Study: 'Staggering' number of youths having elbow surgery
By Delia O'Hara
Tommy John surgery, a surgical repair for injured elbows that has saved the careers of many a major league pitcher, might seem an extreme treatment for a high school athlete. But an epidemiological study has found that teenage pitchers now undergo more of the procedures than any other group. These results highlight the risk of overuse injuries in this age group.
Published last June in the American Journal of Sports Medicine, the study found that athletes aged 15 to 19 presently account for 56.8 percent of ulnar collateral ligament reconstruction procedures, commonly known as Tommy John surgery. The procedure takes its name from a pitcher who won more than half the victories in his 26 years in the major leagues after becoming the first person to undergo the procedure.
The overall average incidence of Tommy Johns during the period studied, 2007 to 2011, was just under four per 100,000 patients in the database the analysis used. However, the incidence for patients aged 15-19 was 22 per 100,000 patients, which the study’s authors call "a staggering statistic."
Cause for alarm
That rate is cause for alarm, says Charles Bush-Joseph, MD, a professor of orthopedic surgery at Rush University Medical Center and one of the study's authors. While the overall average annual use of the Tommy John procedure during the four-year period studied increased 4.2 percent for all patients — already remarkable — it went up 9.12 percent among 15- to-19-year-olds.
The ulnar collateral ligament, or UCL for short, is a band of tissue in the elbow that binds the upper and lower arm bones together. Damage to the UCL is typically an overuse injury, caused by throwing at extreme "intensity, duration and frequency," according to Bush-Joseph, who is also the head team physician for the Chicago White Sox.
"These young players are having problems due to increased frequency of throwing hard and aggressively," he says. “They’re playing too much, they’re playing when they’re fatigued, and their technique and conditioning may not be the best.”
Even serious young athletes "played (only) three to six months when I was young," Bush-Joseph recalls. "Sports are so competitive now that kids are playing (baseball) for nine to 12 months" every year, on travel teams and in multiple leagues, tournaments, showcases, indoor ball and other programs.
A growing concern
Before this study, good data was lacking on the incidence and demographic distribution of Tommy Johns in the Unites States. The new retrospective analysis, which used a private payer database, PearlDiver, found that Tommy John surgery was most often performed in the second quarter of the year — during the traditional high school baseball season — and performed far more often in the South than in any other region of the United States, echoing earlier research at Rush that showed that Major League Baseball players who grew up in the South are more likely to have Tommy John surgery as well.
That regional variation is likely due to the warm climate promoting year-round play, Bush-Joseph says. However, indoor baseball and travel teams are now extending the baseball season in places like Chicago, too, exposing more young Northern pitchers to possible damage from overuse, he says.
The next most likely group after teenagers to have Tommy John surgery is patients aged 20 to 24, who account for 22.2 percent of the procedures, the new study found.
Concern for these young athletes is running high in both the medical and baseball communities. The American Sports Medicine Institute has issued recommendations in its "Position Statement for Youth Baseball Pitchers" that include limiting pitching to no more than 100 innings per year, taking a break from overhead throwing for an optimal four months per year, and plenty of vigilance about rest and proper technique.
And Major League Baseball has launched its own "Pitch Smart" initiative, which includes guidelines for coaches, young players and parents to follow to avoid overuse injuries.
Surgery saves career, but doesn’t help them
Tommy John, a southpaw, had notched a 13-3 record for the Los Angeles Dodgers when he blew out his left elbow during the 1974 season. Since the late orthopedic surgeon Frank Jobe, MD, performed the first UCL reconstruction on John that year, the surgery has proved a boon to professional and amateur pitchers alike. The Yankees' Ivan Nova, Matt Harvey of the Mets and Arizona's Patrick Corbin are just three of the MLB pitchers returning to the mound this season after Tommy John surgeries.
One in four major-league pitchers (and one in six minor-leaguers) has undergone the procedure. So many of them have returned to compete at a high level that some think a Tommy John can actually improve a pitcher's performance.
A 2012 survey reported that 28 percent of college and high school players thought the surgery would improve a pitcher's performance above pre-injury level. About the same number of student respondents did not think overuse was a risk factor for a UCL injury. Among high-school players in the survey, 51 percent said they thought it was a good idea for healthy players, whose elbows were not injured, to have a Tommy John as a means to enhance their performance.
About 200 young athletes have come to Rush University Medical Center for the procedure after injuring their UCL, but Bush-Joseph says he also is asked "all the time" to perform Tommy Johns prophylactically on healthy players.
However, he cautions, the procedure does not actually enhance an athlete's performance. That perception probably arose because players typically perform better after a repair than immediately before one — because they are no longer injured, he explains.
Prevention beats repair
In fact, athletes who have the Tommy John surgery in high school have a higher risk of reinjuring themselves later, especially if they haven't corrected "whatever errors led to the tear in the first place," Bush-Joseph says.
Another perception he hears is that the injury is going to happen to a pitcher sooner or later — that it's inevitable — "but that's not true if care is taken," Bush-Joseph cautions.
The Chicago White Sox have the lowest incidence of Tommy Johns in the MLB, according to an analysis published on the ESPN website last April. Internists and orthopedic and sports medicine specialists from Rush have been serving as White Sox team physicians since 2004.
"We do have a higher prevention rate than most other clubs do," Bush-Joseph says. "As a ball club, we want the least injured reserved days we can have. Yes, one in four (MLB) players have had Tommy John surgery, but three out of four haven't had it. We're good at this surgery, but the goal is not to get injured in the first place. The idea is to train to lower the risk."