Why Is The Game of Baseball Demanding A Better Tommy John Surgery?
The Need For Triple Tommy John — TJ3
The Modern Player has Unprecedented Elbow Stress
In 2023, more professional pitchers underwent Tommy John surgery than in the entire 1990s combined, highlighting a profound shift in the demands of baseball. In 2022, Major League Baseball reported 427 pitchers on the injured list, resulting in 30,728 lost days and $486 million spent on sidelined players. As the Yankees’ Head Team Physician and a Tommy John Surgery expert, I’ve witnessed this evolution firsthand in professional and amateur athletes. The situation is even more concerning at the youth level, where teenagers are now the fastest-growing group needing Tommy John surgery.
Early in my career, UCL injuries were primarily a problem for seasoned
professional pitchers with thousands of innings behind them — veterans whose elbows had worn down after years of heavy use. But today, in 2024, the landscape has drastically changed. UCL injuries no longer target only the overworked professional; they now affect pitchers at every stage — first-year high school students, college standouts, and aspiring Major Leaguers. Alarmingly, these injuries are no longer rare among position players. Professional and high school outfielders, infielders, and even catchers succumb to UCL injuries at unprecedented rates.
The current epidemic extends beyond baseball. Softball players, gymnasts, javelin throwers, and even the coaches who train them are now ending up in my operating room, their elbows breaking down under the same strain that once only plagued pitchers. The scale of the problem is staggering. Just last week, on a routine Tuesday, I performed Tommy John surgery on ten athletes, including three professional pitchers undergoing the procedure for the third time. That’s right — third. The ligaments we once thought we could protect are tearing again, pushing us into uncharted territory.
The Ever Changing Demands of the Game
The relentless emphasis on velocity and power has driven players to throw more frequently and with greater intensity — stresses the human arm was never designed to endure. With higher stakes than ever, athletes are pushed to maximize their performance to compete at elite levels. Pursuing scholarships, access to top universities, lucrative contracts, and endorsement deals drives players to make their bodies to the limit. Coaches, under pressure to win, often demand more from their athletes, accelerating the wear and tear on their arms. Today’s hyper-competitive environment is fueled by the chase for maximum velocity.
Bigger and Stronger Athletes
At 6 feet 3 inches and 190 pounds, Tommy John does not represent today’s typical athletes undergoing the surgery that bears his name. In 1974, the average height of an MLB pitcher was approximately 6 feet 1 inch and 190 pounds. More significantly, stronger athletes increasingly dominate Major League Baseball pitching. Today’s pitchers, averaging around 6 feet 2 inches and weighing between 210 to 225 pounds, reflect the evolving physical demands of the game, driven by the pursuit of higher velocity — but not without consequence.
Recent studies show that a player’s weight, body mass index (BMI), and height contribute to UCL injury risk. Heavier players with higher BMIs are more prone to these injuries. Height also plays a significant role; as the average height of pitchers continues to increase, so does their average arm length, directly affecting the stress on the UCL. Think of it as a lever — the longer the arm, the greater the torque generated during a pitch. More torque means more stress on the UCL, making taller pitchers with longer arms particularly vulnerable. Simply put, the bigger the player, the higher the risk to the UCL.
Pitchers Throwing with Higher Velocities
The physics of throwing is clear: as pitch velocity increases, so does the stress on the UCL. Recent research shows that injury risk rises by approximately 15% to 20% for every one mph increase in velocity. The modern era of baseball is witnessing an unprecedented surge in 100 mph fastballs — what was once rare is now routine. In 2019, pitchers threw 1,056 pitches at or above 100 mph; by 2022, that number soared to 3,348, making 100 mph fastballs more common than double plays or stolen bases. This surge in velocity is reshaping the game, with higher UCL injury risks driven by simple physics: the faster the pitch, the greater the stress on the elbow.
It’s not just about throwing hard — it’s also about how quickly pitchers ramp up to high speeds. A pitcher consistently throwing 95 mph is already at risk due to the immense forces on their elbow, but a pitcher who rapidly jumps from 89 to 95 mph is in even greater danger. This trend of rising fastball velocities has accelerated dramatically. In 2008, the average Major League fastball was 90.8 mph. By 2013, it reached 92 mph, with eight pitchers regularly hitting triple digits. Today, pitchers averaging 93 mph are twice as likely to land on the injured list the following season than those throwing under 90 mph.
Even more alarming, this drive for velocity starts younger than ever. Young
pitchers throw harder at earlier ages, often fueled by radar gun readings. The once rare 100 mph barrier is now almost routine in professional baseball, but this relentless push for speed comes with serious risks. Recently, I treated a 13-year-old whose father tracked his son’s velocity with a radar gun, documenting the steady increase that eventually led to injury.
Designer and Max Effort Pitches
In recent years, “designer pitches” like sweepers and power changeups have gained popularity, with pitchers seeking more movement through higher spin rates and velocity. Spin rates have increased across all pitch types, including fastballs, changeups, sliders, and sinkers. The sweeper and power changeup, in particular, demand extreme grip pressure and intense forearm rotation — movements that place tremendous stress on the UCL and flexor tendon, pushing them to the brink of tearing.
UCL Fragility
In 2021, MLB introduced the MLB Draft Combine, a significant addition to the draft process modeled after the NFL Combine but tailored for baseball. We analyzed the MRIs of 245 top amateur pitchers, the best in the nation, to assess the condition of their elbows. The results were surprising and alarming: 70% of these young athletes had abnormal findings in their elbow MRIs.
To break it down, about 27% of these pitchers already had some level of UCL tear. Partial-thickness tears, where the ligament is damaged but not completely torn, were found in 24% of players. Full-thickness tears, where the ligament is completely torn, were present in 3%. The location of these tears varied: the UCL can tear proximally (closer to the body), distally (farther from the body), or in the middle (mid-substance). Most full tears were located distally, while partial tears were spread across all areas.
Additionally, 36% of the pitchers showed signs of preligamentous edema — swelling or fluid buildup around the UCL — indicating significant elbow stress. Muscle strains were observed in 14% of players, mostly mild, but still evidence of overuse. Not all tears are the same, but these findings reflect these young arms’ intense strain.
UCL Weakness
The UCL is surprisingly weak, facing an uphill battle against the immense stress it endures. Let’s look at the numbers: the UCL’s failure strength is around 32 Newton meters, but throwing a baseball generates about 50 Newton meters of force on the ligament — far beyond its capacity. By all measures, the UCL should tear with every pitch. So why doesn’t it? Why does this weakest link in the chain somehow hold on, each pitch ticking away like a time bomb? And when it does get injured, the UCL struggles to heal effectively.
Several factors influence healing, with tear size and location being the most critical. Full-thickness tears are less likely to heal compared to partial tears. Tears in the UCL’s upper portion (proximal) tend to heal better than those in the lower portion (distal). Even if healing occurs, the UCL often gets scarred, with calcifications, fibrosis, and some looseness. This already weak ligament may only partially regain its strength.
Additionally, the presence of calcifications and fibrosis means that if Tommy John surgery is needed, the reconstructed ligament faces even greater stress, potentially compromising the success and longevity of the surgery.
Need for Accelerated Timelines for Return
The timing of a UCL injury can be devastating, impacting a player’s season and, more importantly, their career trajectory. For high school players hoping to get recruited an injury during a crucial year can make a decade of training and dreams of playing at the next level feel like they’re slipping away — not just for the player but for their parents, too. For professional players, the stakes are even higher. Suffering an injury when a new contract is on the line can mean losing millions of dollars, putting immense pressure on athletes to get back on the mound as quickly as possible.
Many players are willing to risk accelerating their rehab in pursuit of these
rewards, often pushing their bodies to the brink to avoid missing crucial opportunities. This is where accelerated rehabilitation becomes a critical, albeit risky, course correction. It’s a race against time — a balancing act between healing and performance that can dictate a player’s future. For some, the urgency to return to pitching isn’t just about the game; it’s about preserving their entire career and everything they’ve worked for.
Career Duration
A new and unsettling reality is emerging in baseball: the relentless pursuit of velocity is taking a toll on the longevity of professional careers. While the NFL has long dealt with the harsh impact of short career spans, MLB is now confronting a similar challenge. The average NFL career lasts just 3.3 years, with many players going broke within three years of retirement and filing for bankruptcy within 12 years.
The impact of this trend in baseball is significant. Rookies who debuted in 2000, before the league’s velocity obsession began, enjoyed average careers of 6.95 years. By contrast, rookies who debuted in 2020 are seeing their average career length shrink to just 3.19 years. It’s as if MLB pitchers are becoming the new NFL running backs — pushed to their physical limits, with careers cut short by the relentless demand for power and performance. Surgery can get players back on the field. Still, the real
challenge and ultimate goal are keeping them there, preserving their health, and extending their careers in a game that often prioritizes power over longevity.
Revision Tommy John Surgery
So what happens if a player re-tears their UCL after Tommy John surgery? Most often, the answer is to undergo the surgery again. However, the success rates for revision surgeries are notably lower than for the initial procedure. Redo surgeries come with increased risks, longer recovery times, and a reduced likelihood of players returning to their previous level of performance. The challenge then becomes: how can we improve outcomes for those facing a second or third Tommy John surgery?
Advancements in surgical techniques, personalized rehabilitation protocols, and tailored approaches to each athlete’s unique anatomy and biomechanics are crucial. Understanding why the first surgery failed — whether due to technique, overuse, or inadequate healing — allows us to refine our approach.
Innovations like biologic enhancements, such as platelet-rich plasma (PRP)
injections or stem cell therapy, aim to promote better healing of the reconstructed ligament. Additionally, more precise rehabilitation strategies that focus on strengthening the entire kinetic chain, from the shoulder to the core and lower body, can help support the elbow and reduce stress on the UCL. Ultimately, improving outcomes for revision surgeries means fixing the ligament again, addressing the underlying reasons for failure, and supporting the athlete’s recovery journey. By integrating advanced
techniques and personalized care, we can give players a better chance of returning to the game and thriving in it.
