SPECIAL REPORT: Use of Tommy John Surgery for Young Elbows on the Rise

Medpage Today—August 22, 2008

In combination with overuse, poor conditioning and a lack of focus on strength training contribute to the increasing occurrence of injuries that need to be corrected by Tommy John surgery, according to David Altchek, M.D., of Hospital for Special Surgery in New York.

"The most important thing is this issue of adequate preparation from an athletic point of view," he said. "We see a lot of kids who are talented pitchers because they have natural talent but haven't trained into athletes."

They don't spend enough time focusing on strengthening the core muscles of the back and abdomen, he said, leaving them vulnerable to fatigue, poor mechanics, and injury.

"Their mechanics get altered while they're pitching through fatigue and that overloads the elbow specifically," said Dr. Altchek, who is also the medical director for the New York Mets.

Dr. Altchek agrees that pitchers should be subject to a pitch count. "If we only let a major league pitcher throw for 100 pitches, which is kind of a generally accepted number, there's no way we should let a kid get even close to that," he said.

He said that he doesn't have data to back it up, but thinks that 50 pitches in an outing is all a kid should be throwing, at least until the growth plates in his arm have closed, perhaps around age 15.

Dr. Altchek also doesn't believe that the surgery will make a pitcher stronger than before the injury, and he offered two explanations for why that might appear to be the case.

Pitchers who eventually need Tommy John surgery may have had subtly declining performance for several years before finally going under the knife, gradually adapting their mechanics to a damaged elbow. After surgery, they would get a relative boost in performance, but not greater than when the elbow was completely healthy.

Another contributing factor is the extensive rehabilitation required after the surgery. Full recovery to the point where a pitcher can return to games takes about 12 months, and sometimes more.

Part of the rehabilitation is the strengthening not only of the elbow but the shoulder as well, likely getting both into better shape than they had ever been in before, Dr. Altchek said. The improved strength and work on mechanics leads to enhanced performance.