Dr. James Andrews On Elbow Injury

Dr James Andrews the go to guy for TJ surgery. Credit: Screen cap by Fred Owens

Wednesday afternoon Mike Ferrin and Jim Duquette interviewed Dr. James Andrews on MLB Radio’s Power Alley  about the seeming epidemic of elbow injury requiring ligament repair (Tommy John) surgery.  I made a lot of notes during the interview and thought I’d pass them along to you as part of our discussion about pitching mechanics.  After asking him to discuss the legacy of Dr. Frank Jobe  they moved on to the hot topic of 2014; TJ surgery.

It’s An Epidemic

As of tonight 20 players have had TJ surgery this year  and while he would later say this spike was an anomaly I’m not convinced.  When ask why it was happening, Dr. Andrews opined throughout the interview that the apparent sudden rash of elbow injury requiring surgery had their root cause not in things that happened today or even in the last couple of years but began back when the players first learned and honed their craft. He listed four things that jived really well with what I’ve said when discussing how to prevent this from continuing. I’ll list each along with what I understood it to mean. The full interview is available if you subscribe to XM’s “On Demand” service. I’ll differentiate between my comments and the doctor’s so there’s no mistake.

1. Year around baseball: Dr. Andrews says that before the advent of travel teams and sport specialization pitchers gave their bodies time to recover from the rigors of pitching.
2. Too many simultaneous or overlapping leagues. Dr. Andrews says this kind of program makes rules about inning pitched useless.
3. Too man young players throwing breaking balls before their body is ready for it.
4. Throwing too hard too young.  Dr. Andrews said that his research shows that the “. . .red line for high school pitchers is 85mph.”  Any faster damages the still immature ligament.
5. Young players don’t tell their coach their arm hurts so the coach can’t take action. They forget it was sore until they are asked about it when they visit his office. Then they “oh yeah, back when I was 12 my elbow was sore. . .”; they tell mom but not the guy who could help them.

My Thoughts  (worth at least what you’re paying for them) If you don’t care skip to the next paragraph.

1. Year around baseball is a horrible idea. From the time a player is recognized as a potential professional he’s encouraged to concentrate on one sport and develop his skill set so that his major league dream can come true. Our rush to specialize is doing more harm to pitchers – and I’d argue every other player – than good. It used to be the best athletes were two or three sport stars, Dave Winfield could have been a pro basketball player instead of becoming a Hall of Fame outfielder, Deion Sanders was in fact a professional is two sports and the list goes on. Playing multiple sports makes a young player a better athlete and athleticism is always in demand.  There’s research that supports the benefits of multisport athletes and lots of college coaches prefer them still you have the well intentioned and uninformed who forget that kids aren’t adults. That has to stop. The same goes with overlapping or simultaneous leagues, what does a 7 innings a week limit mean if the player is getting 7 innings in three leagues. This is a parental responsibility issue, they have to put their put down.

2. Too many of the wrong pitches thrown too often. Throwing a breaking ball is both a science and an art. Nothing can stop a kid messing with one on the side but letting someone whose body has not yet matured damage his arm is simply unacceptable. In the dark ages when I was a child our little league had to former major league farm hands to guide it. When pitchers too young to be trying wanted to throw breaking balls the first thing they were ask was , “can you throw your fastball where you want it all the time?  No? Then I suggest you learn to do that first, then we’ll move on to a change up.”

3. Coaches at the high school level need to remember that while winning is the desired outcome, playing well and growing is still the goal. Their job – and I know they take it seriously – is to see when a player needs to sit even if it means not winning. The pitcher who shakes his arm, has an odd look on his face after throwing a pitch or just doesn’t look right has to be taken down no matter how much he protests.

We now return to the interview.

Dr. Andrews said that he sees young players – high school juniors, seniors and college freshmen – every day with elbow injury who either have to have surgery or spend 4-6 months and lose a season doing rehab.  That’s far too many young people shortening it ending a sports career before it’s started. A decade ago these injuries were rare in youth ball.

Ferrin ask what could be done at the major league level to improve either prevent elbow injury. rehab from it and prevent a second TJ.  Doctor Andrews said that no one works harder at keeping players healthy than major league baseball teams. No one is rushed back he said, before they are ready. The investment is simply too high and these teams look at the long term. They do a far better job than high school and college coaches with short seasons who have a shorter view of success.

Bits and Pieces about Elbow Injury and Repair

He threw out some things that I felt were interesting but perhaps most of us weren’t aware of. First of all TJ surgery is not ligament replacement about 80% of the time. It is instead a graft of a tendon from the wrist (89%) or a hamstring (20%) onto the existing ligament.

This is a torn UCL

The Figure 8 Repair

The tendon most often used is the palmaris tendon from one of the pitcher’s arms. It’s harvested (sounds nicer that cut out doesn’t it?)  and woven in a figure eight pattern through holes drilled in the ulna and humerus. Tendons from a cadaver are in some surgeries as well, this was the option used in Brandon Beachy’s second surgery. Once the tendon is grafted onto the ligament a process called collagenation essentially transforms it into a ligament.

Ask whether TJ was always required he said, “There’s nothing that can’t be made worse by surgery.”  He went on to explain why if that’s the case, surgery was the choice so often. Rehabbing an elbow injury with exercise and perhaps platelet rich plasma (PRP) injections can take four to six months, at the end of that time surgery may still be required while opting for the surgery and rehab is 12-14 months (or longer, ask Brandon Beachy).  The player looks at that and says when do we operate?

• TJ surgery has, according to Dr. Andrews research, a 75% success rate. He said he knows there’s a 90% plus number out there but his research comes in at 75%.
• About 25% of current major league pitchers have had at least one TJ surgery.
• A second surgery is needed about 2% of the time.
• Younger cleaner elbows are more likely to be able to return at or close to their prior level of performance. Older arthritic ones usually do not.
• While there are no specific studies in general terms tobacco use slows healing of all orthopedic surgeries.
• PRP injections are used to attract stem cells to the area and encourage more efficient healing.
• Stem cells are widely expected to promote healing more quickly but it is difficult to prove because no one wants to be in the control group. (Duh)

That’s a Wrap

Dr. Andrews said that this epidemic of TJ surgeries is an anomaly not a trend and he next year would likely be back to historic numbers. that seems to contradict what he said about the root cause. If the root cause is at the little league, high school level and involves too much baseball, travel teams and single sport focus this is a generational trend that can only slowed by changing the mindset at that level. In an interview on public television he said that since 2000 there’s been a “five to seven fold increase in youth sports injuries.”  Today he’s seeing injuries in young – high school and younger athletes – that were once seen only in older professionals. That too seems to indicate the problem lies with coaches from the lowest levels through college and since there is no sign of a decrease it obviously isn’t being sufficiently addressed. I know the he works closely with Bud Selig and MLB and can only hope that together they are reaching and teaching the right thing to the right people. If not the trend isn’t  going away anytime soon.