Whats with all the Tommy John surgery?

A few days ago, it was announced that Blaine Hardy became the latest Twins pitcher to go in for Tommy John surgery. He joins a long list that includes players as notable as Noah Syndergaard and Chris Sale. So whats up with all these guys’ elbows? It could be that this an unintended side-effect of the MLB shutdown throwing (pun intended) off their spring regimen and forcing them to work out in unconventional ways. It could also be something much simpler.

Tommy John surgery is a fairly invasive procedure as far as a 90-minute outpatient surgery goes, with a very long recovery time. Generally, it takes at least six months before a pitcher can start throwing again, and at least a year before they resume playing. It takes another year before they typically perform at their pre-surgery level. Hitters, such as Miguel Sano, can potentially come back sooner, but it still takes quite a while. Therefore, Tommy John is usually the last resort for pro athletes and teams. You’ll hear guys describing a “pop” in their elbow, that goes along with a sudden UCL (Ulnar Collateral Ligament) tear. Typically this damage is built up over time though. These tears are what the procedure is designed to remedy. In UCL reconstruction procedures, a section of tendon is typically harvested from the forearm, the hamstring, or the big toe, to graft into the elbow. The surgeon then makes a 3-4 inch incision in the outside of the elbow, and cleans out the damaged areas. They then drill holes in the bones, and connect the graft in place. Sometimes they can also keep part of the original ligament in place, sometimes they can’t. Johns Hopkins has a better summary than I can give you.

So, Tommy John surgery is generally used to repair repetitive elbow damage over time, makes sense right. Pitchers are obviously at the highest risk for this damage, due to the repetitive motions they make, over and over, to throw a little white ball over a little white pentagon 60 feet away. Why now though, when guys are barely able to find a place to throw, and are coming off the period where they are getting the most rest?

For one thing, the timing fits well for most pitchers. The 2020 season is going to be a mess no matter what. It may not happen at all. That is still a distinct possibility. It may also be shortened, or we may see games played into December in domes. We really don’t know. We do know there is a better chance of the 2021 season being played (still not a sure thing though, may the deity of your choice have mercy on us all.) So it fits, then, that guys would be willing to sacrifice the possibility of pitching in 2020 to be a better pitcher, with less injury risk, in 2021 and forward.

Lets go back to Blaine Hardy for a minute. He was confident in his ability to pitch this season, and was just under care of the Twins PT for pain management purposes. With the shutdown, he was no longer able to receive that level of care from the team, and had to weigh his options. Given the shortened season, and the odds of having an improved elbow to show teams for 2021, it seemed to be the best route forward for him.

If—and this is where I turn to conjecture—if the rest of these guys already knew they had wear-and-tear on their elbows, but normally would have been able to manage the situation and pitched through it, then this might have been the logical time to opt for something they normally wouldn’t have chosen, or at least not chosen until forced. Similar to Hardy’s predicament, they all lost the access to daily medical care that may have been keeping them feeling good and in pitching condition. If they lose the shortened 2020, they are still ready to go by mid-season of 2021. For others, who take the “Rich Hill” route, they may even be able to pitch the entire 2021 season.

Dr. Neal ElAttrache, one of the top orthopedic surgeons in the US went on record stating that these surgeries are looked at as “essential,” stating in the San Francisco Chronicle “I know that I’m going to get criticized for taking care of these kinds of guys, but it’s essential to their livelihoods, If you have somebody’s career at stake and they lose two seasons instead of one, I would say that is not a nonessential or unimportant elective procedure.” Note that Dr. James Andrews has suspended performing Tommy John procedures, as a non-urgent procedure, so not all surgeons agree with this premise.

I think Dr. ElAttrache hit the nail on the head in the second sentence for why these guys all did it now: if they waited, they may not have needed the surgery, but they also may have ended up missing another season due to having it at a later date. By going under the knife now, at worst, they miss whatever ends up happening this season, and maybe half of next season, before coming back. If they waited until they possibly needed it next spring, that’s two-and-half years gone.

Guys who have already had Tommy John are sometimes considered an increased injury risk by fans, but the data doesn’t seem to bear that out. More-so, the reason I think these guys in particular are at a decreased risk is that I think they are proactively dealing with damage they would normally pitch through. In other words, these guys are having the procedure done before they would need to—but they would eventually need it anyway.

So, the recent spate of Tommy John procedures among baseball players—including guys we had no indication of elbow issues for, is probably equal parts preventative and practical considerations at play. Many of these guys would have pitched as normal under the medical care of their teams this season, but for various reasons took advantage of the shortened season to get a procedure out of the way. They may have been in pain, or known about structural damage, but played through it—until they lost access to their medical teams. Rather than possibly be out two-or-more years if this season is entirely cancelled, and then they need surgery, guys are taking advantage of the timing. Since everyone is missing at least part of this year, its that much less of a setback compared to their competition.