Baseball’s Elbow Problem

By James Colapinto

Credit to Wikimedia Commons.

Matt Harvey

It’s August 24th, 2013, and Matt Harvey is having an off night.

Over the 2013 season, Harvey has distinguished himself as one of the best pitchers in baseball. Amid an otherwise dismal season for the New York Mets, the 24 year-old has become the brightest young hope for the team. He will finish the season with the 3rd lowest earned run average (a rough measurement of the number of runs a pitcher allows his opponents to score) in the majors. Less than three weeks ago, he pitched a “complete game shutout”–throwing an entire 9-inning game without allowing the opposing team to score a single run. Mets fans eagerly look to him as a key prospect for their team’s future. Today though, he struggles, giving up 13 hits in a 3-0 loss to the Detroit Tigers. At first, nothing seems too concerning. Interviewed after the game, he reports that he feels “pretty tired”–understandable going into the final month of Major League Baseball’s 6 month-long, 162 game season.

The next day, Harvey reports having some tightness in his forearm. A seemingly innocuous complaint on the surface, it is recognized for its seriousness by the Mets medical team. Harvey is sent for an MRI, which comes back with devastating news: his ulnar collateral ligament (UCL), a triangular bundle of connective tissue fastening the medial epicondyle of the humerus to the proximal end of the ulna, is ruptured. He will not pitch again for 18 months.

The act of overhand throwing, as primitive as it may seem, is an evolutionary innovation as unique to humans as our bipedal locomotion and massive cerebra. The anatomy of the shoulder and arm allows for the throwing of projectiles with both significant velocity and accuracy, and these anatomical features appear 2 million years ago in Homo erectus. No other primates have this capability. Chimpanzees, despite being much stronger than humans, can only manage to throw projectiles around 20 mph. Untrained humans can fairly easily reach 60 mph. The vast majority of professional baseball pitchers can throw a fastball above 90 mph, with some reaching over 100 mph. 

There are risks involved in taking the body to its physiological limits, though. Soft tissue is only so strong, and the elbow undergoes tremendous stress during the act of throwing. The violent and repetitive act of pitching often ends up exceeding the limits of the elbow. In pre-adolescent players, the stress can cause the end of the humerus to fracture. In older players, the breaking point shifts from bone to ligament: specifically, the UCL.

A few weeks after his diagnosis, Harvey underwent one of the most well known procedures in professional sports: ulnar collateral ligament reconstruction. Most know it as “Tommy John surgery”. 

Tommy John and Frank Jobe

John in 1981. Credit to Wikimedia Commons.

On July 17th, 1974, Tommy John of the Los Angeles Dodgers felt a twinge in his arm while pitching during a game. Suddenly, he was unable to throw and his fingers were tingling. The MRI had not been invented yet, but the Dodgers medical team was able to discern that John had ruptured his UCL. At the time, this diagnosis was catastrophic for a pitcher. A few years earlier, the career of legendary Dodgers pitcher Sandy Koufax ended when his UCL gave out. Without the stabilizing force of the ligament, a pitcher’s arm was rendered “dead”.

In response to John’s injury, however, one of the Dodgers’ team physicians, orthopedic surgeon Frank Jobe, proposed a new procedure to recreate the damaged ligament. Jobe would take the tendon of the palmaris longus from John’s right wrist and thread it through holes drilled into John’s left humerus and ulna into a figure-8 pattern. John agreed to the procedure. He spent the entire 1975 season rehabilitating his repaired elbow, and returned to the Dodgers in 1976.

Jobe was cautious, wanting to make sure that the surgery provided long term benefit before attempting it again. After successful surgeries on several more baseball players, as well as a javelin thrower, he became confident in the procedure, publishing his results in the Journal of Bone and Joint Surgery in 1986. Three years later, Tommy John retired after a career spanning 26 seasons. 14 of those seasons came after his UCL reconstruction. The procedure that saved his career would come to be known by his name.

Tommy John surgery has become one of the most common surgeries in sports, both professional and amateur. In 2017, 26% of active major league pitchers were reported to have gone through the procedure at some point in their life. It is well-established as a safe and effective treatment for UCL rupture, and 90-95% of those who receive the procedure return to their sport. It is not unusual to return to pre-injury performance following the procedure, and the reconstructed ligament appears to demonstrate greater durability than the original. This surgery has become so ubiquitous and successful that some parents even seek to have their athlete children receive it preemptively, thinking it will make their child throw faster. In reality, evidence suggests that the surgery reduces throwing velocity, and that preventing injury is a far more pragmatic approach.

In 2014, Frank Jobe passed away at 88 years old. He left behind a remarkable legacy. In World War II, he served as a medical supply sergeant and participated in the Battle of the Bulge. He was a clinical professor of orthopedics at University of Southern California School of Medicine and founded the Biomechanics Laboratory in Los Angeles. And of course, he innovated a medical procedure that revolutionized baseball and continues to rescue the careers of pitchers, like Matt Harvey, to this day. On his medical accomplishments, Jobe mused, “Sometimes it just makes you want to cry watching those guys go on to great things. It really does.”

Current Challenges

Today, Tommy John surgery poses a new problem. With baseball becoming increasingly competitive, rates of UCL reconstruction rose 343% from 2003 to 2014, with the highest increase in the 15-19 year old age group. All of which begs the question: could baseball, from little league through to the majors, be doing more to prevent these injuries rather than relying on an invasive reconstructive surgery that requires over a year of recovery time? While major league pitchers often have tightly controlled pitch counts (not exceeding a certain number of pitches in a game) and rest days, youth baseball leagues often do not have nearly the same restrictions, and often any rules that may be in place are ignored. Little league pitchers are pushed to pitch for longer and more frequently than is safe, and managers can be ignorant of the risks or warning signs of arm injury.

Adding to this problem is a distinct shift toward specialization in youth sports culture. An increasing number of youth athletes are focusing on a single sport from a young age, and dedicating the majority of their physical activity toward participating in and training for that sport. Many youth baseball players join “travel” teams, where they can play as many as 70 games per year for up to 8 consecutive months. This culture of playing and training as much as possible is thought to produce elite athletes, but evidence suggests that young athletes who specialize early have a greater risk of injury than unspecialized athletes, even when correcting for hours of activity per week. Specific to baseball, pitchers who pitch in more than 8 months per year are at increased risk for shoulder and elbow surgery

Increasingly, sports medicine researchers are encouraging unstructured play and participation in a variety of sports to reduce overuse injury. Unfortunately, opportunities for multisport participation appear to be decreasing. Local sports leagues are being displaced by travel teams, which typically involve more specialized players, greater time commitment, and increased financial burden. The displacement of local leagues not only decreases opportunities for youth to participate in multiple sports, but also reduces the options available to families who cannot afford a travel league. Additionally, many school districts in the United States have decreased the time dedicated toward physical education and recess, in favour of increased time in the classroom. These cuts reduce the opportunities for children to diversify their physical activity and try different sports, especially those from lower income households. In order to reverse this trend, youth sports needs a fundamental realignment of ideals, moving away from producing elite athletes for families that can afford the price, and toward creating equitable opportunities that allow children to engage with multiple different sports, regardless of financial status. Until these changes occur, though, Tommy John surgery will continue to be a familiar phrase for baseball players and fans alike.

Author: James Colapinto

James Colapinto completed his B.Sc. in Developmental Biology and M.Sc. in Plant Development at the University of Toronto. He is interested in sports medicine, addiction and mental health advocacy, and classical music. He is an avid Blue Jays fan and mediocre right fielder.