who has reconstructed more than 1,000 ulnar collateral ligaments.

Minutes earlier, he had excised the tendon — a flossy white strand of tissue resembling a shoelace — from the patient’s forearm and looped it through freshly drilled holes in the bones of the elbow.

“You want it as tight as you can get it,” he says. “So he can throw hard.”

UCL reconstruction — known as Tommy John surgery after the former L.A. Dodgers left-hander whose career it first saved — is dramatic in its restorative power, yet it is remarkably simple up close.

Pluck a superfluous tendon from one part of the body, tie it into another and, with rehab work, it will turn into a ligament. The operation is usually finished in less than an hour; the rehab, a year.

No medical procedure has influenced a sport more than Tommy John surgery has baseball.

It has sustained the careers of pitching greats John Smoltz and Mariano Rivera, as well as young phenom Stephen Strasburg, among hundreds of others. Matt Harvey, the promising New York Mets righty considered the future face of the franchise, may be next on the list — he has been diagnosed with a partially torn UCL.

An as-yet-unpublished survey of professional pitchers in both the major and minor leagues pegs the number who have had the surgery at more than 20 per cent — one out of every team’s five-man rotation.

The Blue Jays sent three pitchers to Andrews last year: starters Kyle Drabek and Drew Hutchison, and reliever Luis Perez.

They were among 33 major-league pitchers who needed Tommy John surgery in 2012, up from a previous high of 21 in 2007. Sixteen have had it so far this year.

Today, the surgery stands as both a grim diagnosis and a medical triumph.

“Before Tommy, these pitchers would just be sent home and we’d say, ‘Sorry, you’re through,’ ” says Dr. Frank Jobe, the longtime Dodgers’ physician who performed the first UCL reconstruction on Tommy John in 1974.

Jobe, who turned 88 this month, was honoured by Baseball’s Hall of Fame this summer for the revolutionary procedure he invented nearly 40 years ago.

Today, the surgery’s success rate is nearly perfect, which partly explains why it has become so popular.

“It’s crazy that Tommy John surgery will be around long after I’m in the ground,” says John, 70, from his home in New Jersey.

But amid the accolades there is also growing concern — beginning with Jobe himself — that the surgery may have become too common, especially among young pitchers, who are throwing harder and more often than ever before.

“People think, ‘If I blow out my elbow I’ll just get Tommy John and I’ll be all right,’” Jobe says. “That isn’t the answer.”

Has a quick-fix surgery become a panacea for a sport that’s pushing pitchers beyond their breaking points? Or has medical science developed the ultimate cure-all?

Pitchers who pop

Kyle Drabek threw his final pitch of the 2012 season on June 13, 2012.

He let go of a 91 m.p.h. inside fastball and heard the sound every pitcher fears.

Pop.

His arm went numb, tingling from his pinky all the way up to his neck.

His UCL, already once repaired, was torn again. This time, ligament was ripped off the bone.

“It jolted my body,” recalls Drabek. “My elbow felt like a shotgun — as if it popped out and came right back in.”

Drabek was headed for his second Tommy John surgery and more than a year on the disabled list.

He knew it would be a long road back to the big leagues. But it never crossed his mind that he wouldn’t eventually return.

Contrast that with 39 years ago, when Jobe first proposed the procedure as a means of salvaging John’s career.

“I didn’t know whether it would work or not, but it was worth a try,” Jobe says, pegging the chances of success at the time at 1 in 100.

John was a 31-year-old southpaw for the Los Angeles Dodgers with a tidy 2.97 earned-run average and .539 winning percentage when, on July 17, 1974, while pitching against the Montreal Expos, he walked off the mound at Dodger Stadium with a pain in his elbow.

“I was trying to throw a sinker, low and away,” John says of his final pitch that season.

When he let go of the ball his arm throbbed.

“I said, ‘Get Dr. Jobe, something bad has happened,’ ” John recalls. “That’s when the journey began.”

There were no MRIs in those days, so Jobe conducted a clinical examination of John’s arm.

He had a hunch John had torn his UCL. To check, he held the upper part of John’s arm straight while turning his palm to open the joint.

“He did me a favour by tearing the thing off completely,” Jobe says. “So that when I examined his elbow I could open it up about 45 degrees. There was no doubt in my mind it was torn.”

Jobe had previously used the palmaris longus tendon — plucked from the forearm — to strengthen the joints of polio patients. He wondered if he could use the same tendon to replicate a UCL.

Salaries were on the rise — John’s annual earnings jumped from $77,000 to $114,000 in his first year after the surgery — and while players had yet to insure their body parts, a healthy pitching arm was becoming an increasingly valuable commodity.

Jobe explained to John that he would be able to live a normal life without the surgery. He could work in his yard, play catch with his kids. But he would never be able to pitch again.

“It was a no-brainer,” John says.

John missed the 1975 season, but returned to pitch the next 14 seasons without missing a start, winning more games after the surgery than before. He finished in the Top 10 in votes for the best pitcher in baseball in four of the first five years after the operation.

His surgery remains arguably the most successful to this day.

“When I had it done I thought I was the most unlucky son of a gun in the world,” John says. “My God, now it’s like tonsillitis.”

Today, more than 85 per cent of patients return to the mound fully healed, while most of the failures are due to an undiagnosed shoulder injury or — with young amateur pitchers who lose interest in the sport — a lack of commitment to the rehab program. Even those on their second surgery, like Drabek, make it back 65 per cent of the time.

Despite winning 288 games over 26 major-league seasons while posting a 3.34 career ERA, John says he isn’t bothered that his name has become synonymous with the surgery, while his on-field accomplishments are largely forgotten.

“Why should I resent the fact that my name is on a surgery that’s 80 to 90 per cent successful and keeps pitchers playing baseball? If it was Tommy John Proctological Surgery for Hemorrhoids or something, maybe that would bother me.”

Under the knife

Today the surgery remains basically the same.

Some technical aspects have gone in and out of vogue — how to affix the tendon graft to the bones, for example, or whether or not to transpose the ulnar nerve — but the heart of the matter has not changed: you create a new ligament with a tendon from elsewhere in the body.

First, some quick anatomy.

The two primary bones of the elbow joint are the humerus, the bone of the upper arm, and the ulna, which extends from the elbow to meet the wrist on the pinky-finger side of the hand.

Whereas tendons connect muscles to bones, ligaments connect bones to bones. In a Tommy John surgery, a tendon is used to replace the damaged ligament.

“Mother Nature, fortunately, turns it into a ligament,” explains Andrews in a phone interview. “But that’s why it takes a year, sometimes a year and a half, for it to mature.”

The UCL, which connects the humerus to the ulna on the inside of the elbow and is the joint’s main stabilizer, comes under tremendous stress during a baseball pitch.

A pitcher generates force through his trunk and his shoulder as he winds up, accelerating his arm speed. His whole body is moving forward, except for his pitching arm, and that resistant force is controlled entirely by the UCL.

“Technically, throwing 80 miles an hour or more, they’re generating enough force through the medial side of the elbow that it should tear the ligament,” says Cain. “It’s just not a natural motion to throw a baseball overhand.”

Every major-league pitcher exceeds the ligament’s so-called “red line” on almost every pitch, he says.

Doctors know this from cadaver testing, which found the force of a baseball player throwing 80 m.p.h. or more would tear the UCL every time.

So why don’t pitchers blow their arms on every pitch? Because they’ve built up the arm strength to support the velocity they are generating, whereas the average cadaver has not.

Nutrition, genetics, age and rest also factor in to the strength of one’s ligament.

While it is possible for a UCL tear to occur on a single pitch, most are the result of repetitive stress — a series of microscopic tears to the ligament’s fibres — rather than an acute injury. Like a frayed rope, the ligament eventually gives way or is stretched so thin it can no longer function.

Not all tears become traumatic, though. With sufficient rest and good nutrition, the ligament can heal itself.

Though Drabek felt no pain prior to his final pitch, his ligament was likely weakened by accumulated micro-tears.

The popping sound he heard was literally the ligament detaching from bone.

But no two tears are alike and not every pitcher hears the pop. Sometimes the ligament frays until it snaps, other times it becomes stretched to the point it can no longer function.

Hutchison, for instance, noticed soreness in his elbow and then felt the area becoming hotter and hotter. “I knew something wasn’t right,” he recalls.

Whether torn off the bone or stretched beyond repair, the surgery is the same.

It begins by harvesting the tendon that will be used to replace the ligament.

In most cases, doctors use the palmaris longus tendon in the forearm, which has little function. But roughly 20 per cent of people don’t have that tendon. (You can see for yourself if you’re one of the unlucky ones by touching your thumb to your pinky finger. If you have it, the tendon should be clearly visible under your skin.)

For patients without a palmaris tendon — or, in the case of Drabek, who already used his in a previous surgery — doctors turn to the gracilis tendon in the hamstring.

For a palmaris graft, doctors make two incisions — one at the wrist crease and another further up the forearm. They cut the tendon off the muscle and pull it out, before attaching sutures on both ends and setting it aside among the surgical instruments.

“Just looks like the tendon on a steak,” Cain says, as he pulls the white strand out of the young lefty’s forearm, scraping off bits of bloody muscle.

For a successful reconstruction, doctors need 13 to 17 centimetres of tendon.

“Normally we get about 15 centimetres,” says Cain. That’s longer than a UCL, because it must be looped through the bones.

Once the graft is prepared, Cain cuts open the inside of the young lefty’s elbow, spreading the skin to expose muscles, nerves and tissue.

First he will identify a skin nerve and protect it to prevent post-op numbness. Then he will find the much bigger ulnar nerve and move it out of the way.

(When the reconstruction is complete, the nerve will be moved to a different position — transposed — which is Andrews’ modification of Jobe’s original technique.)

With the ulnar nerve out of the way, Cain identifies the UCL and takes note of the damage. He then splits the ligament lengthwise in order to see into the joint and ensure he can drill through the bones accurately.

Doctors cannot reproduce the way in which a ligament is naturally fused to a bone, so they must drill holes in the ulna and humerus to create a tunnel through which the tendon can be passed.

Using a surgical power drill with a long and narrow cylindrical bit, Cain creates a V-shaped tunnel in the ulna and a Y-shaped tunnel in the humerus, the latter with a single entry and two exits.

The tendon graft is pulled first through the tunnel in the ulna and then through the Y-shaped tunnel in the humerus, creating a figure-eight loop of tendon between the two bones. If the tendon has enough length, it is looped twice.

Cain ensures the tendon graft is sufficiently tensioned before sewing it to itself and also to the original damaged ligament, which is stitched back together and left in place for what Cain calls “extra ecology” to support the new ligament.

Human tissue is used because it has the capacity to heal and regenerate itself. Synthetic tissue does not, and would eventually fail under repetitive stress. The tendon graft has a blood supply. Cells will regenerate and the bone will fill in around the ligament.

The last thing Cain will do is move the ulnar nerve in front of the elbow and away from the reconstructed ligament, slinging it in place with a piece of tissue, so it does not get scarring around it.

“There’s the reconstruction,” says Cain, gesturing inside the boy’s elbow, where the old tendon has been made into a new ligament.

In roughly a year, the young lefty will be back pitching.

When he puts his hands together and sets on the mound, his fleshy red scar will look like a grin in the crook of his elbow.

The long road back









While the surgery may only take about as long as three baseball innings, the loss of playing time is, of course, much longer.

“The operation is just a part of it,” says Jobe, who credits John with helping establish what have become standard milestones in the rehabilitation process.

Without any precedent after that first surgery, Jobe told John to follow his body and tailor his rehabilitation toward how he was feeling.

“Your body will tell you what it needs,” John recalls Jobe saying.

John took about a year from his surgery before he was throwing in competition. “So that turned out to be a key number,” says Jobe.

Today, 12 months from the date of surgery to a return to full-strength competition remains the standard.

Kevin Wilk, who has designed rehab protocols for Andrews’ patients for more than 25 years, says he prefers a nine-month goal, calling the 12-month rule “a parrot-type response” that has become an accepted truth simply by way of repetition.

“But the good part about saying a year is that the pressure’s off. If they make it back earlier the player is very happy, everybody’s a hero. You say nine and they don’t make it back until 12 then you look like you haven’t done your job right.”

Drabek, Hutchison and Perez were just thankful they had each other through the long, trying process.

The worst part of their time holed away from their teammates? The boredom.

Drabek got a dog. Hutchison turned to Netflix.

“I’ve worn out every series, every movie,” he says.

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For the first few months especially, the day feels infinite.

“When you’re in the cast you can’t sweat and you pretty much feel worthless,” says Drabek. “They throw ice on you, stretch you and you can’t do anything the rest of the day.”

During the first week after the operation, the pitcher’s arm is placed in a splint with the elbow bent at 90 degrees. Exercises are limited to gripping, range of motion in the wrist and flexing of the biceps and shoulder.

While the overall length of rehab has remained largely the same since John, details of the protocol have changed.

Doctors are far more aggressive in establishing range of motion in the arm earlier — within the first couple weeks — but take longer in the throwing stage before competition.

In weeks two through seven, range of motion is gradually increased in the elbow and the focus is on strengthening the shoulder. Light weightlifting is introduced after the first month.

Wilk says the aim is to keep the shoulder strong. “The worst thing is you have your elbow surgery and you neglect your shoulder and you wind up having shoulder problems once you start throwing. That would be a travesty.”

Strengthening of the shoulder continues through the second month and kicks into a higher gear in the third month.

Throwing doesn’t begin until four months post-op. But Wilk says the most important work happens before you ever even pick up a ball.

“The throwing is icing on the cake.”

Icing or not, Hutchison had the date circled on his calendar.

“Dec. 27,” he says.

Not since he had first picked up a baseball had he gone longer without throwing one.

“That was tough. I’m a natural competitor and I love to compete. When you can’t do that, your edge is gone. It’s nice to get back on the mound and get that feeling back.”

In 2007, while rehabbing his first Tommy John surgery, Drabek watched his first post-op throw bounce just in front of him. “I spiked it. You almost feel as if you’ve never thrown a baseball before.”

This time he had a better idea of what to expect. “Once you get that first throw out of the way it becomes baseball again. You just have to make sure you take it slow, especially at the beginning, when there’s nothing to rush for.”

The rehab starts with just light toss from about 12 metres and gradually increases to 30 metres over the next month.

Barring a setback, the pitcher will advance to throwing off a mound in a non-competitive situation around the fifth or sixth month. By month seven, if all is going well, pitching off a mound in a competitive situation begins. A minor-league rehab assignment could begin by the eighth or ninth month.

Few advance through those phases in such a clear-cut fashion, however.

Drabek began his minor-league rehab assignment with the Class-A Dunedin Blue Jays on June 22, more than a year after his surgery.

Hutchison, who delayed his surgery until August last year while waiting to see if rest would heal his ligament, began his rehab assignment on July 14.

Exactly how the ligament heals during the rehabilitation is a bit of a mystery, since nobody has studied the healing properties of a UCL tendon graft.

“The only way you would be able to do that is to sacrifice somebody’s reconstruction,” says Wilk, adding that no animal has an elbow like a human.

Through clinical examination and studies of medial collateral ligament grafts in the knee, however, the understanding is that for the first 10 weeks, the new ligament is simply incorporating into the capsule of the elbow. The area is rich in blood vessels, which aid in early healing.

With each phase of the rehab, more stress is placed on the ligament, Wilk explains. If it responds well, you continue to add more.

In response to the controlled stress, the new ligament will grow in size and strength as the collagen of the tissue thickens through a process called hypertrophy.

The bionic arm myth

As the success of Tommy John surgery became famous, a powerful myth took hold among many young pitchers and their parents: the procedure would make you throw harder. Parents were bringing their kids in to have pre-emptive Tommy John surgery, hoping it would boost the chances of a scholarship or making it to The Show.

Though repeatedly dispelled, the myth persists.

Andrews says he has had to deny parents looking for pre-emptive surgeries while weeding out youngsters faking symptoms to get onto the operating table.

“I tell them, ‘I can’t make a ligament as good as what the good Lord made.’ ”

Pitchers, especially younger ones, do often return throwing harder than they did leading up to the surgery — but not because of their new ligament. Sometimes the original injury led to arm fatigue and decreased velocity before the surgery; sometimes the pitcher is stronger and in better condition after rigorous rehab.

The other myth? Everybody comes back.

“I don’t think there’s an awareness of the complications or the downsides of this,” says Cain. “As physicians, we always tend to remember the failures more than the successes. So if we do 100 of these we remember the four or five or six that didn’t get back for some reason.”

Too much, too soon?

Not far from St. Vincent’s, Glenn Fleisig continues his work trying to prevent pitchers from ever needing to go under the knife.

Fleisig is the research director of the American Sports Medicine Institute, a non-profit research arm of Andrews’ practice. It’s where Fleisig runs the institute’s state-of-the-art biomechanics lab. Half-naked pitchers, dotted with small reflective patches, are recorded by high-speed cameras to test the merits of their mechanics and the potential risks of injuries.

“We like to view this as essentially an MRI for coaches,” Fleisig says.

As far as it relates to pitching, biomechanics is the study of the kinetic chain in a pitcher’s delivery — how force is generated and transferred prior to throwing the ball.

Bad mechanics are anything that put a pitcher’s body out of its most efficient and healthy position. Specifics vary from pitcher to pitcher, depending on anatomy, strength, flexibility and other factors.

As a general example, a pitcher’s shoulder rotates most efficiently when the arm is at a 90-degree angle. Deviating from that position can cause tissue impingement in the shoulder or additional stress on the elbow, while decreasing the ability of the shoulder muscles to produce and absorb energy.

The mechanical flaw causing the problem can be subtle, such as the placement of the pitcher’s foot or the rotation of their trunk. Once a pitcher’s front foot hits the ground, muscle memory takes over. A pitcher can’t think his way into better biomechanics.

This is where Fleisig and his lab come in. His advice aims to establish the best kinetic timing to ensure the body is moving most efficiently. Sometimes changes to a pitcher’s delivery are simple, such as adjusting the length of his stride; other times it can be more complicated, such as altering arm angle or hip rotation.

Though it remains an imperfect science — “We don’t have the ultimate equation for anybody, so we can’t say: ‘You do this and you have zero chance of getting hurt’ ” — Fleisig says better mechanics statistically reduce the likelihood of injury.

Fleisig doesn’t buy the argument that pitching is inherently strenuous and some pitchers are simply prone to injury.

“That’s like saying, ‘Oh you’re going to die anyway, so don’t worry about it. Don’t wear your seatbelt.’ If it was meant to be, it’s meant to be.”

Besides, not all injuries are created equal. A strained oblique, which may result in a month or two on the disabled list, is preferable to a torn UCL or rotator cuff.

Though Fleisig and the institute have amassed considerable evidence to support the merits of biomechanics, it remains a divisive subject among major-league teams.

The Chicago White Sox, whose pitchers have suffered fewer injuries than any other team, are against it. The Baltimore Orioles, meanwhile, send every pitcher in their organization to Fleisig, who says that 20 of the 30 major-league teams will send at least one player to his lab.

He won’t say whether the Jays are one of those teams.

What’s clear is that the surgeries are on the rise, among amateur and professional ranks, at least over historical levels.

Last year, Andrews and his staff performed 213 Tommy Johns — 22 more than in 2011 and 102 more than in 2010. At St. Vincent’s, one of the four operating suites is dedicated to UCL reconstructions twice weekly.

Most disturbing is the rate at which high school and youth pitchers are requiring the surgery, accounting for up to a third of all procedures done now.

“I can tell you that percentage wise there are more high school pitchers getting hurt. That’s a fact,” Fleisig says.

Noticing the alarming spike in UCL reconstructions among teenage and youth pitchers in the mid-2000s, Fleisig and Andrews led a successful campaign to implement strict pitch counts in Little Leagues across the U.S., from no more than 75 pitches a day for children 10 and younger, to no more than 105 a day for 17- and 18-year-olds.

From previous studies, they knew the single biggest factor in arm injuries among youth pitchers is how much they throw. The second biggest factor is how hard they throw.

“We kind of caught it, the epidemic rise,” Fleisig says. “We’d like to make it go down, but at least we stopped it from going up.”

Baseball Canada followed suit in implementing its pitch-count rules. The new regulations also spell out mandatory rest between outings.

Jobe, like others, wants amateur coaches to continue to manage pitch counts. But he would also like to see a greater attention to biomechanics throughout all levels of play.

“Players are throwing much harder than they used to,” he said. “So if you get off on your mechanics a little bit, you’re going to hurt the ligament.”

Andrews believes the biggest culprits threatening young pitchers are year-round baseball and radar guns.

“Radar guns should be outlawed in high school,” he says.

He also believes major-league rosters should be expanded to allow teams to carry more relievers. He considers them more vulnerable due to their up-and-down pitching schedules.

“The thing about baseball is it’s hard to change.”

But the game is changing.

The Washington Nationals drew fierce criticism last season for shutting down their best pitcher, Stephen Strasburg, when he reached a predetermined limit of 160 innings. Strasburg missed all of the 2011 season recovering from Tommy John surgery.

The Jays’ minor-league pitching prospects are all on strict pitch counts, although the club will not divulge details.

While Drabek is thankful for Tommy John surgery, which has now twice extended his life in baseball, he wishes he had never needed it.

“It takes away two years of your career you can’t get back.”

Drabek was among the group of September call-ups the Jays added to their expanded roster this week. He’s in the bullpen for now and may not start again this season.

Perez was also called up. He made his season debut Wednesday, striking out his first two batters but suffering the loss in the Jays’ extra-innings defeat to the Arizona Diamondbacks.

Hutchison was left off the expanded roster. Manager John Gibbons says there are not enough innings to go around.

When he puts his hands together and sets on the mound, his fleshy red scar will look like a grin in the crook of his elbow.