The misperceptions of Tommy John surgery

Editor's Note: Dr. Geier is Director of MUSC Sports Medicine and an orthopaedic surgeon. He writes a sports medicine column for The Post and Courier.

Opening day in Major League Baseball is Thursday. It is a time of hope, as fans in all major league cities dream of pennants and World Series titles. Unfortunately, for the second straight year a perennial playoff hopeful saw its playoff hopes jeopardized before the season ever started.

Last year, Minnesota Twins pitcher Joe Nathan suffered an elbow injury in spring training and missed all of last season after undergoing Tommy John surgery. This season saw St. Louis Cardinals ace Adam Wainwright suffer a similar fate. And the most promising pitching star to arrive in baseball in years, Stephen Strasburg, was also lost to Tommy John surgery midway through last season.

Despite these high-profile injuries, a tremendous amount of misunderstanding about the injury itself seems to exist. I mentioned in a previous column a high school pitcher featured on ESPN's "Outside The Lines." The pitcher argued that he could pitch as hard as he wanted and as often as he wanted because he could always have surgery if he ever got hurt. A new study suggests that this athlete's misperceptions about Tommy John surgery are very common.

A Tommy John injury means that a pitcher has partially or completely torn his ulnar collateral ligament on the inside of his elbow. That ligament experiences tremendous force placed on it with repetitive throwing, especially with increased pitch counts and off-speed pitches over many years. Typically the ligament doesn't heal, and rehab often does not help elite pitchers return effectively, so surgery is indicated. The surgery, nicknamed after the first professional athlete to undergo the operation, involves taking a tendon from another part of the body (usually the wrist) and using it to make a new ligament on the inside of the elbow. Rehab is lengthy, requiring 12 months or longer to return to pitching. It is often the second season back before the pitcher feels he is back to normal.

The study, done by Christopher S. Ahmad et al., surveys 189 baseball players (ages 10-23), 15 coaches and 36 parents. A large percentage of respondents had significant misperceptions of the injury. First, 24 percent of players, 20 percent of coaches and 44 percent of parents thought a player could return to pitching within nine months of surgery. Also, in terms of risks, a huge percentage of players, parents and coaches did not believe that increased pitches thrown or off-speed pitches contributed to risks of UCL injury.

More surprisingly, the study demonstrated that the respondents overestimated pitching performance after surgery. A significant percentage of players, coaches and parents believed that control, speed and performance would improve after surgery.

And nearly 5 percent of the group thought Tommy John surgery should be performed on players without injury in order to enhance performance.

The problem with the argument that control and velocity improve after surgery is that UCL injuries are rarely acute events but rather overuse injuries that often manifest over several years. The pitcher's velocity decreases and control declines as his elbow becomes more painful. When he gets back to full pitching, he compares his "new" performance to his impaired performance just before surgery, not what it was when his elbow was healthy. And there is no evidence nor belief among sports medicine surgeons that Tommy John surgery to reconstruct a normal, non-injured elbow will improve performance or is even a reasonable idea.

The worrisome aspect of this entire problem is that UCL injuries are somewhat preventable injuries, especially for younger athletes. And the misperceptions of UCL injury and surgery, as the study demonstrates, might explain why kids aren't afraid to take chances. Unfortunately, watching their friends play while they are sitting on the bench for a year or more is a bad way to learn the realities of Tommy John surgery.

For more information about pitching injuries and other sports medicine topics, please go to Dr. Geier's blog at drdavidgeier.com.