The Rise in Tommy John Surgery in HS Pitchers

JT,

Old news. And not great!

TJ is now deployed as 'preventive' surgery!
Imagine that.

With so much confidence, MLB is drafting prospects who require arm surgery (UCL). And sign for big bucks! (Yet who really takes the bigger of risks here, MLB or the player?......Now that's a story!)

Of course one will not publish the 'failure' rates!
(Where the baseball arm does NOT get back on the field!)

The Houston writer (SAM KHAN JR.) may need to do more research. Or at minimum try to get a date with Jenny Dial (and that's another story!)

I was reading about accutane, a strong acne drug, and the long list of potential side effects. The long list of nasty side effects included depression, suicide, liver failure and this: Calcification of tendons and ligaments. Could this be a contributing factor? I heard a few of his teammates are on it.

Bear,
I realize you're talking about a bit different failure rate, but the failure rate for the surgery is less than 15% and the failures tend to be due to not following the rehab protocol. Obviously if a pitcher has TJ surgery and loses a year of playing time he's going to have trouble getting back into a rotation which is what you may have been referring to.

I also don't think there are many incidences of preventative TJ surgery. I'm sure there are a few misguided parents asking for it, but I believe the vast majority of surgeons would refuse that request.

The reality is that part of the increase is due to bigger kids throwing harder sooner in their careers. The non-throwing training that helps pitchers throw harder and put more stress on the UCL doesn't necessarily prepare the UCL for the added stress. HS kids are generally a bit taller, and are far more filled out and stronger in general than they were back in the day.

MTS,
Interesting point. Is Accutane a prescription drug?

quote:

Originally posted by CADad:

...


MTS,
Interesting point. Is Accutane a prescription drug?

Yes it is. It is ranked the 5th most dangerous prescription drug.

i can't believe it's preventetive.(SP) no one in there right mind would have it if you didn't need it. much less a doctor doing it.

but ya never know.

CADad,
Here is an extract from a March 2008 presentation by one of the team orthopedists for the Phillies on a study of Milb players with elbow and shoulder surgery.
This report concludes only 43% of the pitchers with shoulder or elbow surgery ever returned to successfully sustain the same or higher level of competition.
Even less success for shoulders, alone.
It does not break out by elbow alone but clearly the success rate could not be anywhere near 85% based on these overall numbers.
Not sure the source of information that the failure rate is due to the effort and compliance with rehab.
My observations have been that most of these players are dedicated beyond words in trying to get back on the field.

"Over a four-season period, Cohen and colleagues studied 44 players from one professional baseball club (major league, AAA, AA and A) who underwent 50 shoulder and elbow operations by a variety of surgeons. There were 27 shoulder surgeries performed on 26 players and 23 elbow surgeries performed on 21 players. A key finding of the study was that players returning after elbow surgery were more likely to comeback to the same or higher playing level than those who had shoulder surgery. Thirty-five of the players were pitchers with 43 percent returning to the same or higher playing level.

The researchers found that overall, only 20 of the 44 players (45 percent) returned to the same or higher level of professional baseball. For ballplayers at the major league, AAA, or AA level, the study found only 4 of 22 (18 percent) were able to return to the same or higher level."

infielddad,
The surgery is 85% successful and that is different from returning to the same level of play. Keep any pro player out of playing baseball for a year and they are going to have problems making it back to the same level.

That's good information you posted.

I think I'll put off the surgery. I was hoping to get back up to 70 mph, but I don't think I'd be able to after the layoff.

quote:

The surgery is 85% successful and that is different from returning to the same level of play.

I'll have to ask.
What is your definition of success if it isn't returning to the same level of play?
Since you said the player results which were unsuccessful resulted from failure to rehab as prescribed, I had the clear impression "successful" meant returning to the same level.
Since it doesn't, what does it mean?

When my son was younger if you had UCL issues you just didn't pitch anymore, but played another position or just gave up baseball. Plus kids pitch much more than they did when he was younger.

If this procedure can prolong any pitchers game, why not, there is nothing wrong with that. However, if you overlook arm health because you know the surgery is available, that's not a good thing.

JMO.

Be careful of those numbers since they may include elbow surgeries other than TJ surgery.

quote:

The Modified Docking Procedure for Elbow Ulnar Collateral Ligament Reconstruction
2-Year Follow-up in Elite Throwers
George A. Paletta, Jr, MD* and Rick W. Wright, MD,
From the * Center for the Athlete’s Shoulder and Elbow at the Orthopaedic Center of St Louis, Chesterfield, Missouri, and Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, Missouri

Address correspondence to Rick W. Wright, MD, 1 Barnes Jewish Plaza, Suite 11300, St Louis, MO 63110 (e-mail: Rwwright1@aol.com).


Background: Ulnar collateral ligament injury is most common in the overhead-throwing athlete. Jobe et al published the first report of ulnar collateral ligament reconstruction in throwing athletes with a 62.5% success rate. Recently, Altchek developed a new docking technique for reconstruction of the ulnar collateral ligament. The authors report the first series using a further modification of the docking technique using a 4-strand palmaris longus graft for reconstruction of the ulnar collateral ligament.

Hypothesis: The modified docking technique yields a high rate of successful return to preinjury level of competition in elite baseball players.

Study Design: Case series; Level of evidence, 4.

Methods: The authors retrospectively reviewed 25 elite professional or scholarship collegiate baseball players who underwent elbow ulnar collateral ligament reconstruction using the modified docking procedure with a minimum 2-year follow-up.

Results: Twenty-three of 25 (92%) were able to return to their preinjury levels of competition. The mean time to return was 11.5 months (range, 10–16 months). Complications included 1 transient postoperative ulnar nerve neurapraxia and 1 stress fracture of the ulnar bone bridge that occurred at 14 months postoperatively, after a full return to pitching.

Conclusion: The modified docking technique yields highly successful return to preinjury level of competition rates (92%) in a select group of elite baseball players.


Key Words: ulnar collateral ligament (UCL) • elbow • pitchers

quote:

Be careful of those numbers since they may include elbow surgeries other than TJ surgery.

I appreciate they "might." Most were UCL, I think we would both agree to that.
What is the date of your study reference?
Your's describes a 92% return for 25 professional and/or elite college players. The Phillies March study has a considerably different and lower result but was limited to those in professional baseball.
For the most part, each study is reporting on a very similar level of player with vastly different results reported in the return to competition.
I would propose the data is out on the 85% or any reliable percentage.
Unfortunately, from the post JT made to start this thread, there are going to be far more subjects available for study.
I don't think anyone should think TJ is the answer with high reliability until more is known.

infielddad,
Agree.

First published 7/06

Thanks for sharing your article. A lot to be learned I think from each.
And many thanks for TJ for sharing these results.
When you consider the 7 fold increase from 2004 to 2007 is just in Dr Andrews patient population, this isn't old news at all, it is new and important news.

It's tempting to read that 43% return to the same level or higher and conclude that 57% weren't successful. But consider the pitchers who didn't undergo TJ surgery: what fraction of them come back next year at the same or higher level? It's nothing like 100%-- lots of them get released for reasons unrelated to their elbow. To take an extreme hypothesis, if it turns that only 43% of the non-TJ pitchers return, then we could say that TJ surgery has a near 100% success rate.

I'd also expect that a study of collegiate pitchers would show a higher liklihood of return than a study of MiLB, because professional baseball has a pyramid structure that is very narrow at the top. Most professional players are released. Collegiate baseball, at least for the first three years, isn't pyramidal, and most players, whether they have had TJ surgery or not, come back next year at the same level.

Back in January the University of South Carolina Sports Medicine Dept. had Dr. Andrews do a seminar for trainers and sports docs. They let parents, coaches, players, etc. come on the second day. He talked about the statistics that are in the article JT linked. Also went in to the risk factors for teen pitchers. His stats from the seminar were: Routinely throwing more than 80 pitches in a game increased the likelihood of surgery 380%; pitching competetively more than 8 months out of the year increased surgery chances by 500%; pitching when fatigued (not enough rest between outings, or way too many pitches in an outing) the likelihood of surgery went up 3,600%. He also had a study done on fastballs and curveballs - there was a lot of science in this one. But basically he found that throwing really hard (which he defined as 85 or better) created more stress on the elbow than throwing a curveball.

quote:

Originally posted by 3FingeredGlove:
It's tempting to read that 43% return to the same level or higher and conclude that 57% weren't successful. But consider the pitchers who didn't undergo TJ surgery: what fraction of them come back next year at the same or higher level? It's nothing like 100%-- lots of them get released for reasons unrelated to their elbow. To take an extreme hypothesis, if it turns that only 43% of the non-TJ pitchers return, then we could say that TJ surgery has a near 100% success rate.

I'd also expect that a study of collegiate pitchers would show a higher liklihood of return than a study of MiLB, because professional baseball has a pyramid structure that is very narrow at the top. Most professional players are released. Collegiate baseball, at least for the first three years, isn't pyramidal, and most players, whether they have had TJ surgery or not, come back next year at the same level.

So I guess you are saying it is baseball, not the injury/lack of recovery which accounts for the 43% finding.
Well, here is the summary and conclusion by Dr Cohen:
""As a surgeon, obviously these statistics were disappointing and somewhat lower than what we would like them to be," said Cohen. "This may give us cause, however, to look at how we evaluate and treat these injuries to the throwing arm. Our goal is to get these elite athletes back to their premier pre-injury health. This is important both to the player who is making a living off his athletic ability and the organization that wants its players in top shape. We may need to examine if there is a way to 'fine-tune' these procedures to customize them for the demands of a professional baseball player."

Contrary to your view 3Fingered, Dr Cohen concludes the findings were based on the medical/surgical results, not the baseball issues of attrition. They were due to the inability to get the player back to the level of the "pre-injury health."
He specifically studied the ability to return to the former level, not the ability to progress in the organization, which is most often the deciding factor in releasing a player. If you cannot return to your pre-injury performance due to injury, you will also get released or a medical separation. The two end up at the same place. The reasons are totally different. Dr Cohen studied and reported on the latter and expressly states the medical findings were disappointing.
Since it was his study, he is a team physician for the Phillies, and he was studying professional players, one would think his conclusions that there was a decrease in performance from pre-injury status and that it was medically driven is sound.

Lefty's dad. Interesting. I've heard 80 mph as being the threshold where the risk starts going up. I'm not surprised about the curve, since curves are typically thrown about 10-14 mph slower than fastballs. I do wonder about sliders which are often thrown at only 5-8 mph less than fastballs. My guess is that a good hard slider is just as hard or harder on the UCL as a fastball. On the other hand, I know of a kid with a history of UCL damage treated conservatively, who (there's a lot of speculation involved here) seems, IMO, to be protecting his arm and losing velocity on his fastball by turning it over excessively, yet is able to throw his slider without any outward signs of any problems.

What doesn't show up in this is the overall probability of needing TJ surgery. A 360% increase in risk might be worth it if the overall probability is pretty low or even the 500%, depending on what benefit they got from throwing 80+ pitches or pitching year round, but I doubt there's any way that a 3600% increase in risk is acceptable.

What this tells me is that a HS coach has to be more careful with his hard throwers than he does with his soft tossers. Generally, the opposite of what he'd prefer.

CADad,
Dr. Andrews also made a point to say that he thought kids pitched too much and didn't throw enough. Some of my notes are at home, I'll get them out tonight and see if there's anything else pertinent there.

no one really know's why the ligament tears, bone spur rubbing on it ,stress etc. but i believe it's to much velocity to quick. i read about a study they did on cadaver's that explained how much stress is put on the elbow throwing a baseball. factor in throwing a baseball at 90 on a not fully developed arm?

in regards to the pre surgery comeback. if your in college or high school, you have some time to work that arm back. they say a year but another year getting the feel and trust back. milb doesn't alway's wait that long for the arm to get there. my son is within a few mph of his pre surgery and it's been about 21 months. but the curve and change feed of that fastball.


kids just don't throw enough. rocks, baseballs, whatever.

Here's a couple of links to the study infielddad referenced earlier.
Serena Gordon article
AOSSM Press Release

The Gordon article has the additional information that 52% of pitchers with an elbow injury returned to the same playing level or higher. Bear in mind that the sample size is small (11 out of 21 pitchers), so the true fraction could be significantly different. However, it's unlikely that random sampling by itself could explain the difference between this study and the Paletta/Wright study that CADad referenced. Both studies nominally formed their statistics on return to "level of competition" or "playing level". I continue to think that the higher success rate in the P/W study arises in part from its inclusion of collegiate players, who are classified at one level of competition (or higher if drafted) for 4 years, and are therefore not much subject to non-injury related survivorship bias.

I am sorry to be persistent, but I have seen situations recently that makes the survivorship bias argument a problem.
In 2004, our son played on a team with a left handed pitcher, an 8th/9th round pick I believe.
The pitcher was coming off TJ done in 2003 and one of those who could have been a round 1-3 guy so "worth the risk." Everything I read about him said he was 92-93 pre-surgery.
In 2004 in short season A, he never got over 83-84 and had no command.
By Spring Training in 2005, he was the same and he was released.
Now, according to the study, he would have returned
back to his pre-injury level of competition and be considered a success story.
When you saw him on the mound, he was anything but back to his pre-injury health or velocity. Just from the 2004 draft class for our son, I can think of that pitcher and two others who had TJ, who returned to the same level of play, but their velocity not close to the level before TJ. Each was released.
Whether they would have survived based on their skill level pre-injury is anyone's guess(the lefty would have certainly been a AA/AAA guy).
But each of the 3 would, in a study be shown to have returned to playing at the same level. They would be a success.
The problem for each is that post TJ, they weren't.
A few months ago on this site a post almost trivialized TJ as a zipper and you are better than new. My view is that these studies can tell you whether they returned to their pre-injury level of play. They don't tell you whether they succeeded or not but your eyes and personal experience can tell you there is much more to this than survivorship bias.

I know of quite a few pitchers who had TJ and returned to velocity (one higher) than pre surgery. Velo returned but command, the last thing to sometimes return, took about two years.

I think that lots has to do with the rehab, who rehabs you, who works with you after rehab, your drive to succeed and your future potential before surgery. My sons BF had to learn how to pitch all over again, getting rid of bad habits that may have caused the injury. Another friend had good mechanics, but he pitched too much in HS. Both doing well in pro ball and drafted high.

I agree, TJS does NOT guarantee that you will return the same. Anyone with the statment you will be better than new is way off base.

i ask myself what if my son was in high school and needed tj? would he really need it? by that i mean will he need it to make a living? will he get a free ride in school if he gets it? very important question's to a very big decision.
he is glad he had it,very happy to be where he is today. and it wasn't easy, nor will it be. there are no garantees after surgery. but better to have tried than to live with the what if's.
if you need the surgery ,the 85% number will be engrained in your memory. funny thing, never the 15%.

20sdad,
that is a very thought provoking conclusion.
My input would be that if you and your son needs to or has had TJ, you have to use the 85%, maybe even the 92% for focus and to generate the mental determination to recover. You cannot think about and cannot accept the other.
Why I am being so persistent is in the hope that parents and coaches of those who are 9-18 are just as tenacious and dedicated to paying attention to the 15% or 53% and do everything they can to protect those arms from overuse and cumulative damage.

infieldad
i know why your doing it ,and it is a great public service. i have been preaching the praises of pitch counts etc. since my son's surgery. i find most parents feel it won't happen to them, or it's 3 days rest he'll be ok. or dicek threw 120 the other night. or my kid isn't throwing hard enough to hurt himself.

ucl tears don't announce themselves. an ounce of prevention is worth a pound of cure.

quote:

Originally posted by infielddad:
Why I am being so persistent is in the hope that parents and coaches of those who are 9-18 are just as tenacious and dedicated to paying attention to the 15% or 53% and do everything they can to protect those arms from overuse and cumulative damage.

Quite right. Furthermore, protecting arms (and shoulders) is important even if one were to believe the higher percentages of success. A pitcher doesn't get to choose to have an UCL injury in preference to rotator cuff or labrum problems. The elbow can also have nerve or bone damage. A pitcher should be protecting against any of these possible injuries.

quote:

Originally posted by infielddad:

Old fricking news, jack.

The surgical procedure (i.e. in which a ligament in the medial elbow is replaced with a tendon (often from the patient's forearm, hamstring, knee, or foot) will soon be 35 years from being successfully performed (by Jobe) on the first professional athlete. A thirty five year old procedure is, by definition, frickin greying!

OBTW: I have seen surgeon's success numbers as high
as 85 to 90%. This is NOT the same as the rehab success percentages (which are much lower.)

The risk is damage to the nerve.
(Remember... when Marshall informed Jobe to go
back into John's elbow to re-route the ulna nerve!)

Why do arm's sometimes throw harder after surgery and about a year of rehab?
#1 Pitchers' rehab conditioning is maturing.
#2 UCL degradation takes several years.

Degradation.. How? The collateral becomes stretched, frayed or torn. There are stresses
with the throwing motion.

Who remembers the "Little League Elbow" injury
debate/ discussion. Growth Plates. That too is frickin old news!

Knock yourself out with some or all of
these References (some have frickin aged, some are fresher than others .....

Should you need or want an interpreter, ask JT he's a helpful kind of guy and is in the business. (I prefer these over the Cliff notes.

a. Keri, Jonah, Interview With Frank Jobe. http://espn.go.com/mlb/columns/bp/1431308.html

b. Fleisig, G.S., The biomechanics of baseball pitching, in Biomechanical Engineering. 1994, University of Alabama: Birmingham. p. 163.

c. Lyman, S., et al., Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc, 2001. 33(11): p. 1803-10.

d. Lyman, S., et al., Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers.
Am Journal Sports Med, 2002. 30(4): p. 463-8.

e. Whiteley, R., Baseball throwing mechanics as they relate to pathology and performance - a review. Journal of Sports Science & Medicine, 2007. 6(1): p. 1-20.

f. Purcell DB, Matava MJ, Wright RW (2007). "Ulnar collateral ligament reconstruction: a systematic review". Clin. Orthop. Relat. Res. 455: 72–7. doi:10.1097/BLO.0b013e31802eb447. PMID 17279038.

For those using only Cliff Notes type info:
check out URL for the 2003 USA Today article:

http://www.usatoday.com/sports/baseball/2003-07-28-cover-tommy-john_x.htm

Regards
Bear

postscript: Have you ever heard of "Tommy Bear" surgery (on the elbow/arm). Now that [procedure] is a "relatively" new!

Look at our Thursday post on Rounding Third titled
"Ego Driven Madness". We feel that the rise in injuries starts right in the home.

RT Staff

good stuff, IMO.

RT Staff - That is a great article that many on this site could benefit from reading. Please consider posting the entire article in the pre-high school thread, they need to think about these things sooner than later, IMO.

quote:

Old fricking news, jack.

If true, why did Dr Cohen of the Phillies just complete a study where he finds the surgical reports disappointing on the patient population studied?
Why did Dr Andrews report on a comparative study comparing 2004-2007 with TJ on high school patients in prior years?
I am not sure what you are trying to prove with your posts.
Anyone who has been in baseball knows the procedure goes back 35 years. This thread is about how the use of the procedure is expanding almost exponentially.
Perhaps it might be "old fricking news" in your mind, but it surely isn't news that has received enough publicity to cause a change in behavior in overuse.
Also, concerning that 85%. With the prolific increase in the number of TJ's being performed, maybe that number, like Dr Cohen reports, needs to be reevaluated and studied further.
It this is such "old frickin news" why don't you tell Dr Andrews to quit studying the explosion in surgeries performed and tell Dr Cohen to stop studying the results he found terribly disappointing?

The first problem is calling UCL degradation an overuse problem!It’s only an overuse problem in the “Traditional mechanics” way pitchers are taught to start the ball. Fix the mechanics and the problem is gone!

When you bring the ball up with your hand on top of the ball the way it is taught everywhere by almost everybody you will then turn it over and bounce your forearm back before it goes foreword, this is what causes over stress at this area. This is a fact!

Do not look to orthopedic surgeons for any answers; they are not educated on ballistic kinesiological movements. When you leave surgery they all tell you to go back to you’re pitching coach and do it right when doing it right (?) Is what got you on the OR table in the first place.

This fix is so simple it’s ludicrous!

Yardbird

If you so called "fix" is so simple why are there not others on the same page with you?

I think that I understand what Yardbird is saying.

My understanding (as I said above) for success of a pitcher after TJS, the recovery is a three step process. Successful surgery, proper rehab and proper instruction to correct any mechanical problems that may have caused the injury in the first place.

quote:

Originally posted by infielddad:
[QUOTE]Do you really know....jack.

/QUOTE]

Hey Rook,.......

For those arms that are blessed with a heater, many of the "older" baseball pros agree arms have so many pitches in it.
With life-time conditioning, arm injuries are sometimes delayed....

Wait a NY minute........ why match....

...if interested in some discussion off-line it's as simple as 1-2-3.
...one...lose the att,
...2nd introduce yourself,
...3rd send an emme and ..maybe we can collaborate (before this get's too frickin old!).

Trhit,

This single pitching mechanic tenet can be learned so easily by just raising your hand up the back side supinating so the forearm arrives to driveline height before your glove arm leg touches ground then you may drive your forearm inside of vertical while pronating.
This produces ½ the Vulgas stress that the bouncing traditional mechanic does.

“If you so called "fix" is so simple why are there not others on the same page with you?”

There are and many more each year. Some are willing to test things and learn, others prefer not to.
When I try to explain to traditional believers they give me the patented “but that’s pie throwing” garbage with out any explanation on why their statement has any merit.
Our game is trapped in tradition and seems incapable of changing over to non-injurious
Mechanics, you try to figure it out?