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What’s Tommy John Surgery

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Noah Syndergaard will undergo Tommy John surgery on his right elbow and is expected to be out until at least April 2021, per @JeffPassan

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Before that first surgery in 1974, players who complained of having a dead arm were told their only option was retirement. Many believe the great Sandy Koufax, who retired at age 30 from an arthritic elbow, would have been able to pitch longer had the surgery been available.

Tommy John surgery has extended many careers and earned those players millions of dollars since 1974. For Atlanta Braves great John Smoltz, the operation allowed him to continue his career and pitch nine more seasons, appear on five All-Star teams and earn induction into Cooperstown in 2015. Hes the first pitcher to have the surgery and make it into the Hall of Fame.

Unfortunately, the rate of Tommy John surgeries doesnt appear to be slowing down. In 2019, there were 18 surgeries performed on MLB players. Just three months into 2020, including Syndergaard and Sale, six MLB players have gone under the knife for the procedure. According to one report, since Johns first surgery, there have been 473 MLB players who have had the surgery, once if not multiple times.

Why Is It Called Tommy John

There was a Major League Baseball pitcher named Tommy John who made his MLB debut at age 20 in 1963. He played for various MLB teams like the Indians, the White Sox, the LA Dodgers, the Yankees, the California Angels, and the Oakland Athletics.

In 1974 Tommy John suffered from an injury, a damaged UCL in his elbow. He was the first to ever receive surgery to repair his UCL. The operation was successful and saved his baseball career and pitching arm.

After just over a year of recovery, Tommy John went on to continue his career in the MLB until his retirement 26 years later in 1989. He had success following his surgery with appearances in multiple World Series and winning the AL All-Star, NL All-Star, NL Player of the Month, the hutch award, and the Lou Gehrig Award.

Since Major League Baseball player Tommy John was the first to receive UCL reconstructive surgery that is why it is now referred to as Tommy John Surgery.

What Causes Ucl Injury

The UCL is the major stabilizer of the elbow and repeated motion can cause it to break down and wear away over time. If Tommy John Surgery is recommended, it usually means overuse caused the UCL to fray, tear or become loose. The arm and elbow will not be able to be used without extreme pain if the UCL is loose.

A fall on an outstretched arm can also cause stretching, fraying and small tears in the UCL.

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How Is A Ucl Injury Diagnosed

Most people will have tenderness on the medial side of the elbow. Other causes of tenderness include medial epicondylitis and ulnar neuropathy . Athletes with a UCL tear will have a positive moving valgus stress test which is an exam that can be done in the office by a trained sports medicine specialist. This test basically mimics the stress that is placed on the elbow during throwing and reproduces the pain that is experienced by the patient. In addition to a good physical exam, stress x-rays and an MRI are usually obtained to confirm the diagnosis.

How The Surgery Is Performed

How Tommy John surgery works

Tommy John surgery is performed by using a grafted tendon to replace the damaged ligament. The surgery begins with an incision on the inside of the elbow joint. Then a healthy tendon is harvested from another area of the patientâs body or a donated tendon is prepared. Next, the damaged ligament is removed and replaced. Finally, the incision is stitched up and the elbow is placed in a large bandage. A typical Tommy John procedure takes 90 minutes. Because the surgery is an outpatient procedure, patients can also return home the same day.

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Who Is Tommy John

Tommy John is a former Major League Baseball pitcher. In 1974, he became the first to have this procedure done on an elbowall because his surgeon improvised after realizing the UCL he was about to repair was gone due to wear and tear.

One year after surgery, John returned to pitching professionally and continued until 1989. His successful, unprecedented, and surprising recovery led to the surgery coming to bear his name.

Pain Management After Surgery

After your surgery, you will have some pain. However, you can take over-the-counter pain and anti-inflammatory medications, to keep the swelling down.

You should also have your elbow in an elevated position. During your physical therapy is when youll experience the most pain. However, your therapist will work with you to optimize mobility while still keeping you comfortable.

If you feel a significant level of pain at any point during your therapy, immediately alert your physical therapist. This could be a sign of inflammation and needs to be treated carefully to reduce further damage.

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What Is The Ulnar Collateral Ligament

Collateral ligaments are the outer and inner ligaments that hold the elbow joint in place. Specifically, the ulnar collateral ligament is the ligament that connects the inner side of the humerus bone to the inner side of the ulna bone . This ligament stabilizes and supports the elbow and makes it possible to perform motions like throwing a ball.

The Benefits And Risks Of Tommy John Surgery

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A professional baseball pitcher throws tens of thousands of full-force pitches over the course of their career. These athletes depend on their ulnar collateral ligament , a tiny band of tissue located in the elbow, in order to repeatedly and consistently pitch at speeds of 90 mph or more. Over time however, the force generated by their throw and the repetitive stress of pitching can cause a UCL to tear. A UCL tear inhibits a pitcherâs ability to grip a ball, perform overhead motions, and throw with the speed necessary to compete.

Fortunately, UCL tears are no longer the career ending injuries they once were. Ulnar collateral ligament reconstructionâbetter known as Tommy John surgery after the Dodgers pitcher who first received the surgery in 1974âcan effectively treat a tear. During the surgery, the damaged UCL is completely replaced with a healthy tendon, providing effective relief of the patientâs symptoms. However, Tommy John surgery is not always necessary for UCL injuries, and like all surgical procedures, there are risks of complications. Itâs important to know the benefits and risks of Tommy John surgery in order to guide your discussion with an orthopaedic specialist.

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Recovery And Recovery Time

Since people may heal differently, it can be challenging to pinpoint an exact Tommy John Surgery recovery time. Some places say athletes should wait six to nine months before returning to competitive throwing and nine months to a year before actually competing again. Generally, its safe to say most UCL reconstruction recoveries take about a year, although some athletes need up to two years to get back to the level they were at before the surgery.

During recovery, its crucial to stay in close contact with your doctor and physical therapist, as they can assess your progress and personalize your recovery plan. However, you can think of Tommy John Surgery recovery in four main phases, which follow.

How Do Ucl Injuries Occur

In throwing athletes, like pitchers, the UCL is put under major stress when you pitchor throw overhand. The UCL stabilizes the elbow during throwing, along with several muscles, nerves, and tendons overuse and overstress of the UCL can lead to injury.

What Happens During the Procedure?

During Tommy John surgery, your doctor will take a tendon from another part of your body and use it to repair the injured UCL. The tendon may come from below your knee or from the forearm of your uninjured arm. In some cases, tendons are used from cadavers. Unless you receive a cadaver tendon, youll have incisions in two areas on your body: where the healthy tendon was removed and where the UCL was repaired.

When Can I Return to Activity?

If you undergo Tommy John surgery, your chances of returning to your sport are very good. In fact, some pitchers even report that they throw better after the procedure, possibly due to rigorous rehabilitation .

According to a study published in April 2014 in The American Journal of Sports Medicine, 80% of 147 Major League players evaluated were able to return to competition after Tommy John surgery. Another study published in the same journal also found a high rate of return to pitching and that pitchers tended to perform better after surgery than before.

It may take some time for you to return to a high level of play, but youll be rewarded for your patience and hard work with a healthy throwing arm!

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Risks Involved In Tommy John Surgery

Like any other surgery, Tommy John surgery also has some risk factors and complications involved. For instance, bleeding and blood clots can occur.

An infection could also occur after surgery that could lead to severe complications. Its important to note that these complications are present in all surgeries.

However, by choosing the right surgeon and closely following your post-op instructions, these can be minimized. More specifically, the complications directly associated with Tommy John surgery are:

  • Temporary weakness and numb feeling
  • Re-injury that will require another surgery
  • Pain and discomfort when throwing
  • Lower mobility that prevents you from fully extending the elbow

As stated previously, these complications can be avoided by following your surgeons instructions and doing physical therapy. If you have a history of blood clots, tell your surgeon so they can administer the proper medications.

Impact Of Tommy John Surgery

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John went on to win 164 games after having the surgery, 40 more than before. His successful comeback proved once and for all that baseball players could still be successful after undergoing major surgery. In 2012, Lindsey Berra of ESPN noted that roughly one in seven major league pitchers had undergone Tommy John surgery at some point in their careers. “It’s become an accepted side effect of the job,” said George Paletta, team physician for the St. Louis Cardinals. Doug Miller of MLB.com wrote that “baseball history was altered some would say saved forever” when John returned from his recovery, observing that “Today, the tearing of a pitcher’s ulnar collateral ligament is no longer a career-ending calamity.” ESPN personality Dan Patrick and longtime baseball commentator Bob Costas discussed the impact that Tommy John surgery has had on the game, stating in 2012 that there could be a case for John being awarded the Buck O’Neil Lifetime Achievement Award. The initial Tommy John surgery, John’s subsequent return to pitching success, and his relationship with Dr. Jobe was the subject of an ESPN 30 for 30 Shorts documentary in 2013.

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What Does The Tommy John Surgical Process Look Like

Most ligament tears cannot be stitched back together, so they will have to be reconstructed. The torn ligament is replaced with a tissue graft . Tommy John Surgery can be done arthroscopically or through open surgery. Which method is chosen will depend on a variety of factors, such as the size/severity of the tear and the patients medical history.

The patient will be put under general anesthesia while the 60-90 minute surgery takes place. Generally, there are three phases of the Tommy John Surgical process:

  • Harvesting the GraftThe tissue graft will be harvested from another part of your body or from a donor/cadaver. It is typically taken from a tendon either in the forearm or hamstring.

  • Cleaning Out the JointAfter your surgeon assesses the internal injury, damaged tissues will be removed. If applicable, the surgeon will attach the remnants of the original ligament to the tissue graft, reinforcing the structure.

  • Securing the GraftTwo holes are drilled into the humerus and ulna bones in order to attach the new tendon. The graft tendon is then threaded through the holes and secured by sutures, buttons, or screws.

  • The patient will be able to go home the same day if all goes well.

    Why Do So Many Pitchers Need Tommy John Surgery

    Throwing a baseball at high speed places tremendous strain on the arm, especially for those who do it 90 or 100 times a game, on more than 30 occasions each season.

    Imagine revving your cars engine up to 9,000 RPMs, Kearns said. Thats kind of what youre doing to that elbow.

    Some players need Tommy John surgery because theyve suffered acute tears in the ligament. More often, the ligament has simply become stretched out, Osterman said.

    Your ligament is lined up with pieces of collagen, kind of like a rope, he said. That rope kind of gets frayed like an old clothesline over time.

    Signs of injury can include pain inside the elbow, along with a decline in pitching velocity and accuracy. In recent years, this type of damage is occurring more often in teenage pitchers, because they throw too much before building up the necessary strength, the surgeons said.

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    What Is The Success Rate Of Tommy John Surgery

    Boston Childrens Hospital reported that the success rate of Tommy John surgery is 80 to 90 percent. Similarly, The American Journal of Sports Medicine conducted a study on a total of 179 pitchers who underwent Tommy John surgery. The study found that 148 pitchers returned to pitching in the MLB, 174 pitchers were able to RTP in the MLB and minor league combined , with only 5 pitchers unable to RTP to either the MLB or minor league.

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    What Can I Expect When I Have A Tommy John Surgery

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    After you schedule surgery, you may need a pre-surgical physical to make any necessary accommodations based on your health history. When you arrive at the hospital, youll speak to your surgeon and anesthesiologist. You will likely be under sedation with a nerve block in the arm for this procedure. This is an outpatient surgery, so you will go home the same day.

    Following the procedure your arm will be placed in a cast or splint with you slowly beginning to move your arm. You can return to most normal activities, including driving, when you are off the pain medicines, typically one to two weeks. After the cast or splint is removed , physical therapy will help you gain back your range of motion and strength. Your therapy will also focus on strengthening your shoulder and core, so there is less load on the elbow when you recover.

    Tommy John surgery has a long total recovery process. It is typically a full year before athletes are throwing at 100 percent, but it may be more or less depending on the individual.

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    What Are The Symptoms Of A Ucl Injury

    The UCL can be injured during a single stressful event or it can slowly stretch out over time. Sometimes a pitcher may feel a pop in the elbow during a pitch followed by the immediate onset of pain, swelling, and possibly bruising. The more common presentation, however, is an insidious onset of symptoms that include pain during throwing that may result in a loss of pitch velocity and accuracy.

    Tommy John Surgery Success Rate

    The success rate for baseball players is significantly high when Tommy John surgery is performed. In fact, after Tommy John surgery, about 83% of players are able to return to Major League Baseball.

    Its important to mention that a full recovery can still affect your pitching performance. There is also a possibility for re-injury, which can lead to other surgeries. Nevertheless, the advances of this surgery are continuing every year.

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    Tommy John Surgery Cost

    The costs for any reconstructive surgery depend on the severity of your injury, the surgeon, and your insurance plan. However, there are rough estimates of the cost of Tommy John surgery.

    For starters, non-surgical treatments can range from $500 to $5,000 with health insurance. Unfortunately, the cost of non-surgical treatments goes up without insurance. On average, these treatments can range from $10,000 to $26,000 or more.

    The cost of Tommy John surgery usually ranges between $15,000 to $50,000. However, an exact number cannot be given without talking to your health insurance provider. The overall price may be significantly lower, but it all depends on your health coverage.

    What Does Tommy John Surgery Involve

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    In short, Tommy John surgery involves harvesting a tendon from the patients body and attaching it to serve as the new UCL. The harvested tendon, or graft, can be taken from various tendons in the body. Tommy John surgery is usually a 60-90 minute outpatient procedure performed under general anesthesia.

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    Q: At What Point Does Surgery Become Necessary To Repair An Elbow Injury

    Dr. ElAttrache: Surgery becomes necessary when we can’t help the pain with nonsurgical treatments like rest, ice, and physical therapy. We’re seeing an increased number of patients needing this surgery due to more sports specialization and year-round play from a younger age.

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