Updated: May 5, 2022
As healthcare professionals, we tend to rest on our laurels. We become comfortable with certain outcomes if they fall within our expectations. I believe that we fall victim to survivorship bias when it comes to post-surgical outcomes. If you are unfamiliar with the survivorship bias, let me give you an example.
But first, let me ask you a question. What do you think is the return to pitching rate of MLB pitchers who have Tommy John surgery? In other words, how many make it back to pitching in a MLB game? One more question for you: how many innings do you think that those pitchers throw on average after surgery in their career?
Think about your answers for a second before reading further.
Here are the answers: MLB pitchers return to pitching after Tommy John surgery 80-97% of the time(1). That seems like a great statistic, right? However, if we dig a little deeper into the numbers, as Jon Roegele did, we see that the average MLB pitcher who comes back from Tommy John surgery only pitches in 60 games and throws 100 innings (these statistics were from the years 2000-2009) (2). As he pointed out, that is what we expect from a good season for a reliever. That was the average career of MLB pitchers after having Tommy John.
Now to get back to survivorship bias: name a pitcher who has undergone Tommy John surgery. Chances are you named an elite pitcher or Stephen Strasburg (sorry, I couldn’t resist).
You probably did not think of the end of the bullpen pitcher who had Tommy John and never made it back, or the fifth starter who faded into oblivion. We are biased by the success stories of pitchers who underwent surgery, and we forget about the failures.
Another point to consider: these numbers are for MLB pitchers. These are the premier athletes in the sport with the best financial and medical resources available to them. If the numbers are this bad for these athletes, what chance does a high school kid have? MLB teams invest millions of dollars into their athletes and will go to great lengths to help them succeed. If you are a high school junior and tear your UCL, college coaches probably don’t have a whole lot invested in you. It’s a lot easier to cut bait on a player who isn’t part of a program yet.
Unfortunately, I mostly see athletes around the middle school to college age, when they don’t have great resources or time to commit to getting back on the field. In my opinion, these athletes need the most help, but they are often given the least. Chances are, if you have surgery, the physician will give you a return to throwing program. There is a high likelihood that it is a copy of a protocol established by Dr. James Andrews (3). Here is where the resting on our laurels really comes into play. Do you know when this return to throwing protocol was published? 2002. Most of the athletes I see weren’t even born by 2002. You know what other data comes from the early 2000s? The return from Tommy John information I cited above.
It seems like we have settled on a preferred rehabilitation and return to throwing program for UCL repair surgery and deemed our job completed.
Let’s take a closer look at the typical return to throwing program. On the first couple days of throwing, the program calls for warming up with 10-20 throws at 30 feet, making 25 throws at 45 feet, resting 5-10 minutes, and then doing that again. By my calculations, that is at least 70 throws on your first day back throwing. Typically, you do not return to throwing until 4 months after surgery at the earliest. Most athletes didn’t throw much before surgery (due to their UCL being torn), but let’s be generous and say someone didn’t throw for 4 months. Imagine not throwing for 4 months and then making 70 throws. Also, do that after major surgery to your elbow. That seems a bit counterintuitive.
Also, this program is written for anyone above Little League age. However, the 13 year old and 30 year old elbows are vastly different. If someone’s long toss was 120 feet before surgery, shouldn’t they have a different starting point compared to someone who could throw 300 feet?
So what is the answer? Do we accept a system that is good, but not great, particularly for younger athletes?
The answer is simple really, we need more individualization. We should not be treating the 13 year old like the 30 year old. We can quantify arm stress with tools like Pulse to measure individual arm stress. Also, it is important to gradually introduce throwing and load with plyoballs, footballs, and other equipment before even introducing a baseball to the equation. Lately, I have also been getting a lot of use out of the Pocket Path by Dave Coggin.
All of this is to show that individualization is key along with a clear process involving a team. Too often, an athlete gets surgery, goes to physical therapy, and then is discharged to throw on their own or with their coach. There needs to be more communication between parties and overlap to allow for the addressing of individual needs. Many clients still see me for “physical therapy” even after they have returned to throwing because issues will come up that need to be addressed. Think about an MLB team: the trainer, pitching coach, surgeon, and physical therapist are in constant communication about each athlete.
Our goal at Eclipse is to bring the professional model to the people who need it most. Hopefully, this becomes the norm in the healthcare industry, but right now I often see disjointed and outdated approaches from providers. This is disappointing because we have the tools and ability to do better for our athletes.
If you have any questions about return to throwing or anything else that I brought up, leave a comment below or email me at firstname.lastname@example.org
1 Thomas SJ, Paul RW, Rosen AB, et al. Return-to-Play and Competitive Outcomes After Ulnar Collateral Ligament Reconstruction Among Baseball Players: A Systematic Review. Orthop J Sports Med. 2020;8(12):2325967120966310. Published 2020 Dec 28. doi:10.1177/2325967120966310
3 Reinold, M. M., Wilk, K. E., Reed, J., Crenshaw, K., & Andrews, J. R. (2002). Interval sport programs: guidelines for baseball, tennis, and golf. Journal of Orthopaedic & Sports Physical Therapy, 32(6), 293-298.