Looking back as the Major League Baseball (MLB) season begins to wind down and we head into the playoffs, it seems as if there have been a rash of elbow injuries around the league this season. Major media organizations have been commenting on the increasing rate, or as some have characterized, an “epidemic”, of elbow injuries in young throwers. Based upon the media reports, it does seem that an alarming rate of young throwers are going down with ulnar collateral ligament (UCL) injuries.
Over the past several seasons, many high profile baseball players, including Stephen Strasburg of the Washington Nationals, Matt Harvey and Bobby Parnell of the New York Mets, Jose Fernandez of the Miami Marlins among many others have suffered season ending UCL injuries. So far this year alone, 29 players have either underdone or are planning to undergo UCL reconstruction (also know as Tommy John surgery). MLBreports.com has attempted to collect a list of MLB players who have undergone UCL reconstruction, starting with Tommy John himself in 1974 up to the current date (http://mlbreports.com/tj-surgery/)?1. Just looking at the list, you can see how the incidence in major league baseball players has exploded over the years. A recent study in the American Journal of Sports Medicine out of Rush University in Chicago reported that from 2010-2013, an astounding 216 MLB pitchers underwent an UCL reconstruction.2
Growing up a competitive high school baseball player, I remember occasionally hearing about players injuring their elbow and undergoing Tommy John surgery, but is certainly was not a common occurrence, and it was certainly uncommon in high school and youth level sports. This begs us to ask several questions. First what is the ulnar collateral ligament and is there really an increasing rate of injuries in baseball players? If there is, what is causing these injuries and is there anything that we can do about it. What do we need to know about ULC reconstructions?
Famed orthopaedic surgeon and a pioneer of Tommy John Surgery, Dr. James Andrews at the American Sports Medicine Institute (ASMI) has published their rate of UCL reconstructions and were alarmed by the rate of these surgeries occurring in youth and high school athletes. Over the past decade approximately 20-30% of all Tommy John surgeries were performed in youth or high school athletes.3
As you can imagine, throwing a baseball is a complicated processes that uses the muscles to generate a tremendous amount of torque arm. Studies have shown that the velocity generated around the elbow can reach as almost 3000o per second!4 During the acceleration phase of throwing, the main restraint to this tremendous force at the elbow is the ulnar collateral ligament. The ligament can be injured with a single acute injury, but more commonly it seems repetitively overloaded until it ultimately fails. Athletes will often have pain on the inside of their elbow and notice a sharp decrease in velocity and endurance. Often this causes athletes to seek medical care.
Several factors have been shown to be risk factors for UCL injuries including poor throwing mechanics, fatigue, poor physical conditioning, early throwing of breaking pitches, improper warm ups, high velocity throwing etc. However, one risk factor that has stood out the most is overuse. The sheer volume of throwing that young throwers are doing these days seems to have a direct correlation to the rate of UCL injuries. Several studies have shown that pitching year round, pitching on multiple teams, playing catcher when not pitching are linked to increased UCL injury rates. When we perform these surgeries, the ligament often does not appear as if it has recently torn, instead it appears as if it has slowly worn out over time.
Dr. Andrews recently released an excellent Youth Baseball Position Statement with the hopes of curtailing this epidemic. Among his recommendations are to watch carefully for signs of fatigue and to follow pitch/inning counts to prevent overuse. He also recommends optimizing throwing mechanics; avoid the early use of breaking pitches and allow throwers to take 2-4 months off from throwing each year. Nowadays with year round baseball, this can be a tough proposition for an athlete. If there are signs of elbow or shoulder pain, throwing should be discontinued until a sports medicine physician can evaluate them. This is an excellent position statement and should be read by all athletes, parents of athletes, coaches and sports medicine professionals. It can be found at http://www.asmi.org/research.php.
Even with careful monitoring however, these injuries do occur. Unfortunately there are also many misconceptions about the surgery.5,6 One of the major misconceptions by players, parents and coaches is think that it will allow them to throw harder after surgery. While performance may improve after surgery, this is likely due to the fact that they were under performing with the injury prior to their reconstruction. Studies have shown that almost 20% of patients undergoing Tommy John surgery will never return to their previous level of throwing7 and these are in professional athletes with a huge amount of financial resources behind them including physical therapist, athletic trainers, personal trainers and a team of physicians.
So as the MLB season comes to a close and youth summer ball transitions to fall ball, we need to pay attention to the health of our throwing athletes. Athletes, parents and coaches need to be mindful of how many pitches are being thrown throughout the year and make sure that they get enough rest during the off season to allow their elbow to recover. With proper education and awareness of everyone, hopefully we can then prevent this epidemic of elbow injuries from continuing.
For additional information visit the MUSC Health Sports Medicine website.
1. Tommy John Surgery Tracker 1974 – Present: http://mlbreports.com/tj-surgery
2. Erickson BJ, Gupta AK, Harris JD, et al. Rate of return to pitching and performance after Tommy John surgery in Major League Baseball pitchers. Am J Sports Med. 2014;42(3):536–543. doi:10.1177/0363546513510890
3. Youth UCL Surgery “Tommy John Surgery”. AMSI. http://www.asmi.org/research.php?page=research§ion=UCL
4. Werner SL, Fleisig GS, Dillman CJ, Andrews JR. Biomechanics of the elbow during baseball pitching. J Orthop Sports Phys Ther. 1993;17(6):274–278. doi:10.2519/jospt.19126.96.36.1994.
5. Position Statement for Tommy John Injuries in Baseball Pitchers. AMSI. http://www.asmi.org/research.php?page=research§ion=TJpositionstatement
6. Ahmad CS, Grantham WJ, Greiwe RM. Public perceptions of Tommy John surgery. Phys Sportsmed. 2012;40(2):64–72. doi:10.3810/psm.2012.05.1966.
7. Cain EL, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38(12):2426–2434. doi:10.1177/0363546510378100.