A national epidemic: Tommy John surgeries at Duke part of broader trend

The pop of a catcher’s mitt is one of baseball’s most natural sounds. Pitch after pitch, the ball travels 60 feet, 6 inches to home plate, finding its way into the catcher’s padded leather glove with a resounding thud.

The pitching motion itself is unnatural—a whirlwind of moving parts unique to each individual who toes the rubber. The more a pitcher throws, the more wear and tear he puts on his arm, and the greater the likelihood that his elbow—not the catcher’s mitt—will pop.

And when that happens, all a pitcher can do is wait for the doctor to come into the room and say the three words nobody in baseball wants to hear: Tommy John surgery.

Since 2000, the number of Tommy John surgeries being performed across the country has skyrocketed—including a troubling rise among amateur pitchers—and just this past year, three Blue Devils were among that group. But a former Duke pitcher may hold one of the keys to slowing down a major threat to the national pastime.

The Tommy John epidemic

Duke head coach Chris Pollard has been in the game of baseball for a long time. He spent 13 seasons at Pfeiffer and Appalachian State before coming to Durham to take the helm prior to the 2012-13 season. Heading into April of last year, Pollard’s pitchers had avoided surgery-requiring damage to the elbow’s ulnar collateral ligament.

That was about to change.

Already a bit short on a pitching staff without Marvel and graduated ace Drew Van Orden, Duke was dealt another blow before its season began. Just days before the calendar flipped to 2015, the team announced that southpaw Trent Swart—a weekend starter whose 2.99 career ERA ranks as the best in program history since the start of the aluminum bat era in 1974—would miss the entirety of the upcoming season following Tommy John surgery of his own.

Swart battled elbow trouble throughout 2014, dealing with what he described as a “burning sensation after each individual throw.” Although the pain caused him to miss more than a month in the middle of the season, he was later cleared to pitch and returned for the Blue Devils’ late push into the 2014 ACC tournament.

Duke was cautious with its stud left-hander, easing him back into action on specific pitch counts. Swart took some time to rest following the season before resuming his normal offseason throwing program, but the pain that bothered him during the season would not go away.

Like Marvel, as he went to get his elbow checked out, Swart had an inkling of what was to come.

“I kind of prepared myself [for the diagnosis] last year when I had the initial injury because I wasn’t sure what they were going to say, if I needed it or if we were going to go through the rehab process,” Swart said. “I think I would have been more shocked then, but then after I came back and started feeling the pain again, I was mentally prepared.”

The third Blue Devil to require Tommy John surgery was Michael Matuella—who was projected to be a top-five pick in the 2015 MLB draft after MLB.com tabbed him as the No. 2 overall prospect in December. After firing six shutout innings in a season-opening win against California, Matuella experienced forearm stiffness and was shut down for a few weeks.

As with Swart, Matuella saw game action only in measured doses upon his return, even as Duke began competing in conference play. Pollard finally took the leash off the 6-foot-6 right-hander March 20 against Pittsburgh, when Matuella threw 91 pitches in 6 1/3 innings.

But the Great Falls, Va., native took the mound just one more time—a 93-pitch effort against Boston College—before it was announced April 1 that he too would need surgery to repair his torn ulnar collateral ligament. The injury adversely affected Matuella’s draft prospects—the right-hander fell to the third round and was drafted 78th overall by the Texas Rangers in the MLB draft earlier this month.

Three pitchers undergoing the procedure in less than a year may seem extreme, but the recent flurry of Tommy John surgeries is far from unique to Duke. Just two of the 14 ACC teams did not have a pitcher on their 2014 or 2015 rosters who had undergone Tommy John surgery at some point in his career.

At the professional levels, the figures are even more staggering. Since the first operation 41 years ago, just shy of 1,000 known UCL surgeries have been performed on major- and minor-league players, the vast majority of them pitchers. Seventy percent of the procedures have come in the past decade—with a record 103 in 2014—making the words “Tommy John surgery” everyday vernacular in the baseball world.

Even high school players—a demographic absent from the official numbers—are having Tommy John surgery with a regularity unprecedented for professional hurlers 20 years ago. Pollard said in April that three of his incoming freshmen underwent the procedure in high school, part of a growing national trend.

The list of Tommy John patients includes budding MLB stars such as Stephen Strasburg, Matt Harvey and Jose Fernandez, as well as hundreds of other young pitchers who have had their careers halted by recurring pain in their elbows.

It has become, as Pollard and many others have called it, an “epidemic.”

The origins of Tommy John

In 1974, Tommy John got off to a 13-3 start with the Los Angeles Dodgers, racking up five complete games and three shutouts in the process. But his season came to a screeching halt when he felt a pop in the middle of one his starts.

“I was pitching outstanding ball, and my arm never hurt. There was a normal hurt, but not to where you’d have injections and all that,” John said. “It was one pitch—boom—and the pain was severe, I mean very, very severe.”

The left-hander’s ulnar collateral ligament—which runs between the humerus and the ulna on the inside part of the elbow—was completely torn. John and Dr. Frank Jobe, a member of the team medical staff, gave the injury four weeks to heal, but it became clear that the injury would not mend on its own.

Surgery was the only option to revive John’s pitching career—but nothing similar had ever been attempted. John said Jobe gave him a 1 or 2 percent chance at returning to the majors after the surgery, which was to be the first of its kind.

Fourteen seasons and 164 wins later, John retired at age 46, the first of hundreds of pitchers to resurrect their careers thanks to the surgical technique pioneered by Jobe, which now bears the name of its first patient.

“[Jobe] was going out giving lectures about the ulnar collateral ligament transplant surgery with the palmaris longus tendon [from the forearm] and he said ‘I got tired of calling it that. It was too long. Then I started saying ‘The surgery I did on Tommy John,’” John said. “And people were like ‘Oh, yeah’ because people knew about that. And then he said ‘Tommy John surgery’ and boom, it stuck.”

Risk factors for injury

John was one of just a handful of pitchers to undergo Jobe’s UCL surgery in the 1970s and 1980s, but that figure has ballooned since the turn of the century. Although there are many factors that may contribute to the wear and tear on a young pitcher’s arm, medical experts have honed in on overuse as the primary culprit.

Although he is the player most closely associated with the injury, John’s injury—a burst of severe pain with little prior warning—is the exception rather than the rule. The majority of UCL tears occur over a long period of time—the accumulation of years’-worth of pitches that put stress on the elbow.

A principal cause of the escalation of Tommy John surgery in young players is that the number of pitches being squeezed into each of those years has greatly increased from previous decades.

Dr. Neal ElAttrache of Kerlan-Jobe Orthopaedic Clinic in Los Angeles and the current Dodgers team doctor—was the surgeon who operated on both Marvel and Swart, and said that overuse can be broken into several categories. Kids are specializing as baseball players—specifically as pitchers—as early as 11 years old. Those pitchers then play baseball year-round, denying their arms the chance to rest and recover during the typical winter offseason. In addition, pitchers often play for more than one team at once—for example, a high school team and a club team—which may have separate pitch or inning limits that do not carry over, allowing kids to throw an excess number of innings per week and putting additional strain on the ligament.

The urge to pitch more innings and for more of the year stems from the feeling that doing so is the key to being noticed by scouts, said Van Orden, who started on weekends for Duke in 2014 before being drafted in the fifth round by the Washington Nationals in the 2014 MLB draft.

“I think it definitely is [being done] to be seen. At every level it seems kids are being told ‘You have to do this, you have to play travel ball if you want to end up playing in high school,’” said Van Orden, who now pitches for the Hagerstown Suns in the Nationals’ minor league system. “It’s almost out of fear of not being seen that they’re playing more.”

Improper mechanics are also likely at fault. Each pitcher has a slightly different throwing motion, but a widely held convention for avoiding injury is to develop a smooth, repeatable motion that uses all parts of the body in a coordinated sequence of transferrable kinetic energy.

Duke pitching coach Andrew See pointed to two specific mechanical points in a pitcher’s motion that he looks at to evaluate whether or not they may be at a greater risk for arm injuries moving forward—a pitcher’s spatial relationship between his elbow and shoulder and a stride across the body.

Pollard noted that another reason for the spike in procedures in recent years has been a change in culture around the diagnosis. In the past, doctors recommended surgery after the ligament had been mostly or completely torn. Now, Pollard said he believes surgery to repair partial tears has become more common, a function of the surgery’s success rate—defined as the chances of returning to the same level of competition or above—which stands at better than 80 percent.

Dr. Jeff Dugas, a colleague of the renowned Dr. James Andrews at Andrews Sports Medicine in Alabama, said the decision on how to best treat a UCL injury is based on a number of factors, including the stage of the pitcher’s career, prior injury history and the timing of the season.

Dugas—a 1994 graduate of the Duke School of Medicine—added that the severity of the tear also plays a role. In some cases, several weeks without throwing could give the ligament time to heal. Lower-grade tears of the ligament may also be treatable with stem cell or PRP injections. The central question remains: “How partial is partial?”

“MRIs are maybe the best test we have, but they’re not a perfect test, and they don’t always tell you the whole story,” Dugas said. “You have to know the starting point to know what you could be dealing with. Is that 20-year-old pitcher—did he have some problems when he was an 18-year-old or 17-year-old in high school? Is this the second time around, third time around, or is this the first time a kid’s ever had pain in his elbow?”

Pitchers are also throwing harder now at all levels of baseball than in years past—yet another source of stress on an unrested arm. Jon Roegele, a writer for The Hardball Times and the curator of the most comprehensive publicly available Tommy John database, has cross-referenced his list of nearly 1,000 known surgeries with PITCHf/x data, looking at the relationship between pitchers’ velocity and whether they have ended up needing Tommy John surgery.

“Pitchers who were heading toward Tommy John surgery the last three years across the board, across every pitch type, threw harder on average than pitchers who were not heading toward Tommy John surgery,” Roegele said. “They tended to throw pitches that are thrown harder more often, so they threw more fastballs and sliders as opposed to curveballs and changeups and that sort of thing.”

Those findings seem to line up with what Pollard has observed out on the recruiting trail—pitchers are throwing faster, younger.

“When I first started coaching, if you went out and you saw a kid that threw 90 miles an hour in the late 90s, you didn’t recruit that guy because you said ‘Oh, he’s going to be drafted in the first round, no need to recruit that guy,’” Pollard said. “Now an average college staff has 10 guys that throw the ball 90 miles an hour.”

For years, people in baseball circles have stressed the importance of not throwing breaking balls too early. To date, no study has definitively proven that throwing breaking balls qualifies as a risk factor for Tommy John. Thrown with improper mechanics, however, Dugas said that the torque generated by throwing a curveball with still-developing growth plates could put a pitcher at risk of injury.

Both ElAttrache and Dugas mentioned a general rule for the appropriate time for a young pitcher to begin throwing a curveball: when he can shave. Swart, Marvel and Van Orden all said they did not begin throwing breaking balls until either just before entering high school or early in their high school careers.

“It just makes you a better pitcher,” Marvel said. “You have to learn how to pitch without that option, just fastball-change, and I think it makes you better as you get older.”

With overuse that dates back 10 to 15 years, the rash of Tommy John surgeries at the major league level matches up with the beginning of the boom in high school and college pitchers—the major league pitchers just made it farther than their peers before breaking down.

The road back

Most pitchers are able to make a full recovery from UCL reconstruction, but the road back is a long and difficult one. The timeline ranges from 12 months to 18 months and involves a series of incremental steps.

Although the surgery has not changed much in the the 40-plus years since Jobe first pioneered it, the understanding of how to rehab the elbow has greatly evolved.

“Back in my day, you got your arm stronger by throwing a baseball—not by lifting weights, not by doing bands, not by doing any of those things but by throwing a baseball,” said John, who added that he threw for a time limit instead of a set number of pitches. “If your arm doesn’t feel good that day, then don’t throw. But if your arm feels good, then throw.”

Nowadays, after being freed from an elbow brace that restricts motion, the arm is placed in a lockable brace to allow for a range-of-motion regimen beginning at the end of the first week, Dugas said. To work on flexing the elbow, the next step is a plyometric program starting around week eight, which involves exercises with weighted balls and gradually progresses until the pitcher is mimicking the throwing motion in a rehab setting.

At around the four-month point, the pitcher gets back on a field to begin an interval throwing program—which takes another three to four months—progressing from lobbing the ball from 45 feet away to a long toss at 180 feet.

Once that can be accomplished without pain, the pitcher heads to the bullpen to begin flat-ground sessions, throwing nothing but fastballs at first. In the next two to three months, breaking balls are added as the pitcher participates in simulated action like batting practice but not competitive settings.

“There’s a difference between throwing in competition and throwing a bullpen in batting practice. Typically, the difference there is velocity that bumps up when they get into a competition just from the adrenaline of the situation,” ElAttrache said. “It takes a variable amount of time for people to get their command back and to get to what they consider their competitive form and technique.”

At the end of April, Swart was in his second week of throwing from about 40 feet, essentially on pace with his rehab plan. After having surgery in November, the Carlsbad, Calif., native said he is on a 15-month window to return to game action and added that the rehab process has allowed him to focus on other things besides his arm that should make a difference when he returns to the mound for the Blue Devils.

“I feel stronger than I did last year overall, because I’m going to have so much time to focus on shoulder strength, body, core, legs, all that, that I never really had before because I’m in season,” he said.

Nearly a year removed from his surgery, Marvel has extended out to 150 feet and added in flat-ground bullpen sessions to regain his fastball command. He opted not to participate in summer ball, targeting a return to regular competition in the fall as a “normal baseball player.”

The tracking system

Adding to the complexity of the Tommy John epidemic is the lack of easily accessible data at the youth level. Games are recorded far less consistently and meticulously than college or professional games, leaving no hard track record—aside from anecdotal evidence—of the mileage on a pitcher’s arm before he enters a college or professional system.

Former Duke baseball player Ted Sullivan has a solution for this problem, albeit via a roundabout method. After spending two years in the Cleveland Indians minor league system, Sullivan hung up his cleats but found himself unable to walk away from the game entirely.

He started coaching Little League, where he was tasked with recording games the old-fashioned way—counting pitches thrown with tallies in a scorebook. The effort spent adding up numbers took up time Sullivan felt he could put to better use—and he saw an opportunity to apply 21st-century technology to a problem that dates back to the 1800s.

“I would, by day, work at a venture-backed technology company seeing how mobile apps were changing industries almost overnight, and yet I didn’t see that happening within amateur sports, which is an industry and a market that I really loved so much,” Sullivan said. “The last thing I wanted to do was spend another 30 minutes after the game totaling up stats.”

In 2009, Sullivan founded a start-up called GameChanger, which features a mobile app that provides an electronic method of scorekeeping for amateur baseball, giving parents and coaches an easy way to keep up with every pitch.

Counting pitches has been part of the app since its first version—though Sullivan said it was designed only to relieve the time burden on a youth coach. But in March 2015, GameChanger became the first app to be PitchSmart certified, earning the support of the joint initiative between Major League Baseball and USA Baseball focused on preventing injuries to young pitchers. Future iterations of GameChanger could provide a player ID to track pitch counts across different teams, enabling parents and coaches to better protect young arms from overuse.

Pollard and the rest of the Duke staff have jumped on board with GameChanger, using it to track everything down to intra-squad games. Sullivan has not marketed his product heavily to college teams—instead focusing on youth markets, the source of the problem—but now has a foothold with more than 125,000 teams, which could combat the issue of overuse in young pitchers.

“We can help by delivering the education to the decision makers at the grassroots level, and we can make the monitoring really easy,” Sullivan said. “Before that 10-second conversation with the umpire [to share pitch counts] you’re not counting up all the little tickmarks in the scorebook to count pitches. You’re just looking at the iPad that says 15 pitches.”

Other solutions

In 2008, Little League Baseball implemented a series of pitch count rules designed to ensure that youth pitchers got the proper amount of rest. The new rules divided players into categories based on their age and the number of pitches thrown in a given day, mandating up to three full days of rest before taking the mound again.

As the first nationwide organization to put a hard pitch count into place, Little League got the ball rolling on a lot of the discoveries being made today, Sullivan said.

The implementation of pitch count rules has yet to catch on at the high school level, where only three states currently use such restrictions, Dugas said. Many other states could follow the path set by Little League and adopt pitch count policies in the near future, a positive step toward reducing excessive pitching at a young age and, eventually, the number of UCL injuries.

“You’ll probably see a number of states go to pitch counts—Alabama’s going to pitch counts, among others,” Dugas said. “I think you’ll see that science is having a positive effect on the injury rate, but the injury rate is going to take time to slow down because it’s going to take time to implement these rules.”

Dr. Andrews serves on the PitchSmart advisory committee, and it was his July 2014 report published with the American Sports Medical Institute that now forms the base of knowledge regarding Tommy John injuries. The report helped debunk several of the myths surrounding the surgery—including the notion that having Tommy John surgery will allow a player to throw harder after recovery.

Any increase in velocity following the surgery typically results from the long, intensive rehab period before the pitcher gets back on the mound. As Swart noted, the months away from pitching give the body a break it rarely receives during the rigors of a competitive season and allow the pitcher to strengthen different areas that can help him once he returns.

The efforts of MLB to aid in the cause marks a major step in changing the culture surrounding elbow injuries. But at the same time, the surgery’s track record of success in pitchers returning to game competition has kept the dream of making a big league roster alive for the injury-stricken college or high school pitcher.

“One of the things that I think is important for historical context is there were two players drafted in the first round of the 2014 MLB draft who—we’re not talking about guys that had Tommy John in the past—they had to have it, meaning they were injured prior to the draft and had not yet had the surgery,” Pollard said. “And they still went in the first round. Clearly, Major League Baseball doesn’t look at a kid needing or having had Tommy John surgery as a dealbreaker anymore.”

Although players seem to be opting toward surgery with less hesitation, there are potential consequences on the back end that become real possibilities as the initial procedure occurs at a younger and younger age. Roegele has 61 cases of repeat Tommy John patients on his list even though Dugas put the risk of requiring a second surgery at around 1 percent.

As research is conducted on the comprehensive effects of the surgery, nobody has the definitive answer as to when a pitcher is in the clear. John cited a Washington Post article stating that a pitcher who had Tommy John surgery is expected to be healthy for the first eight years after surgery but then is back at an increased risk of injury from the ninth year onward.

The secret to avoiding this precarious situation is the multi-million dollar question facing baseball people everywhere. Yet the unnatural motion of repeatedly hurling a projectile more than 90 miles per hour makes risk an inevitable part of the conversation, and John suggests just one failsafe solution exists—stay off the mound altogether.

“I’ve got a program that’s 100 percent guaranteed, sure thing that a kid is never going to hurt his arm,” John said. “He doesn’t throw a baseball. But if you’re going to throw a baseball, there’s a chance of getting hurt.”

This article was updated to include Dr. ElAttrache's affiliation with Kerlan-Jobe Orthopaedic Clinic.