About 40 years ago, when baseball pitchers suffered an elbow injury, the diagnosis was simple: Their pitching days were finished.
“I’ve met a lot of players from the 1960s, and when pitchers like Sandy Koufax suffered his ligament injury to his elbow, his career was over,” said Dr. Timothy Kremchek, an orthopedic surgeon based in Cincinnati.
“If we had the technology to diagnosing injuries such as his that we have now, and the ability to assess the injury, it wouldn’t have been the ‘death sentence’ it was to the career of pitchers as it was back in the 1960s.”
And perhaps the most important step in that career resurrection process was the creation of the surgery to replace an injured ulnar collateral ligament.
That surgery has become dubbed “Tommy John surgery” after it was first performed by Dr. Frank Jobe on pitcher Tommy John in 1974.
After Genoa High School graduate Chris Bassitt suffered a a ruptured ulnar collateral ligament in 2016, Dr. Kremchek performed Tommy John surgery on Bassitt’s right arm in August of that year.
The surgery involves two steps: the first is to drill tunnels into the ulna and humerus bones, and the second is to replace the injured ligament with a new tendon (called a graft) that passes through the tunnels in a figure 8 pattern to restore movement to the joint.
“The injury, for a guy like me, was quite common,” Kremchek said of Bassitt’s situation. “One of the reason I see so many pitchers is because the injury is not that common to most orthopedic surgeons — you have to see a lot of ‘throwers’ to see it a lot.
“It wasn’t an overly unique injury, which was good for Chris because it became easy to design his rehab program and improved his prognosis to reach the major leagues.”
Dr. Kremchek said one of the reasons so many baseball pitchers suffer this particular injury — in 2017, more than one-quarter of pitchers to appear in an MLB game had undergone the surgery — is the Catch-22 nature of become a top pitcher: It takes a lot of throws to reach success, and more throws lead to a great chance of suffering the injury.
“We know that, over a period of time, an arm has only so many throws in it,” Kremchek said. “Everybody is different because everybody has different mechanics, has different strengths of their shoulders, and different strengths in their core muscles. And the amount of stress an elbow can take is different. …
“And young pitchers who throw hard in high school have a very high chance of having an injury to their elbow and shoulder because they throw hard.”
While the first successful surgery was performed almost 50 years ago, Dr. Kremchek said the surgery has changed little over time.
“I met Tommy John, and I spoke with Dr. Frank Jobe about his particular surgery, and virtually none of it has changed,” Kremchek said. “The rehab, the program used to get back to throwing, and even the progression from a surgical standpoint is pretty much the same as it was in 1974.
“As much as medicine has changed enormously in the last 10, 20, and 30 years, and with as much as we have learned about shoulder rehab and core rehab, the surgery hasn’t changed much. And that’s amazing to me.”
Dr. Kremchek said he has completed about 2,000 Tommy John surgeries during his career, and that repetition has helped him in the same way practice helps any aspiring pitcher throw more successfully.
“When I was first training to do this surgery, it would take me two or three hours to do the surgery — to properly do the approach, to do the graft, to evaluate the nerve, everything,” Dr. Kremchek said. “Now I can do the surgery in 30 to 45 minutes. …
“I have a team that knows what to do and how to do it, and that makes it a much smoother surgery.”
When asked if the UCL injury and Tommy John surgery was preventable, Dr. Kremchek said, “There’s no injury in sport that is completely preventable. There are things we can do to educate our kids that would lessen the chances of having the surgery: Pitch counts, improved mechanics, not playing year-round, and limiting the prospect camps and showcases at the wrong time of the year.
“But if a kid gets hurt, I don’t want them to think they have to quit the game. It’s devastating when it happens, but it makes me feel good that we can fix them up and get them back.”
The most obvious preventive measure, in Dr. Kremchek’s eyes, is using pitch counts and other “usage” limits to protect young arms.
“I’ve recognized that injuries from overuse — and in some cases, abuse — that happen in a pitcher’s younger years may not be recognized then,” he said.
“But they come back to haunt those pitchers later on.
“What we find is that kids who are 12, 13, 14 years old — who are throwing lots of pitches and throwing curveballs — may not feel an immediate effect. But it catches up to them down the road.
“When they reach the pinnacle of their ability, that’s often when these effects are being felt. And if you know the answer and you still do it, then it’s abuse. And if you don’t know, that’s ignorance — and I’m trying to take away that ignorance.”
Dr. Kremchek has had instances where coaches, parents, and players have heard the stories of pitchers improving their fastball speed after the surgery and have asked about undergoing Tommy John surgery on an elective basis.
“That’s being naïve,” he said. “A lot of times a pitcher who comes back from Tommy John surgery does throw harder. But the reason they do is because, when these pitchers get hurt, they do things they have not focused on before: core exercises, strengthening, stretching, shoulder programs.
“Now they’re working on things that make them bigger, stronger pitcher. The surgery did not make them throw harder; they are working on things that will help them throw harder.”
The recovery process, which can take as long as a year, features three phases.
The first involves putting the elbow in a splint for seven to 10 days to immobilize the arm, then working on a gentle range of motion using a brace exercising the arm and shoulder while conditioning the rest of the body.
The second phase, which begins about six weeks after the surgery, features exercises to help strengthen the elbow — but prohibits putting stress on the graft itself for four months.
Phase three begins about four to five months after the surgery and at first involves tossing a ball without a windup. After six months pitchers are allowed an “easy” windup, and they can throw from a mound for the first time at seven months.
At nine months, pitchers are allowed to return to competition if they pass three requirements.
First, they must be pain-free; second, they must have regained full strength in their arm; and third, they must have regained full range of motion in the elbow.
Dr. Kremchek realizes the full recovery is long and potentially torturous. But he tells players and parents there is a positive side to the entire process.
“Don’t get me wrong, this is bad, I tell them,” he said. “But one of the positives is that it gives the player a chance to become bigger and stronger, and that will help them become a better pitcher.
“And second, they’re going to miss the game he has played his entire life. With all of the playing and throwing year-round, a player can get run down and burned out. This will get them excited to play the game again, and I think that creates a mental edge.”
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