Baseball Injury Prevention: Why is Tommy John Surgery on the Rise?
By Dr. John Mishock, PT, DPT, DC
Fifty years ago, Tommy John, a pitcher for the Los Angeles Dodgers, had a career-saving experimental elbow surgery to repair a torn ulnar collateral ligament (UCL) by Dr. Frank Jobe. As of 2024, 36% of all active Major League pitchers have undergone Tommy John, and the rate continues to increase yearly. There were more Tommy John Surgeries in the MLB in 2024 MLB than in the entire decade of the 1990s. (USA Today, 2024) Studies show that Tommy John Surgery has an 80-90% success rate; however, it is not without cost. The economic cost of Tommy John Surgery per MLB player to return to play is estimated to be two million dollars. (Meldau et al. J Shoulder Elbow Surg. 2020) Beyond the economic cost, many players (20%) only recover partially, never reaching their full throwing potential. (Mayo et al. Ortho J of Sports Med 2021) At the youth level, baseball players are 10 times more likely to sustain a UCL injury before high school than in the 2000s. Twenty-eight percent of all youth baseball pitchers experience elbow pain during the season. (Carr et al. 2022) In this article, I will discuss the theories behind the near epidemic of UCL injuries in our baseball players.
The leading cause of injury is the sheer throwing volume in our youth and adolescent baseball players during games, seasons, and years. This overuse is not just a statistic, but a reality that our young players are grappling with. Pitchers are more likely to have surgery if they pitch more innings per game and games per season, throw more warm-up pitches, throw more than 100 innings per season, and go over the recommended pitch counts. (Erickson et al. Am J of Ortho 2016) Youth pitchers were 21% more likely to develop elbow pain when throwing between 50 and 74 pitches. The incidence of injury increased to 35% when throwing between 75 and 99 pitches in a game. (House, Nat Pitching Assoc). The billion-dollar tournament baseball industry has led to excessive throwing and overuse without adequate rest and recovery. The large throwing volume produces excessive microtrauma in the UCL at early ages. The wear and tear often cause pitchers to be labeled as having an “old arm” due to overuse. This is not just a problem, but a challenge that our young players are facing, and it’s time we understand and address it.
Another reason for the high UCL injury rate is throwing velocity, not curve balls, sliders, or sweepers. In the MLB, the average fastball velocity leaped from 88 mph in the 1990s to 90.5 mph in 2008. In 2024, the MLB fastball averaged 94 mph. (MLB stat cast, AM Sports Med Inst, 2024) This desire to throw harder has trickled down to the college, high school, and little league levels. Overhand throwing, by nature, puts valgus stress on the elbow. Valgus stress is a fancy term to mean that the elbow is bending in an unnatural direction in which the forearm (ulna) and arm (humerus) attempt to detach during the late cocking phase of throwing. The 2-inch “Tommy John Ligament” (ulnar collateral ligament, UCL) holds the elbow together during this throwing motion, preventing dislocation. Forces at the elbow (growth plate and or “Tommy John Ligament”) can reach up to 75% of the pitcher’s body weight during throwing. (Fleisig et al. Oper Tech Sports Med. 1996) The stress on the elbow exponentially increases with throwing velocity. Velocity is king, with most travel, college, and pro scouts seeking those who can throw hard versus being a good pitcher in changing speeds, throwing strikes, and hitting spots.
The desire to increase velocity and spin rate has led to a shift in pitching strategies. There’s now a push to have the pitcher throw hard for a short duration, often referred to as redlining. It’s rare for pitchers today to throw over 100 pitches or five innings, leading to a significant reduction in complete games. For instance, in 1977, there were 907 complete games versus 27 in 2024 (USA, today 2024). This high, intense effort over a short period exposes the UCL ligament to overstress. In years past, the emphasis was on efficient pitching innings, with less focus on striking batters out.
Other potential reasons for the increase in elbow injuries are a lack of strength, endurance, and power of crucial throwing muscles of the legs, trunk, and shoulder, the ban of sticky foreign substances causing the pitcher to grip the baseball harder when throwing to create the desired spin rate, the pitch clock causing pitchers to throw while fatigued, and poor pitching mechanics using less legs and trunk in generating power when pitching.
Dr. Mishock’s book,”The Rubber Arm: Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury“, located on Amazon and can be found at train2playsports.com. Dr. Mishock is one of only a few clinicians in Pennsylvania with doctorate-level degrees in physical therapy and chiropractic.
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