"Tommy John" surgery: a career-saving procedure for many pitchers

Mike Dodd

WRIGLEY FIELD, A LAZY WEDnesday afternoon in an early-season game last year between the San Diego Padres and Chicago Cubs.

Unexceptional, really, except for the starting pitchers with the four-inch long scars on the sides of their fight elbows.

Adam Eaton and Kerry Wood, with fastballs clocking in the mid-90s mph, pitch seven strong innings each and strike out a total of 23 batters. The box score--a 2-0 Padres victory--is testament to a career-saving surgery now as routine as it is remarkable.

The doctors call it a UCL--ulnar collateral ligament reconstruction.

Baseball players and fans call it Tommy John surgery, after the pitcher who was the first to have the surgery 30 years ago. By any designation, it is one of the major advancements in sports medicine in the last quarter century.

More than 75 pitchers who have appeared in the major leagues the last two seasons have the scar that goes with the injury and surgery--about one out of every nine.

Only about 20 percent of the UCL surgery patients of James Andrews, the renowned Birmingham, Alabama, orthopedic surgeon, are big leaguers. Another 20-25 percent are minor league professionals, but the majority are college or high school athletes.

These players typically perform as well, if not better, after the operation and have stronger arms, with radar gun readings to match.

"I hit my top speed (in pitch velocity) after the surgery," says Wood, the Cubs' 26-year-old All-Star. "I'm throwing harder, consistently."

"It felt so good when I came back, I said I recommend it to everybody ... regardless what your ligament looks like," Chicago White Sox reliever Billy Koch says jokingly. He blew out his elbow in his third professional appearance, in 1997.

A torn elbow ligament once was a pitcher's sentence to the broadcast booth or the monthly autograph show at the local Holiday Inn. No longer.

Andrews, who performed about 150 UCL reconstructions in the last year, says the success rate for major league pitchers is about 85 percent.

"It's pretty much a sure thing," says John, now pitching coach for the Class AAA Edmonton Trappers, a Montreal Expos affiliate.

"Tip your hat to modern medicine," says Toronto starter Pat Hentgen, who entered his second full season back from the surgery in 2004. "As far as the way my arm feels, it feels like it never happened."

Clubs are no longer wary of drafting pitchers who have had the surgery, and the Yankees went a step further in the winter of 2002. They signed free agent Jon Lieber, a former 20-game winner, to a two-year contract with $3.5 million guaranteed when he was just five months into his rehabilitation. "It showed me a lot about how far the surgery has come," Lieber says.

The surgical procedure hasn't changed much since it was pioneered by Frank Jobe for John in 1974. A tendon is removed from the patient's wrist or hamstring and grafted into the elbow--woven in a figure-eight pattern through tunnels drilled in the humerus and ulna bones.

Doctors typically complete the operation in about an hour--less than one-third of the time it first took--and an overnight hospital stay frequently is not required.

The procedure is not unlike that done for reconstructive surgery of the anterior cruciate knee ligament (ACL) that has revived the careers of many pro football players. "I call it the anterior cruciate (surgery) of the elbow," Andrews says. As an advancement, "Which one is more important? It depends whether you're a baseball player or a running back."

"The credit goes to Frank," says Lewis Yocum of Los Angeles, Jobe's partner and the other prominent UCL specialist. Yocum averages about 100 of the surgeries a year. Before the breakthrough, the sport saw top pitchers such as Sandy Koufax retire with elbow problems referred to simply as "the generic dead arm," he says.

"People with a torn ligament were sent back to the farm or wherever they came from," says Jobe, who still assists on the surgeries. "But Tommy didn't want to go."

Rehab for a career, not a year

Though the surgical procedure has been refined, the major advancements have come in the post-operative rehabilitation, increasing the success rate from about 60 percent a decade or so ago, Andrews says.

"We've learned how much you can accelerate them and how much you can't," he says.

The surgery requires a full year of rehabilitation and typically another year pitching before returning to pre-injury form.

Essentially, the body must convert a tendon into a ligament, get it carrying blood again and train it to start working as a ligament. (A ligament connects bones, stabilizing a joint. A tendon attaches muscle to the bone.) It is very weak immediately after the surgery, and the rebuilding process must be gradual.

The elbow is immobilized in a hard brace for about a week, then the patient begins exercises to regain limited range of motion the second week. By the second or third week, he can use the arm for everyday tasks like eating and combing his hair. He can start swinging a golf club after three months and usually begin a light-tossing program at four months.

The successful patients cite two important caveats: Don't go too fast, and don't ignore your shoulder as you rehabilitate the elbow. If you let it rip as soon as you think the arm feels ready, you'll be visiting Birmingham or Los Angeles again.

"A lot of guys feel so good after seven or eight months (they want to pitch), but the graft is not ready to withstand the force they generate," Yocum says.

"The key is not to push yourself. Just stay with the program," says Yankees reliever Tom Gordon, who had the surgery in December 1999. "You're not rehabbing for one (more) year. You're rehabbing to come back and make a career out of this thing."

Koch said he started isometric exercises on his shoulder while his elbow was still immobilized. It was annoying, he says, "but probably the reason I came back strong."

"A lot of guys come back and their shoulder is blowing up (inflamed) because you go six months without exercising your shoulder," Hentgen says.

Gordon adds: "You've got to take care of both and work both pretty much about the same. Otherwise you have so much strength in your elbow and not enough in your shoulder. Something's bound to happen."

The throwing program typically starts four months after surgery, but it can be a month earlier or two months later.

"With our organization, I didn't throw for six months after surgery," Hentgen says. "I had surgery in August (2001) and didn't pick up a ball until February 15 (2002)."

They look more like little leaguers in the first days. They start with two sets of about 15 throws from 45 feet, on flat ground.

"It was a real slow, tedious process," Koch recalls. "I remember waiting about five minutes before I threw the first pitch just because I was worried about throwing it."

Medically, most pitchers are ready to return to action in 12-15 months. Frequently, it's another year before they return to form.

"It takes a good two years to really have a good feel again," says Gordon, who struggled with tendinitis his first year back.

Orioles pitching coach Mark Wiley calls it getting the "feel of the ball." It's finding the arm slot, the release point, basically, learning how to pitch all over again. "They keep their heads above water and contribute but they're not as consistent" the first year back, Wiley says.

"We're doing now in a year basically what it takes us a whole lifetime to do (the first time)," adds Lieber, who was listed on the Yankees' 40-man roster last January with hopes of earning a spot in the rotation for the '04 season.

Like Wood, Gordon and Koch say, they throw harder than before the surgery. Koch, typically in the high-90s, has hit 108 and 103, according to various reports. But in his first season with the White Sox last season, struggled as their closer and couldn't maintain consistent velocity of his fastball.

A strengthened elbow probably helps. "Dr. Andrews said the tendon from my wrist was a lot longer than normal, so he was able to get an extra loop out of it in my elbow, making that new ligament extra thick," Koch says,

But it isn't the whole reason. Exercises to build the shoulder and forearm make the entire arm stronger. And sometimes, the patient simply matures physically.

The increased velocity "isn't always true by any stretch of the imagination," Andrews says: "For the ones that do it, the reason is all the hard work, all the throwing exercises and the development from all the exercises they'd probably never done before."

"I've seen guys come back better workers because now they've got a wake-up call," White Sox pitching coach Don Cooper says.

Most of the players say they can throw the same pitches post-surgery with basically the same mechanics. Wood is one exception.

"I really had to change the way I was throwing across my body," he says. "If I didn't fix that, I would eventually have the problem again. I don't have that big loopy slurve (combination curve-ball and slider) I was throwing early in my career, which is probably a good thing."

Widespread acceptance

As the success rate of the surgery increases, so does the number of cases. Ten years ago, doctors were more likely to recommend rest for a partial ligament tear. The numbers now favor surgery.

"The (non-surgical) success rate healing these partial tears is a lot lower than we initially thought," Andrews says. "It's at best a 50-50 chance they'll heal with conservative treatment."

Players can end up being hampered by the injury for two or three years, he says, as they rest the injury, then try to return.

"They yo-yo back and forth. They think they're well, they throw and they get sore. In a lot of these cases, we've now become more aggressive to go ahead and reconstruct them earlier," Andrews says.

"We're not reluctant, but we're still hesitant just to go do a surgical procedure because there's an old saying, There's nothing that can't be made worse with surgery.' It's a big operation, and they've got to commit to all this rehab and the length of time it takes to get well. It's a commitment on their part."

"Everybody expects it to be 100 percent. Sorry," cautions Yocum. "Guys go into the operation hoping for a cure. We're able to help the vast majority of them, but it's not 100 percent."

Today's survivors say they take nothing for granted, but they view the once-career-ending injury as just a line in the biography.

"A lot of times I forget I even had it," Koch says. "The only thing that reminds me is the scar."

Before & After
How six pitchers performed before and after "Tommy John" Surgery

Tommy John-Surgery performed in September, 1974

                           Year   Team             W-L     Svs   ERA

Best Year Before Surgery   1974   Dodgers          13-3      0   2.59
Best Year After Surgery    1977   Dodgers          20-7      0   2.78

Mariano Rivera-Surgery performed in August, 1992

                           Year   Team             W-L     Svs   ERA

Best Year Before Surgery   1992   Ft. Lauderdale   5-3       0   2.28
Best Year After Surgery    1999   Yankees          4-3      45   1.83

Kerry Wood-Surgery performed in April, 1999

                           Year   Team             W-L     Svs   ERA

Best Year Before Surgery   1998   Cubs             13-6      0   3.40
Best Year After Surgery    2003   Cubs             14-11     0   3.20

John Smoltz-Surgery performed in March, 2000

                           Year   Team             W-L     Svs   ERA

Best Year Before Surgery   1996   Braves           24-8      0   2.94
Best Year After Surgery    2003   Braves           0-2      45   0.87

Matt Morris-Surgery performed in April, 1999

                           Year   Team             W-L     Svs   ERA

Best Year Before Surgery   1997   Cardinals        12-9      0   3.19
Best Year After Surgery    2001   Cardinals        22-8      0   3.16

Eric Gagne-Surgery performed in April. 1997

                           Year   Team             W-L     Svs   ERA

Best Year Before Surgery   1996   Savannah         7-6       0   3.28
Best Year After Surgery    2003   Dodgers          2-3       55  1.20

Matt Mantel-Surgery performed in May, 2001

                           Year   Team             W-L     Svs   ERA

Best Year Before Surgery   1999   Marlins/Ari.     1-3      32   2.76
Best Year After Surgery    2003   Diamondbacks     5-4      29   2.62

Tommy John-Surgery performed in September, 1974

                           Year   IP       SO

Best Year Before Surgery   1974   153.0     78
Best Year After Surgery    1977   220.0    123

Mariano Rivera-Surgery performed in August, 1992

                           Year   IP       SO

Best Year Before Surgery   1992    59.1     42
Best Year After Surgery    1999    69.0     52

Kerry Wood-Surgery performed in April, 1999

                           Year   IP      SO

Best Year Before Surgery   1998   166.2   233
Best Year After Surgery    2003   211.0   266

John Smoltz-Surgery performed in March, 2000

                           Year   IP      SO

Best Year Before Surgery   1996   253.2   276
Best Year After Surgery    2003    64.1    73

Matt Morris-Surgery performed in April, 1999

                           Year   IP      SO

Best Year Before Surgery   1997   217.0   149
Best Year After Surgery    2001   216.1   185

Eric Gagne-Surgery performed in April. 1997

                           Year   IP      SO

Best Year Before Surgery   1996   115.1   131
Best Year After Surgery    2003    82.1   137

Matt Mantel-Surgery performed in May, 2001

                           Year   IP      SO

Best Year Before Surgery   1999   65.1    99
Best Year After Surgery    2003   55.0    68

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