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I am sure that most readers of this column have heard of Tommy John surgery (TJS), but before delving into that procedure, let’s first look at the anatomy of the elbow. Because the radius and ulna, the two bones of the forearm, cross over each other, we usually look at the forearm with the palm up and the thumb facing out. That way they are uncrossed. The radius extends from the elbow to just below the base of the thumb, while the ulna runs from under the elbow (the bony bump at the bottom of the elbow is the olecranon, part of the ulna) to the base of the palm opposite the thumb. The ulnar collateral ligament, or UCL, connects the end of the humerus, the upper arm bone, to the ulna. Throwing or pitching a ball, especially a baseball, puts extreme tension on the UCL. Over time, repeated strain on this ligament may cause it to tear. This destabilizes the elbow and makes throwing a ball nearly impossible.

Until 1974, a torn UCL usually meant an end to one’s sports career. A surgical procedure to repair a torn UCL with either a ligament from another part of the body or a donor graft, usually from a cadaver, was invented by Dr. Frank Jobe, team physician to the LA Dodgers. Dr. Jobe’s first test patient was Dodger’s pitcher Tommy John. The procedure, performed in 1974, allowed John to return to pitching after an extended period of rehab. Dr. Jobe put the odds of the procedure being successful at 100 to 1, but it worked, and since then this procedure has been done thousands of times. By 2009, the odds of successful recovery from TJS were 85 to 92%. Baseball pitchers usually need 12 to 15 months of rehab, while other players need about 6 months. 80% of pitchers return to pitching, however after two procedures about 35% do not.

Research has shown that a torn UCL is an overuse injury. It was thought that certain pitchers, for example those who throw sliders, are more prone to the injury, but studies have proven that it is the number of pitches thrown that determines the risk of injury. This has led USA Baseball, MLB, and Little League Baseball to initiate the Pitch Smart program. This limits the number of pitches younger players can throw. It has also led to fewer cases of “Little League elbow,” an injury in which the epiphyseal plate (the “growth” plate at both ends of every bone in a child’s body), rather than the UCL, tears. This is a non-surgical injury that can be the end of a young player’s career. Because some pitchers report that their arm is stronger after TJS, some parents of young players have asked physicians to perform it on their uninjured child, but thankfully most of those requests are turned down.

A few words about Thomas Edward John, aka the “Bionic Man,” born May 22, 1943. He pitched in the majors from 1963 to 1989 with the Indians, White Sox, Dodgers, Yankees (twice), Angels, and A’s. He tore his UCL in 1974 pitching for the Dodgers against the Expos. He missed all of 1975, but won 164 games after returning from surgery, 1 win less than Sandy Koufax’s total # of wins. He won 288 games overall, which is the second highest number of wins by any pitcher since 1900 who is not in the Hall of Fame.

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 By Peter Galvin, MD

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