Baseball Performance: What can I expect during Rehabilitation following Tommy John Internal Brace Surgery?

By Dr. John Mishock, PT, DPT, DC 

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 is averaging 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. When you couple the increased velocity with overuse and poor pitching mechanics, the recipe is set for an epidemic increase in elbow injuries and Tommy John surgery.

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) This stress over time can lead to tearing, necessitating Tommy John Surgery. Tommy John Surgery has progressed significantly since Dr. Frank Jobe did an experimental surgery taking a ligament from the Dodgers pitcher’s wrist in 1974. Today, surgeons now use a procedure known as an internal brace for some, almost like a seat belt to the elbow, to create stability and function between the ulna and humerus. This modified technique offers better outcomes with a 4-6 month rehabilitation versus the traditional 12-18-month period associated with UCL reconstruction. (Spivey M.G. Arthrosc Sports Med Rehabil. 2023) The internal brace augmentation offers improved stiffness and strength of the graft, reduced surgical trauma, and less cartilage irritation, leading to a faster return to regular activity and throwing. (Bernholt et al. Sports Med. 2023)

What happens during Physical therapy and Rehabilitation following internal brace surgery?

The rehabilitation protocol involves 5 phases, which I will describe below. Phase I (immediate post-op phase 0-3 weeks): Physical therapy begins immediately after the surgery to protect the elbow and allow optimal healing while maintaining strength and range of motion of the wrist, fingers, shoulder, and biceps. Patient/family education involves understanding how to optimize healing and recovery. The patient will wear an elbow hinge brace that limits the range of motion to 60-90 degrees for approximately 4-6 weeks. Movement of the elbow begins at 1 to 2 weeks after surgery, with the expectation of a full elbow range of motion within 4 to 6 weeks. The physical therapist will perform soft tissue mobilization, gentle isometric exercise, range of motion, and modalities to promote healing and recovery.

Phase II (protection phase 4-6 weeks): The goals are full elbow range of motion, optimal protection and healing of the graft site, and regaining and improving muscular strength. At six weeks, a shoulder functional strengthening program begins, focusing on the critical muscles for throwing. There is no throwing or hitting in this phase.

Phase III (strengthening phase 6-12 weeks): The goals are increasing strength (85% one rep max), motor control, and endurance of the forearm, arm, shoulder, and scapular stabilizers. There is no throwing or hitting in this phase.

Phase IV (Advanced strengthening phase 12-16 weeks following surgery). The goals are to progress strength, power, and endurance equal to the non-involved side. Plyometric exercise (explosive functional exercise) is initiated to improve the power of the lower extremities, hips, core, shoulder, and arm. The patient may feel like they can throw. However, there is still no throwing. However, the athlete can begin hitting at 12 weeks.

Phase V (return to play weeks 16+ following surgery): In this phase, the patient continues an aggressive rehabilitation program. The athlete begins an interval-throwing program based on the surgeon’s criteria and protocol. The interval-throwing program is a controlled return to throwing, focusing on proper pitching mechanics while controlling throwing volume, distance, and intensity. The program progresses until the athlete can return to the mound for in-game action.

Even though Tommy John Surgery has a success rate of 80-95% for return-to-play, it is still a life-altering surgery that significantly impacts playing time. Most athletes should expect to return to competitive play for 6-9 months. However, some never return to their previous level of baseball pitching. Some may need a second or third Tommy John surgery if their baseball career lasts long enough.

With the fastest growing segment of Tommy John Surgeries being 15-19-year-olds, coaches and parents must be vigilant in doing everything they can to prevent the injury in the first place. There is not one way to reduce all potential for arm injury; however, the evidence has shown that arm injury can be reduced or prevented by developing sound, scientifically-based pitch mechanics, not allowing pitchers to throw with arm or body fatigue, following pitch count rules; throwing the fastball less than 50% of the time when pitching; throwing the hard fastball less by changing speeds; optimizing mobility, flexibility, strength and power of crucial throwing muscle groups.

Dr.Mishock is one of only a few clinicians with doctorate-level degrees in both physical therapy and chiropractic in the state of Pennsylvania. He has authored two books; “Fundamental Training Principles: Essential Knowledge for Building the Elite Athlete”, and “The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury” both can be bought on Amazon and train2playsports.com.