The Surgery Heard ’Round the World
Until 1974, Los Angeles Dodger Tommy John was known primarily as an above-average pitcher with a surplus of first names. But after rolling through the first half of the year with a stellar 13-3 record, a painful elbow derailed his season, and threatened to destroy much more. At the time, such arm trouble spelled doom for a pitcher, typically ending a career or rendering the pitcher much less effective if he managed to return. Faced with few other options, John offered himself up as a guinea pig (albeit one with elbows) to the scientific gods. To the benefit of countless future pitching careers, including his own, he donated his left elbow and both his names to an innovative surgical procedure, the success of which earned it the moniker “Tommy John surgery.”
According to USA Today, about 1 in 9 major-league pitchers have benefited from the surgery designed by Dr. Frank Jobe, who was a medical consultant for the Dodgers in the 1970s. The doctor was actually in attendance at the fateful game, when John was forced to leave in the third inning with elbow pain. Dr. Jobe’s successful technique has since revitalized the careers of such pitchers as John Smoltz, Kerry Wood, and Mariano Rivera, all of whom reached the All-Star Game after surgery. Before exploring this surgical wizardry, though, we must first detour through the worlds of anatomy and physics.
The elbow joint is the conjunction of three bones: the humerus, the ulna, and the radius. The humerus runs from the shoulder to the elbow, the others from the elbow to the hand. The hinge of the elbow is formed where the humerus fits into the socket of the ulna, located on the pinky side of the arm. A set of ligaments stabilizes the joint, most notably the ulnar collateral ligament (UCL; there’s one in the thumb, too). Hold your arm up in an L pattern. The anterior portion of the UCL attaches to the medial epicondyle – that forward protrusion you see near the elbow if you’re following directions. About 2 cm diagonally outward, the ligament attaches to the ulna, helping to maintain the stabilization of the elbow and protecting it from rotational stress.
The most dangerous stage of throwing to the elbow is also the funniest to say: “late cocking.” A kinetic study of highly skilled baseball pitchers outlined the incredible stress placed on the UCL during each pitch. The pitcher rears back his arm to an angle of about 165º, where the rotational force of the elbow peaks at an average of roughly 64 Newton-meters (Nm) of torque. How much is that? According to Langer et al., the force is equivalent to holding 150 baseballs. More importantly, how dangerous is that? Well, the UCL bears about 54% of this stress, or roughly 34 Nm. The maximum sustainable torque to the UCL was calculated at 33 Nm in cadavers, presumably by some baseball-loving, physics-obsessed morticians (see what wonders can be accomplished when you donate your body to science?). Allowing for some discrepancy due to the, er, poor health of these subjects, each ball thrown by a living pitcher nonetheless approaches a maximal allowable stress for the ligament.
The curveball is often demonized for its detrimental effect on the elbow, particularly in young adults. However, research has found no significant difference in the torque placed upon the UCL by a curveball compared to that of a fastball. In fact, a more dangerous pitch to the elbow may be the slider, which elicits greater torque: its use is significantly related to elbow pain in 9- to 14-year-old pitchers (the curveball shows a slight correlation with shoulder, rather than elbow, pain). The clearest link to elbow pain is with pitch counts, both per game and throughout the year, which makes sense, considering the maximal stress placed on the UCL with each pitch. My advice? Nothing but change-ups, which cause the least stress on the elbow and will certainly limit your pitch count when you are pulled after six batters go yard.
Thanks to the dramatic stress of pitching, the UCL may develop chronic pain due to small tears in the ligament, or an acute “pop” may instantly debilitate an athlete by completely tearing the UCL. Non-operative treatment is an option for minor damage. In this case, a period of extended rest and anti-inflammatory medicine is followed by exercises to increase the strength and flexibility of the entire arm, as any weakness can cause undo stress on the joint. However, the high demand placed on the elbow, especially at the professional level, often necessitates complete replacement of the ligament. A graft is taken from the patient’s own body, most commonly the palmaris longus tendon (tendons connect muscle to bone or muscle to muscle; ligaments connect bone to bone). To see the tendon, first turn your head to the left, and then the right, just to make sure no one is watching. That’s important. Now reach your hand out in front of you with your palm facing you. Without moving your elbow, give yourself an upside-down middle finger. There’s a good chance you can now see the tendon: it’s the one the juts out from the bottom of the hand, towards the elbow. About 85% of people have this unnecessary tendon. If it isn’t present, a tendon from the leg is typically used.
In Dr. Jobe’s original surgery, he drilled holes near the joint in the humerus and ulna, attaching the tendon by looping it through the holes in a figure-eight pattern (about 15-17 cm of tendon are needed). Special precaution must be taken during surgery to avoid damaging the ulnar nerve, the so-called “funny bone.” In Tommy’s case, inflammation of this nerve during recovery dictated the need for another surgery, further delaying his return. Several modifications have since been made to Dr. Jobe’s procedure, offering better ways to attach the tendon to the bones, to avoid the ulnar nerve or to circumvent the surrounding muscle.
For its monumental role in altering baseball history, Tommy John’s damaged UCL should no doubt be on display at the Baseball Hall of Fame. Instead, it remains in his elbow, for now; the remnants of the UCL are sutured to the graft for additional strength. And that’s it: the patient is sewn up, leaving a four-inch scar, and rehabilitation soon begins.
With modern techniques, over 90% of pitchers return to pre-injury form, with the return to play usually taking about one year. The original surgery was an unqualified success – John won 164 games after his return and was the oldest player in the league when he retired – despite Dr. Jobe giving the pitcher just a 1% chance of returning to baseball. The doctor still works for the Dodgers, but he has been joined by a new select class of surgeons who perform the technique, including the prominent Dr. James Andrews, who performed UCL reconstructions on 196 professional pitchers from 2000 to 2004.
Next week, the first true signs of spring are revealed in small towns throughout Florida and Arizona when major league baseball pitchers and catchers check in to spring training. Keep an eye on those pitchers with the telltale four-inch scar on the pitching elbow. They are flamethrowing proof that each snap, crackle, or pop in the elbow isn’t always a career-ender, thanks to the medical marvel of Tommy John – and Frank Jobe – surgery.
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Sportsology
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