The list of major league pitchers who have undergone “Tommy John” surgery grows longer each year.  We all cringe when we hear that our favorite pitcher has “forearm tightness” and a possible “UCL” injury.  Most know who Tommy John was, but how well do you understand the surgery itself?  Let’s take a look at a little history, the surgery, the recovery, and its implications on the player’s long term outlook. 

The first surgery was performed by Dr. Frank Jobe on Tommy John in September of 1974.  John was able to pitch again 18 months later and went on to win 164 games over 15 years after the surgery.  He retired at age 46 and never had another issue with his elbow.  Major League history was forever changed with this event.  The 80s saw Tom Candiotti and David Wells perform well after the surgery.  Wells may have been the first player who had Tommy John performed by the now famous Dr. James Andrews.  Today the surgery has become so routine that an estimated ? of all MLB pitchers have had the surgery. 

What is the UCL and its function?  UCL stands for Ulnar Collateral Ligament.  A ligament is tissue that connects a bone to another bone (a tendon connects bone to muscle).  The UCL connects the humerus (upper arm) to the ulna (lower arm) on the medial (inside part) of the elbow.  It has three parts and it provides stability to the elbow joint when the elbow is at a 90 degree angle and then the forearm is bent back. The amount of force that a pitcher places on this ligament can be equal to that of a 60 pound weight. When the UCL is torn it causes instability of the elbow, pain, and occasionally numbness in the pinky and ring finger.

The surgery to fix this is similar to what is done for an ACL. A graft is used to replace the ligament. Tommy John’s graft came from his forearm, a part of the palmaris longus tendon.  Today the graft can come from the forearm, hamstring, or a cadaver.  The decision as to what to use is usually the preference of the surgeon and based on what is best for the patient.  The graft is run through drill holes in the bones in a figure of eight configuration and is as strong as the original ligament.

The rehab for this surgery takes about 12-18 months for a pitcher and 6-12 for others.  The reason for this is that the graft is what we call “avascular”, it has no blood supply, and it takes a long time for the blood supply to develop and the graft insertion points to heal.  As we’ve seen, even after a pitcher comes back, it may even take another six months to a year before they are completely back to their pre-injury self.  The surgery is successful about 85% of the time and those who need a second TJ surgery see only a 35% success rate.  Studies have shown that a pitcher can reach a level of performance that was expected pre-surgery, but the surgery will not improve their performance as was believed by some early on.

For those of us who witnessed Tom Seaver throwing between 12 and 21 complete games for 12 straight years while eclipsing 200 innings 14 straight years, Nolan Ryan pitching until age 46, and Bob Gibson with 20+ complete games eight times what has changed? In 2019 there were a total of 45 complete games with the MLB leader having three (Shane Bieber and Lucas Giolito ).  Yes, times have changed, but was this change a result of the increase in elbow injuries and TJ surgery as the teams try to “protect” their young pitchers?  What are the theories behind the surge of UCL injuries?  Number one is overuse.  Today’s youth are pitching year round with the proliferation of off season work out programs and indoor facilities. Before this era, kids would play other sports in the fall and winter and this allowed their arms to recover. It was shown that those who pitched eight months or more per year had an increased chance of tearing the UCL. Throwing more than 80 pitches in an outing was also a factor as the underdeveloped youth could not recover well enough before their next one.  Dr. James Andrews and others suggested that throwing curveballs should be eliminated until the pitcher reached about age 13, but studies could not substantiate that.  Until parents realize that having their sons throw all year round in the quest for that scholarship, etc is actually detrimental to their health, the proliferation of TJ surgery will continue.  It’s estimated that over 40% of all TJ surgeries are now performed on adolescents.

From a fantasy perspective the worst thing you can hear is that your first round draft pick or the guy you spent $35 on in an auction needs TJ surgery. They are an immediate drop and likely won’t be draftable the following year.  Looking for a bargain? Try getting someone who came back from TJ late in the previous season.  If that player will bounce back, it will be now.

Pitchers/Players who returned in 2019:

Shohei Ohtani returned but only hit.  He is projected to pitch in 2020.

Didi Gregorius returned after eight months.  He struggled at first, but hit in the playoffs. Signed with the Phillies.

Brent Suter returned in September and pitched well in the bullpen for the Brewers.

Johnny Cueto made four starts, two good/two not so good.  Probable mid season trade chip for Giants if he pitches well.

Garrett Richards made three starts in September and signed with the Padres.

Taijuan Walker made one appearance in September with the Diamondbacks.  Is a free agent and at age 27, still could be an upside signing for someone.

Keynan Middleton returned in August and made 11 appearances.  Will be a bullpen piece for the Angels.

Jordan Montgomery returned in September but will have a hard time making the roster this spring.

Notable pitchers who will miss time this season and their estimated return. (Date is the date of their surgery):

Lance McCullers Jr. 11/18. Should be back for beginning of season.

Corey Knebel 4/19. Early to Mid season return likely.

Jordan Hicks 6/19 Maybe a late season return.

David Robertson 8/19 Most likely out for 2020

Jameson Taillon 8/19 Most likely out for 2020

Carlos Rodón 5/19  Possible mid to late season return

Michael Kopech 9/18 With all the White Sox moves, if healthy he may start the season in the minors

Michael Fulmer 3/19 Possible mid season return

Chad Kuhl 9/18 Will be in the mix for a rotation spot in for the Pirates

Position Players:

Salvador Pérez 3/19 Expected to begin season, may play more first base/DH

Aaron Hicks 10/19. Will miss at least half, possibly most of 2020