More on Tommy John surgery

In Tom Verducci’s article at (a must read if you haven’t already), he listed nine pitchers with the same mechanical flaw as Steven Strasburg. Verducci wrote in the article, “None of them—at least those with enough post-surgery history—were ever quite the same pitchers again.”

If you’re a good baseball fan you’ve probably already read Will Carroll’s article on Tommy John surgery, but if you haven’t it’s a must read as well. Here’s a taste: “It’s not that pitchers are coming back better, stronger, or faster,” Carroll writes. “It’s that they’re coming back the same, keeping talent in the game.”

Dr. Hagan is a leading expert in the field of the diagnosis and treatment of peripheral nerve and pain disorders. A resident of his was a college pitcher and ended up moving to the outfield because of elbow pain. Together, they began digging into the results of Tommy John surgery.

“Usually the surgeons do a great reconstruction,” Dr. Hagan said. “So, mechanically they’re stable, but the thing that keeps them (baseball players) from getting back to the level of high performance that they historically had performed at is generally pain. Most of them that fail are based on pain, not rupture of the ligament.”

As to the cause of pain after surgery, even years after, it’s the inflammation and potential nerve damage. Doctors now think it can be fixed with regenerative cells from one’s own body and if that’s not possible, they can now take out the nerves that are causing the pain.

These type of nerve problems, aside from happening in sports, can also be caused by diabetes, repetitive motion disorders, traumatic injuries and post surgical complications. Basically, the pain is being caused by an irritation to the nerve and Dr. Hagan can either remove the irritation or remove the nerve.

Even more managing any pain for someone who’s had Tommy John surgery, Dr. Hagan is surprised there’s not more going on to monitor pitchers who fit the profile of having an inverted W pitch motion.

“Nobody is monitoring this like some of us know that they could be doing,” Dr. Hagan said.

I asked Will Carroll what he has heard about ball clubs and team doctors monitoring pitchers who are predisposed to have the mechanics that some say are “at high risk” for ending up with Tommy John surgery.

“Almost none,” Carroll wrote in an email. “A handful of teams (at least 3, perhaps as many as six in some form) are doing biomechanical evaluations. We don’t know who is really pre-disposed and who we just look at as risky. We cannot predict by looking. Even then, is it “better” to change them?”

Dr. Hagan approves of what Tom Verducci wrote about Stephen Strasburg and other pitchers who have had Tommy John surgery — their mechanics have to put them at risk. Injuries like this don’t just happen.

“(The pitchers) love the whip but it puts a lot of strain on that elbow,” Dr. Hagan said. “Every time they do that there has to be some micro-trauma. At first it gets loose, and then the repetitive nature of that is the micro-trauma. That’s why the doctors see it frayed.”

Dr. Hagan knows some ballplayers may have an anatomic predisposition to the injury but still believes, “mechanics has to be a part of it”.

Today there are regenerative medicines and ultrasounds ballclub’s could be using to monitor pitchers with this profile.

“You have the ultrasound technology that is good enough that you can really get a good visualization.” says Dr. Hagan. “Think about the throwing arm. There’s a nice built in comparison. If you’re a right-handed pitcher you have a left arm. Your left elbow doesn’t have the strains on it so you can use that as and internal gauge. Is there inflammation around it?

“In addition to examining the arm for laxity and pain you can look at the sensation in the small finger of the throwing arm. As the ligament gets loose there’s inflammation and pain in that area. It affects the ulnar nerve, so there’s another sensitive tool to look at: how the right hand is comparing to the left.”

Along with the new methods available to monitor the ulnar collateral ligament, Dr. Hagan says there are therapeutic treatments that would help maintain ligament structure even before operation.

But those are new frontiers, and like anything in baseball — the beauty and madness of it—is that change is hard to come by.

9 thoughts on “More on Tommy John surgery

  1. Anna, outstanding post! We need to look harder here at pitching mechanics, and the art and science of handling pitchers. I'll have a post here on that tomorrow. An important factor here is age: pitchers age 24 and younger are at a higher risk of these injuries because their joints are still maturing.

    There is plenty of interesting work online on the so-called "inverted W" throwing motion, for example see here: There's much we don't know, but the problem with the "inverted W" seems to be an issue of timing the arm motion correctly with when the pitcher plants his front foot in his pitching motion.

    I'd love to hear more opinions on how to use high medical technology to monitor the health of a pitcher's arm before a major injury occurs.

    We are SO lucky to have you here, Anna!

    • Yes, the problem with the inverted W is timing. Ideally you want to use the transfer of the body's weight from your back foot to your plant foot to "absorb" a good chunk of the force used in going to the plate. To do that, you need to have the ball in the "loaded' position when the plant foot hits, to begin bringing it to the plate with the body. The inverted W leaves you behind the foot, and instead you do a "whip" motion, pulling the arm up and back down quickly to throw the ball. The up-down motion strains your elbow this way, and the brunt of the effort to come to the plate is borne by your shoulder.

      It's really hard on your arm, in other words, and so far as I know there isn't a single pitcher who uses it who can fairly be described as a picture of durability.

      • Brien, not looking for an argument, just want to point out that the whole theory of the inverted W is still controversial. It's worthy of further discussion.

  2. Holy effing crap! Spectacular article! Keep up the great work! Love that kinda stuff. Welcome aboard!

  3. Oh Wow, thanks for the kind comments! Dr. Hagan has really helped a lot of people with pain. As far as watching pitchers it makes so much sense. I have not watched A.J. Burnett pitch this year. I'm anxious to see what they're doing with him. He came to mind when I put this together. If location has to do with more of a physical issue than release timing after hearing Dr. Hagan it seems like he'd be one to watch.

  4. My son is a college freshman catcher. During a bone chip removal in his elbow, the doctor found his ligament is stretched. Are there alternatives to Tommy John surgery?