Thursday is opening day in Major League Baseball. It is a time of hope, as fans in all major league cities dream of pennants and World Series titles. Unfortunately for the second straight year, a perennial playoff hopeful saw its playoff hopes jeopardized before the season ever started due to a UCL injury and Tommy John surgery.

Last year, Minnesota Twins closer Joe Nathan suffered an elbow injury in spring training and missed all of last season after undergoing Tommy John surgery. This season saw St. Louis Cardinals ace Adam Wainwright suffer a similar fate. And the most promising star to arrive in baseball in years, Stephen Strasburg, was also lost to Tommy John surgery mid-way through last season.

Despite these high-profile injuries, a tremendous amount of misunderstanding about the Tommy John injury itself seems to exist. I mentioned in a recent column an interview with a high-school pitcher on Outside The Lines. The pitcher argued that he could pitch as hard as he wanted and as often as he wanted because he could always have surgery if he ever got hurt. But is a seemingly misguided perception like his unusual? A new study suggests that misperceptions of Tommy John surgery are very common.

The ulnar collateral ligament experiences tremendous forces in this late cocking/early acceleration phase of throwing a pitch.

What is a Tommy John injury?

A Tommy John injury means that a pitcher has partially or completely torn his ulnar collateral ligament on the inside of his elbow. That ligament experiences tremendous force placed on it with repetitive throwing, especially with increased pitch counts and off-speed pitches over many years. Typically the ligament doesn’t heal, and rehab often does not help elite pitchers return effectively, so surgery is indicated. The surgery, nicknamed after the first professional athlete to undergo the operation, involves taking a tendon from another part of the body (usually the wrist) and using it to make a new ligament on the inside of the elbow. Rehab is lengthy, requiring 12 months or longer to return to pitching. It is often the second season back before the pitcher feels he is back to normal.

Misperceptions of Tommy John surgery

The study, done by Christopher S. Ahmad et al., surveys 189 baseball players aged 10-23, 15 coaches, and 36 parents. They showed a large percentage of respondents had significant misperceptions of the injury. First, 24% of players, 20% of coaches, and 44% of parents felt that return to pitching took less than 9 months instead of the realistic 12 months or more. Also, in terms of risks, a huge percentage of players, parents, and coaches did not believe that increased pitches thrown or off-speed pitches contributed to risks of UCL injury.

More surprisingly, the study demonstrated that the respondents overestimated pitching performance after surgery. A significant percentage of players, coaches, and parents believed that control, speed, and performance would improve after surgery. In fact, 6% of coaches, 3% of parents, 8% of high-school players, and 5% of collegiate players felt that Tommy John surgery should be performed on players WITHOUT INJURY in order to enhance performance.

Kids should not suffer UCL injury and need Tommy John surgery

The problems with these misperceptions among parents, coaches and pitchers

To be honest, these results did not surprise me, as I hear some of these ideas among baseball players and their families in my practice. I’ve already addressed the risks of too much pitching and throwing off-speed pitches at too early an age in a previous column. Multiple studies have demonstrated that these are significant risk factors for elbow injuries.

The idea of increased performance after surgery is also very common. The problem with the argument that control and velocity improve after surgery is that UCL injuries are rarely acute events but rather overuse injuries that often manifest over several years. The pitcher’s velocity decreases and control declines as his elbow becomes more painful. When he gets back to full pitching, he compares his “new” performance to his impaired performance just before surgery, not what it was when his elbow was healthy. And there is no evidence or belief among sports medicine surgeons that Tommy John surgery to reconstruct a normal, non-injured elbow will improve performance or is even a reasonable idea.

Tommy John surgery is largely preventable

The worrisome aspect of this entire problem is that UCL injuries are somewhat preventable injuries, especially at the youth and high-school levels. As I said, these are usually overuse injuries from too much pitching and throwing breaking pitches too early. But for many reasons (coach/parent pressure, the need to win, talent showcases, dreams of college scholarships and pro contracts, etc.), youth and high-school pitchers and their parents and coaches are often ignoring our advice, and the tremendous increase in surgeries on high-school pitchers in recent years serves as evidence. And the misperceptions of UCL injury and surgery, as the study demonstrates, might explain why kids aren’t afraid to take chances. Unfortunately, watching their friends play while they are sitting on the bench for a year or more is a bad way to learn the realities of Tommy John surgery.

Note: The following post appears as a column in the March 30, 2011 edition of The Post and Courier.