If you follow Major League Baseball closely, you’re likely aware of the recent “epidemic” of blown elbows. As a certified athletic trainer who has spent many years working with professional baseball players, I have seen it happen and worked tirelessly to prevent them from occurring. Injuries are a little bit like snowflakes. They’re all unique, and they affect each individual differently, even when it comes to something as seemingly straightforward as a UCL sprain. The ulnar collateral ligament is a complex, medial elbow stabilizer made up of three ligaments: the anterior UCL, posterior UCL and transverse UCL. The most common culprit in the UCL reconstruction cases is the anterior band. Sometimes, the ligament tears completely through and other times there are smaller degrees of tearing. We’ve also seen a variety of approaches taken after the diagnosis has been made. Some players and clubs opt for a conservative, rehab approach to see if they can avoid surgery or, at least, prolong it. Others bite the bullet right away and operate to get the process going. The timing of the injury can play a role in the decision as well.
But how do these guys generally perform after having this operation? We know that the success rate is fairly high (around 80-85% return to their prior level of performance). This can be a bit misleading, because what the medical community is more concerned about is the subjective report from the athlete and the objective success of the surgery in restoring the normal stability of the joint. “Success,” in medical terms, has nothing to do with ERA, W-L, or K/BB ratio. Luckily, some researchers have compiled detailed reports for these types of statistics. After all, the information is already there. It just needs to be examined and computed. We know who has had the operation, and we have their stats, both before and after surgery.
Robert A. Keller, et. al, examined certain performance statistics and averaged them over the 3 years prior and the 3 years post surgery. They compiled a list of 168 eligible MLB pitchers who had at least 1 game pitched prior to surgery between 1982 and 2010. They also identified 178, age-related, healthy MLB pitchers to act as the control group. The researchers approximated each surgical date by locating significant gaps in their playing stats. We know that the average player requires around 12 months of post-op rehab and return to play progressions. The researchers used a dependent t-test, or paired samples t-test, to compare ERA, WHIP, IP, and Win% within the Tommy John Surgery group. This is a pre-surgery compared to post-surgery for each subject in the surgery group. The results showed significant differences in ERA, WHIP and Innings Pitched. In all three, the pre-surgery averages were significantly better than post-surgery averages (lower ERA, lower WHIP and more IP). Winning percentage was not stastically significant. Pitchers in the surgery group significantly increased their IP 3 years post-surgery compared to 1 year post-surgery. When looking at the 3 years prior to surgery and comparing the stats in each year for each pitcher, the year before surgery was significantly worse than the year or two before that. Of course, this when the pitcher is beginning to experience the deleterious effects of his injury and/or the cumulative effect of repetitive medial elbow stress is beginning to take a bigger toll on each pitcher’s performance levels. On a side note, in this study, 87% of the pitchers returned to MLB pitching.
In comparing the UCL reconstruction group to the control group, the researchers found that the UCL group was stastically better than the control group 3 years prior to surgery and 2 years prior to surgery in ERA, WHIP and IP, but had lower winning %. Post-surgery, the UCL group had significantly lower IP in the first year compared to the control group, but by the 3rd year had returned to similar average innings pitched. Perhaps the UCL group had better overall pitchers. After all, we can imagine that as these players develop throughout their youth and early adult ages, they are getting used a lot more than inferior pitchers on their teams. Perhaps it’s this abuse, if you will, that leads them down a path to eventually having surgery.
1. Robert A. Keller, MD, Matthew J. Steffes, BA, David Zhuo, BA, Michael J. Bey, PhD, Vasilios Moutzouros, MD. “The effects of medial ulnar collateral ligament reconstruction on Major League pitching performance.” Journal of Shoulder Elbow Surgery. (2014) 23, 1591-1598
Eric C. Makhni, et. al, performed a similar study that was published in the American Journal of Sports Medicine in 2014. For this study, the researchers used similar guidelines for compiling lists of eligible pitchers (at least 1 MLB game pitched, 1974-2012). However, they excluded those who had surgery prior to 1999 because of a significant update in the surgical techniques used. They also excluded those who had surgery after the 2011 All Star Break, because of a lack of sufficient time to rehabilitate fully by the time the study was completed. They ended up with a list of 147 MLB pitchers in the study who had undergone Tommy John Surgery. Within this set of players, they also identified those with 10 or more games pitched as “established” pitchers. And like the study above, they randomly produced an age-related set of healthy pitchers to act as the control group.
Again, the researchers used paired t-tests to examine each pitcher before and after surgery. Performance statistics that were found to be signficantly worse after surgery were: ERA, BA against, WHIP, % of strikes thrown, IP, % of fastballs thrown and fastball velocity. Comparisons with the control group showed very little of statistical significance other than differences in innings pitched, total pitches thrown and K/9IP. In the first study we saw that the Tommy John group actually had better performance stat averages in the 3rd and 2nd year prior to surgery. In this study, we found no statistically significant differences between the Tommy John group and the control group. We should expect that an injured player would perform worse than a healthy player, but we only see significant declines within each player themselves (on average). Again, this leads me to hypothesize that in a majority of the cases, the players suffering these injuries are generally better quality pitchers, and have probably thrown more in their playing careers in terms of volume of innings and total pitches than their counterparts in these control groups.
2. Eric C. Makhni, Randall W. Lee, Zachary S. Morrow, Anthony P. Gualtieri, Prakash Gorroochurn and Christopher S. Ahmad. “Performance, Return to Competition, and Reinjury After Tommy John Surgery in Major League Baseball Pitchers: A Review of 147 Cases.” American Journal of Sports Medicine. (2014) 42: 1323
Dr. James Andrews and colleagues studied 10 year outcomes for baseball players who had Tommy John Surgery and published their review in 2014. A total of 313 subjects between 1994-2011 had the operation and a minimum 10 year follow up. 57 of these athletes could not be reached despite every effort made by the authors. Of the 256 remaining, 228 were pitchers and 28 were position players. 24 of the 256 were Major League players, 88 were Minor League, 104 were collegiate and 40 were high school players. At the 10 year mark, 243 (95%) were retired from baseball. 19% had at least 1 post-operative elbow surgery. 34% had shoulder problems and 25% ended up having shoulder surgery. Overall, 83% were able to return to play at the same or higher level as prior to surgery. College players had a better return to play percentage (92%) than Major League players (79%), Minor League players (76%), and high school players (81%).
The authors found no significant differences in the data between the graft choices used in the surgical procedure, nor was concomitant injury at the time of UCL reconstruction a significant factor. Return to play was also not affected by post UCLR elbow surgery or subsequent shoulder surgery. The average career length post- primary UCL reconstruction was 3.6 years.
Reasons for retirement were recorded and evaluated as well. In most cases, the athlete cited non-injury related reasons for their retirement, followed by shoulder problems, elbow problems, and other injuries. At the 10 year follow up, 93% of the subjects were satisfied with their UCL reconstruction. Only 3% had elbow pain, while 5% has a perceived limitation in the elbow. 92% were able to currently throw without pain and 98% participated in throwing activities on a recreational basis.
3. Daryl C. Osbahr, MD, E. Lyle Cain Jr, MD, B. Todd Raines, MA, ATC,
Dave Fortenbaugh, PhD, Jeffrey R. Dugas, MD, and James R. Andrews, MD. “Long-term Outcomes After Ulnar Collateral Ligament Reconstruction in Competitive Baseball Players: Minimum 10-Year Follow-up.” American Journal of Sports Medicine. (2014) 42: 1333.
There’s a lot to consider here. As I mentioned above, we’re seeing that according to the baseball stats, the higher quality pitchers are on average having this surgery more. My hypothesis is that these pitchers have thrown more in terms of shear volume throughout their entire careers, going back to youth baseball. Dr. Andrews has been a leading advocate for pitch counts in youth baseball for a long time and the changes that have been implement in Little League should have an impact. But we have to give that more time before it reaches the Big League level. Year round throwing and specializing in baseball only at young ages are other things to keep in mind, too.
We’re also seeing that the surgical procedures continue to evolve and improve. Statistically speaking, the odds are favorable for your favorite pitcher to return to form after having this operation. The percentages climb even higher when you add in elite level physical therapists and athletic trainers to care for these athletes post-op. And in terms of baseball performance, be patient that first year. We’re seeing Matt Harvey come back and dominate from the start, but he’s probably one of the exceptions. Most MLB pitchers will return to form in the 2nd or 3rd year after. Sometimes, it takes time to build up that confidence after such a long absence. And in terms of career longevity, keep in mind that of those 313 players that Dr. Andrews’ team followed, most of them do not make it to the Major League level and many didn’t make it as a professional at all. Remember, that a majority of them retired not because they were injured. Many times, retirement happens when they just aren’t good enough for the next level up.
Whenever the discussion about UCL injuries is brought up, we inevitably end up talking about youngsters. There has been a lot of changes to the Little League game in terms of pitch counts and when to introduce breaking balls, as well as guiding kids away from early sport specialization. Each of those variables could be discussed at length in future articles because there is a lot to chew on here. In terms of the studies cited in this article, loose connections could be made. As I’ve suggested several times, quality pitchers tend to throw more in terms of volume, and in many cases, this high volume may begin at a young age. I think we may see some positive results from the rule changes regarding Little League pitchers as those athletes reach the professional ranks. Youth, high school and college coaches may begin to more of a “big picture” approach when considering pitch counts and days off in between outings. It is a difficult thing to assess in the present, which indicates the need for continued research.
For future considerations, as we continue to gain access to more and more data and are able to track these surgical cases, especially in MLB, the studies will become more powerful and provide more predictable outcomes.