Cunningham: Baseball pitchers and the need for ‘Tommy John Surgery’ |

Cunningham: Baseball pitchers and the need for ‘Tommy John Surgery’

Dr. Rick Cunningham
Special to the Daily

It seems that a lot of baseball pitchers go on to have Tommy John Surgery. What injury do they sustain and what sort of surgery is this?

Tommy John Surgery is an orthopedic surgical procedure to reconstruct the ulnar collateral ligament (UCL) of the elbow. Dr. Frank Jobe first performed this surgery on Major League pitcher Tommy John in 1974, and Tommy John was then able to continue successfully pitching in the Major Leagues until 1989.

The UCL is a ligament on the inside or medial side of the elbow that must resist tremendous forces when a pitcher throws a baseball. The UCL is made up of three bundles and the anterior bundle is the all important bundle that resists forces in pitchers.

Most throwing athletes experience pain in the late cocking and acceleration phase of throwing. The UCL sees tremendous forces during these phases of throwing. Not only does the UCL counter these forces but the flexor-pronator muscles of the forearm also resist these forces.

Throwing athletes can injure their UCL either acutely, often experiencing a “pop,” or through chronic wear and tear. Most throwing athletes present with vague pain on the inside of the elbow, and in these cases, the ligament is chronically attenuated and elongated. Patients may also experience numbness in their hand. In the office, patients are evaluated to see if they lack full elbow straightening or extension. On examination, athletes with a torn UCL demonstrate elbow laxity and instability on stressing of the UCL.

As part of the workup of these injured throwing athletes, radiographs are obtained in order to look for elbow arthritis, spurs and bony avulsions. An MRI is very helpful in detecting if the UCL is torn.

With baseball becoming a year-round sport even at the youth level, limiting pitching in players is critical to try to prevent UCL tears and other elbow and shoulder injuries. USA Baseball has published recommended pitch counts for youth athletes. Young pitchers should be limited to pitching 100 innings in any calendar year. The literature is inconclusive on whether throwing breaking balls increases the incidence of UCL tears. However, all studies show that overuse is the main cause of UCL and other elbow injuries.

Partial UCL tears can usually be treated nonsurgically with rest and rehabilitation. If nonsurgical management fails, Tommy John surgery consists of harvesting a tendon graft, typically from the patients forearm. This tendon is then passed through small drill holes in the bone that replicate the native attachment sites of the UCL. Physical therapy is critical to success after UCL reconstruction surgery. UCL surgery does not improve pitching performance, but the surgery has been very successful at restoring many pitchers back to their same level of competitive throwing.

Dr. Rick Cunningham is a Knee and Shoulder Sports Medicine Specialist with Vail-Summit Orthopaedics. He is a Physician for the US Ski Team and Chief of Surgery at Vail Valley Medical Center. Do you have a sports medicine question you’d like him to answer in this column? Visit his website at to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit

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