Updated: May 5, 2022
On his most recent podcast, Eric Cressey talked about the myth that having Tommy John surgery (ulnar collateral ligament or UCL reconstruction) allows pitchers to throw harder. This was something that I heard growing up, but I would have never voluntarily had my elbow cut open just to throw harder. I thought that even if it was true, who would be willing to do something like that?
As many of you know, I went to the University of Miami for my doctorate (let’s go Canes) and while there I saw some high level athletes. I think that Northern Virginia has some special athletic talent, but Miami is a whole separate animal. Anyway, the point of this story is that we had a kid come in for elbow pain once and he was probably 14 or 15 years old. His dad mentioned that he was contemplating having Tommy John surgery so that he could throw harder. His dad’s logic was that he was probably going to get the surgery eventually anyway, and he might as well get it over with now. We tried to tell him there were other avenues to go down before surgery, but they didn’t seem very interested in waiting for physical therapy to help.
The problem with people thinking that surgery will help them throw harder is one of education. As healthcare professionals, we need to do a better job of teaching people that there are problems with surgery. The main issue is the replacement of your native UCL. Whatever the physician puts in its place is never going to be as strong as your own ligament. Oftentimes, the physician will take your palmaris longus tendon to create a new ligament. The palmaris longus is a very thin muscle in your forearm that you can see if you squeeze your thumb and pinkie together. It is the thin tendon you see popping up in the picture below:
Interestingly, the muscle is absent in 14% of people because it does not play a crucial role in anything. In that case, the physician will use another tendon, usually one of your hamstrings.
Anyway, tendons and ligaments have different structures. Your tendons connect muscles to bones, while ligaments connect bones to bones. They have different collagen alignments and several other factors. When a ligament is replaced with a tendon (such as in Tommy John or an ACL repair), the tendon undergoes “ligamentization”. This means that the tendon transforms into a ligament to the best of its ability. The exact timeline depends on the person, but it typically takes 12 weeks to occur (that’s why you need to be careful with a lot of activity before 12 weeks!).
The key thing to focus on is that the tendon will never be exactly the same as the ligament that it is replacing. We also tend to think that surgeries like Tommy John or ACL repairs have a perfect success rate. They do not. ACL re-tear rates can be around 20% and UCL re-tears can occur in 15% of patients. While these numbers are great, there is still a 1 in 5 chance of a re-tear; would you want those odds? Also, a second repair is much harder and has much worse outcomes. Think of all the damage and trauma from the first injury and surgery, now do it again. The surgeon may have to drill even more holes in the bone, it’s not ideal.
So then why do some people throw harder after surgery? Well a number of factors are at play, but it’s important to remember that rehab can last anywhere from 12-18 months before you are pitching in a game after surgery. So what can change in that time?
You will get 1-1.5 years older. This may seem very obvious, but think about how much you change in a year. A study by Sgroi et al. showed that pitching velocity went up 1.5 mph for every year of age and 1.2 mph for every inch of height. So let’s say you take 18 months to return from Tommy John surgery and grow 2 inches during that time (completely reasonable during a growth spurt). Your velocity would increase by over 4.5 mph! Now is that an exact science? Absolutely not, but it makes sense that longer levers would let you throw harder.
Another benefit to Tommy John surgery is time off from throwing. Mental and physical fatigue are a real problem with young athletes, and time away from the field can be a good thing. Unfortunately, more and more athletes are not taking time off from throwing even from a young age, and they end up pitching continuously for years at a time. Think about squatting, are you able to squat a couple times a week for years at a time? No, and if you are then you are doing it wrong. Our bodies need breaks and deloads (a subject of another post). So, by taking time off from pitching, your body may finally be getting the rest that it needs.
The final point and what I think is the most crucial, is actually having time off to look at other issues. It can be almost impossible to make significant improvements in strength or mobility during the season due to busy schedules and fatigue from playing. The off-season is just beginning now for athletes in this area (early to mid November) and the season will typically begin in late February or early March, which gives roughly 3-4 months off. If we factor in some time to actually rest from the season, we are only looking at a couple months to make drastic improvements. What if instead, the athlete were to take a whole year off from competition? This is what happens with Tommy John surgery. All of a sudden, everything is planned out for the next 12-18 months knowing that competitive games won’t be played. You now have several months to work on lower body strength or mobility before picking up a baseball again. This can be valuable time to dive into your entire body to find any weak links in the kinetic chain.
In summary, the actual act of having Tommy John surgery will not make you throw harder. Everything that goes into proper recovery and preparation has the potential to make you a better player when you return. My question is: what if we used similar planning and strategies without actually having surgery. What if, instead of not having a plan and just trying to survive the season, we made a plan to continue developing during the season with a peak during playoffs, showcases, etc. I believe that is the future of player development at the lower levels, and at Eclipse, we try to implement these strategies. Gone are the days of getting in to lift whenever you are able and now we are entering the era of better scheduling with an eye towards long term development. We can use lessons learned from typical rehab programs and implement them in healthy athletes. Imagine if we could get all of the benefits from a Tommy John surgery without having to cut you open?
Are you in Northern Virginia and looking to recover from or prevent UCL Reconstruction or UCL Repair surgery? Reach out and let me know!
Written by Danny Lehnert PT, DPT, OCS, CSCS, CDN, BRM