Beyond the Cut: How Precision Medicine is Influencing Tommy John Surgery
For decades, medicine has followed a one-size-fits-all mindset. Doctors used evidence based guidelines based on the average patient — a fictional person crafted from massive studies and data points that lump together millions of unique individuals. It’s a game of balancing probabilities, not precision, and while this scattershot approach works for some, it fails others.
Enter precision medicine — a revolution that rips apart the old playbook. It doesn’t see patients as statistics; it sees them as the intricate, one-of-a-kind beings they are, defined by their unique genes, environments, and lifestyles. This approach has already transformed lives, especially in cancer treatment.
For decades, the war on cancer has been fought with blunt instruments — chemotherapy and radiation. These treatments, while effective at killing
cancer cells, are notoriously non-specific, indiscriminately targeting any rapidly dividing cells. It’s like trying to extinguish a wildfire by obliterating the entire forest — effective, yes, but at a devastating cost. The side effects — hair loss, nausea, fatigue, immune suppression — are a grim reminder of this scorched-earth approach, a consequence of attacking healthy cells as well as cancerous ones.
The dream has always been a treatment that selectively targets and destroys only cancer cells, leaving healthy cells unharmed. A precision strike. A targeted attack. Immunotherapy is an example of this radical departure, a complete change in strategy. The immune system’s remarkable precision can target cancer cells with astonishing specificity, leaving healthy cells largely unharmed. Its dynamic nature allows it to adapt and evolve to the changing cancer, launching new attacks as needed. It’s not about obliteration. It’s a series of strategic counterattacks.
Cardiology
Cardiology has also entered a new precision era. Imagine a world where we don’t just tell patients to take a pill for high blood pressure but dig deeper into their genetic makeup to understand how their bodies will react. Some patients burn through medications like kindling in a fire; others metabolize them at a snail’s pace. With pharmacogenomics, cardiologists can tailor prescriptions to the condition and the individual, cutting out the guesswork and creating a personalized blueprint for optimal health.
This shift isn’t limited to genetics — it’s happening across the board. Diabetics now rely on continuous glucose monitors that make real-time insulin adjustments based on the unique rhythms of their bodies. Nutrition, once dictated by broad guidelines, is evolving into a world of personalized diets shaped by a person’s DNA and microbiome, proving that the right diet isn’t a one-size-fits-all formula but a highly individualized strategy.
These advances might sound like science fiction, but they’re here, transforming healthcare right before our eyes.
Precision Tommy John Surgery
What does precision medicine have in common with Tommy John surgery? In a word, everything. While Tommy John surgery might seem commonplace due to the number of players undergoing it, it’s far from a one-size-fits-all solution. Each baseball pitcher is unique, with distinct traits such as height, weight, strength, flexibility, pitch selection, and
throwing style, to name a few.
Picture the contrasts: a tall, lanky pitcher with a whip-like delivery versus a
stockier, power-driven thrower. The biomechanical stresses on their elbows are different. And then there’s their pitch arsenal — fastballs, sliders, curveballs, sweepers, splitters — all placing distinct demands on the UCL and forearm muscles. Starting pitcher versus reliever also has implications. These demands shape the strategy for treatment and recovery. Layer on the complexities of flexor tendon and nerve issues, where you are in your career, whether amateur or professional, and where you are in the season, and you have a matrix of variables that demand a custom, precise approach.
The UCL injury patterns itself are diverse. Some players deal with calcified, ossified ligaments with little elasticity, while others face clean tears in an otherwise normal ligament. Table 1 is a long list that illustrates the numerous features influencing UCL injury treatment recommendations.
Table 1: Factors Influencing UCL Injury Treatment Recommendations
- Individual Characteristics
Age
Height
Weight
Arm Length
Flexibility
Strength
Endurance - Position
Starting pitcher
Reliever
Position player - Throwing Characteristics
Velocity
Spin Rate
Use of “Designer” Pitches (Sweeper, Power Changeup)
Percentage of Maximum Effort
Throwing Style and Mechanics
Throwing Volume - UCL Tear Characteristics
Tear Location
Tear Size
Chronicity
Calcifications
Enthesophyte Formation
Bony Avulsion - Associated Injuries
Ulnar Nerve Involvement
Valgus Extension Overload
Flexor Tendon Tears
Arthritis
Revision Surgery Considerations - Graft Considerations
Palmaris longus presence
Graft diameter
Graft length - Career Stage
Early Career
Mid Career - Seasonal Timing
Early
Mid
End - Throwing Programs
Specific Programs Tailored to Recovery and Return to Play - Strength and Endurance Goals
Customized Strengthening and Conditioning Plans - Participation in Velocity Enhancement Programs
Permutations in Tommy John Surgery Patient Factors
When TV commentators celebrate a pitcher’s return from Tommy John surgery, it tends to downplay the incredible complexity involved in the treatment process. Each aspect of the procedure — such as the athlete’s age, the type of tear, throwing mechanics, and graft selection — comes with multiple choices. To understand this complexity, imagine each factor as a variable with several options.
For instance, consider a 35-year-old pitcher with low velocity and a partial tear of the proximal UCL compared to a high school senior with rapidly increasing velocity, a full- thickness distal tear, and aspirations of playing professionally. Each scenario represents a unique combination of factors, and the total number of possible combinations is astonishing. This complexity is calculated by multiplying the number of options available for each factor, demonstrating just how tailored and intricate Tommy John treatment truly is. The unique combinations of factors are called “Permutations”.
The Number of Permutations May Shock You
Let’s calculate the total number of permutations. The number of possibilities or “states” for each factor is multiplied.
First, let’s count the number of states for each category:
- Individual Characteristics: 2 x 2 x 2 x 2 x 2 x 2 = 64
- Position: 3
- Throwing Characteristics: 2 x 2 x 2 x 2 x 2 x 2 = 64
- UCL Tear Characteristics: 3 x 3 x 2 x 2 x 2 x 2 = 288
- Associated Injuries: 2 x 2 x 2 x 2 x 2 = 32
- Graft Considerations: 2 x 2 x 2 = 8
- Career Stage: 2
- Seasonal Timing: 3
- Throwing Programs: 2
- Strength & Endurance Goals: 2
- Velocity Enhancement Programs: 2
Now, let’s multiply the number of states for each category to find the total number of permutations:
64 x 3 x 64 x 288 x 32 x 8 x 2 x 3 x 2 x 2 x 2 = 7,666,803,200
Therefore, based on these simplified assumptions, there are an estimated
7,666,803,200 permutations. In other words, patients with a UCL tear can present in several million different ways. Another way to say it is that no two patients with a UCL tear are the same.
This variability is precisely why precision medicine is becoming crucial in
managing UCL injuries among athletes.
Surgical Permutations
We have not yet touched on the surgical factors involved in Tommy John surgery. The surgical landscape is far from one-size-fits-all. Each patient presents a unique set of variables, and the surgeon must skillfully navigate a vast array of options to create the most effective treatment plan. Every decision is meticulously tailored to the individual’s anatomy, injury characteristics, and career goals, from the best choice of graft and fixation methods to the specific surgical exposure employed. This personalization
ensures that the surgery aligns with the athlete’s biomechanics and performance demands.
Let’s use graft selection as an example. Tommy John reconstruction requires graft tissue, and there are options. A palmaris longus tendon is a typical choice, but not all players have one. (18–20% of people do not have a palmaris.) Graft choices include gracilis tendon from a leg and then a choice of which leg, the drive leg or the land leg, for the pitcher.
Below is a comprehensive list of the surgical options and variations that surgeons can fine-tune during a Tommy John Surgery, demonstrating the complexity and precision required to optimize each patient’s outcome.
Table 2: Tommy John Surgical Factors
- Graft choices
Palmaris Longus
Gracilis
Hamstring (semitendinosus)
Plantaris
Allograft - Surgical Approach
Muscle Splitting: Splitting the flexor-pronator muscles to access the UCL.
Muscle Elevation: Elevating the flexor-pronator mass off the medial epicondyle. - Ulnar Nerve Transposition
No transposition (leave in situ)
Subcutaneous transposition
Submuscular transposition - Tunnel Size and Orientation
Standard diameter vs. smaller diameter tunnels - Tunnel Position
Ulna tunnel positioning - Tunnel Configuration
Docking Technique — Uses a single tunnel on the humerus and two strands pulled through tunnels
Modified Jobe Technique — Classic Jobe technique with two tunnels on the humerus and ulna
Single Point Fixation
Hybrid Techniques — Combination of docking, interference screws, or button fixation. - Graft Fixation Methods
Sutures
Interference screws
Cortical buttons
Suture anchors - Graft Configuration
Two-strand graft (simplest and quickest)
Three-strand graft (increased strength, slightly more complex)
Four-strand graft (strongest configuration, used for native ligament deficiency) - Native Ligament Repair
No repair
Repair to bone
Repair side to side - Enthesophyte
No removal
Removal - Combined Arthroscopy
No arthroscopy
Arthroscopic debridement of osteophytes, loose bodies, or synovitis - Flexor Tendon
Repair consideration if flexor tendon pathology is present or compromised during surgery
Considering the above factors, the total number of surgical permutations estimated is 138,240.
Many factors influence surgical decisions beyond those listed, and some factors are likely interdependent. The actual number of permutations therefore, may be different, but his calculation highlights the complexity and variability of Tommy John Surgery.
Revision Surgery
The Risks of Not Using Precision in Tommy John Surgery
So, what happens when Tommy John Surgery isn’t tailored with precision? I’ve seen the consequences first hand; an example is a high velocity pitcher with a high grade chronic tear that undergoes UCL repair without reconstruction. While UCL repair can offer quicker recovery and excellent results when used on the right patient (precisely used), it’s not a catch-all solution. Not all UCL tears are the same, and this procedure isn’t suitable for everyone.
Other examples where precision Tommy John Surgery improves outcomes are addressing bone spurs that cause lingering pain if not managed or flexor tendons that go unrepaired — the results are predictably poor. Athletes often find themselves back in the operating room, needing additional procedures that could have been avoided.
Precision surgeons tailor every aspect of the procedure — from the choice of graft and fixation method to the decision on nerve transposition and rehabilitation protocols — based on the unique characteristics of each patient. By adopting precision surgery, we move beyond a standardized method applied to an average patient, embracing a strategy that directly addresses the nuanced needs of each athlete, thereby enhancing both short- and long-term outcomes.
Precision Tommy John Surgery empowers athletes and their medical teams to make decisions that align with career timing and personal goals. For instance, a collegiate athlete on the cusp of a professional draft may opt for a more aggressive rehabilitation protocol tailored to their timeline. In contrast, a seasoned professional who has 16 months of recovery afforded to him may prioritize a less aggressive rehab approach.
Applying precision medicine to UCL injuries is not just about refining surgical techniques; it’s about optimizing every aspect of the athlete’s journey through injury and recovery. As we celebrate the 50 th anniversary of Tommy John Surgery, let’s also reflect on the complexity of this fantastic surgery.
