Once a desperate move, Tommy John surgery is now routine tool

In 1974, Dr. Frank Jobe looked down at the elbow on his operating table. Tommy John, the Dodgers pitcher, was unconscious, a good thing considering his elbow was open, a large triangular incision that exposed everything down to where his ulnar collateral ligament had been. Jobe looked down and came up with a plan.

When Dr. George Paletta opened up Adam Wainwright's elbow last week, he made the same cut on the Cardinals ace, and almost to the letter, he followed Jobe's plan. For an operation that has been around nearly 40 years and saved the careers of hundreds of major league pitchers, the operation is still not understood well.

There are myths and mysteries surrounding the operation. In an interview I did with Dr. Jobe and Tommy John back in 2009, Jobe addressed those myths in no uncertain fashion. Tommy John surgery, as the ulnar collateral ligament reconstruction has come to be known, does not make a pitcher better or faster. "Most of that is the insidious nature of the injury," said Jobe. "Even if the ligament just ruptures at once, the very nature of pitching is that you wear down." Tommy John agreed, saying "It's one pitch that you can point to, but it's a lot of pitches before that one that gets you to that point."

In essence, we're not seeing pitchers at that theoretical "100 percent" level. If we think of pitchers like sports cars, then the minute they're driven hard, they lose value and have some mechanical wear and tear. They can be maintained, have all the right oil changes, but they're still not the same way they came off the assembly line. Of course, these are humans, not machines and getting them back to even close to original condition is much harder than swapping in a part, even when done by Jobe, James Andrews, or one of the other super-surgeons.

Not only does the elbow reconstruction get the pitcher back to a fully functional anatomical level, the rehab and rest they've had between the surgery and the return to the game helps immensely. Imagine taking a healthy pitcher and giving him a year off to do nothing but work out and get stronger. I'd imagine most of them would see an increase in velocity that is often pinned to the surgery. The work of physical therapists like Kevin Wilk and Clive Brewster is key to the recovery and to the reduced length of time we're seeing to recovery. It's no wonder that Wilk and Brewster are connected to the surgeons we think of most in regards to the procedure; Wilk is based in Birmingham within Dr. Andrews' medical complex, and Brewster is connected to the Kerlan-Jobe Clinic in Los Angeles.

That rehab time after Tommy John surgery is becoming one of the key points in the recovery. While most still quote the 12-18 month time frame after reconstruction, the fact is that using modern techniques and rehab has the real recovery period down to 9-12 months.

Dr. Tim Kremchek, the team physician for the Cincinnati Reds and one of the leading practitioners of Tommy John surgery, agrees: "Much like ACL reconstruction in football, where we're seeing some kids back on the field in four to five months, we're seeing the same sort of thing with elbows. With the newer, more holistic rehab processes, I'm seeing most players ready in a year, maybe a little less. They're focused on the core, on mobilizing the arm, on proprioception, and that has them back and ready to go." While Dr. Kremchek uses a version of the surgery that is slightly modified from the original Jobe techniques, he believes it's how we look at the rehab process that has kept the perceptions about the recovery time around. "A guy hurts his arm and has the surgery, then he vanishes. We don't see him in the media again until he's throwing and getting ready to do a rehab assignment. We're seeing him every day in rehab, but with a player like Steven Strasburg, where every move is watched, it might look like throwing like he is at six months is unusual. It's not."

Dr. Kremchek saw this last season with Reds pitcher Edinson Volquez. Volquez returned to the mound at 10 months after the surgery and was back playing for the Reds -- in the heart of a pennant race -- just 11 months after his surgery. "It wasn't rushing him, but where the team is at matters," said Dr. Kremchek. If the Reds hadn't been in the lead at the All-Star break, we would have looked at the situation differently. I'm sure with Strasburg, it will be the same thing, magnified by the media."

In fact, the 18-month rehab that's often cited as the standard is as old as the surgery itself. Tommy John took 18 months to return from that first surgery. Few realize that John had a major setback during his rehab, an inflamed ulnar nerve, that required a second surgery. Many surgeons now move that nerve as a routine part of the surgery. Others leave it in place, knowing it's easily fixable and that the problem only occurs in a minority of cases. The "transpose or not transpose" schools of thought can be fun to watch, in an orthopedic kind of East Coast-West Coast rap battle.

What's not argued is that the normal procedure is to remove (or "harvest") a tendon to graft in. Normally, this is done by cutting the palmaris tendon from the pitching arm. The tendon is redundant, so there's no loss in function. (If you're wondering where the tendon is, touch your thumb to your ring finger. You should see a small tendon pop up under the skin of the wrist. That's where the first cut is made. Two more cuts and some snips produce a tendon piece about six inches long that can be put into holes drilled in the elbow.

Watching the procedure is a bit odd. I've had the chance to see the procedure performed several times. The most recent was with Dr. Etienne Mejia, who was demonstrating some new tools designed to make the procedure quicker, easier,and less traumatic. Mejia was demonstrating on a severed cadaver arm(Warning: graphic picture), which made it a bit like something out of The Walking Dead. Watching the procedure, one is struck both by the skill of the surgeon and the relative imprecision. The cuts are deep and require spreading through the fascia and muscle. The holes are drilled with a cordless drill that looks like something you'd pick up at Home Depot. Yet the result is a finely-honed stitching that draws the harvested tendon into place through a series of stitches, draws, and loops.

In weeks, that tendon will begin the process of "ligamentization," as it latches itself into place and literally takes on the biologic properties of the ligament it is replacing. (No one seems sure why the body does this.) One result of this process is what's been referred to as the "honeymoon period." It takes about five years for the tendon to lose all traces of it's previous existence and once it's a ligament, it's as likely as the previous resident to tear under an excessive load. Several pitchers have had Tommy John surgery twice, while some have undergone the procedure three and even four times. Four seems to be the limit, though, since the palmaris on both sides, plus the secondary possibility, the gracilis tendon from near the hamstings, would be exhausted. Cadaver tendons can be used, but seldom are with high level pitchers.

Contrary to some Internet reports, Adam Wainwright is going to undergo his first Tommy John surgery soon. Wainwright did have previous UCL sprains -- at least three that are noted. The first occurred while he was in high school, another in 2004, which caused him to miss most of that season, and then again at the end of the '10 season. A sprain is a tear, but the tears that Wainwright experienced were incomplete. Wainwright's sprains weren't significant enough to require reconstruction, just rest so that the body could repair itself with scar tissue. Given that he was a pretty darn good pitcher for the last five seasons, that seems to have worked out well for everyone.

While some managers amplify the idea that pitchers come back better or that the surgery is "as routine as taking your car to Jiffy Lube," the part of the process that's not as understood is the rehabilitation. One MLB athletic trainer said that the difference between a pitcher before the surgery and after depends completely on how hard they work in rehab. "Give me any pitcher, give him a year off to do nothing but work out, build up his arm and think about mechanics and he'll come back better," he said. "But give me a guy that takes his 'second chance' seriously and works [hard] and those are the guys that come back 'better.'"

The current protocol used by the Kerlan-Jobe Clinic, where many pitchers go for their surgery with doctors such as Lewis Yocum and Neil ElAttrache, is a 10-month process. That's right -- 10 months. It's a very detailed and precise rehab, though it does allow for some personalization depending on the pitcher and for the needs of the team. A pitcher is only braced for the first two weeks, is doing range of motion exercises inside of a month, and works through a full-body conditioning program for the first two months. The focus through this point is allowing the repaired elbow to heal and building up everything else to support it. By the sixth week, the patient should be back to a full range of motion and normal activities, though he is still not allowed to throw a baseball. By the four-month mark, plyometric exercises are mixed in. It might not be too exciting to think about an ace like Strasburg or Wainwright bouncing balls off a training trampoline, but it's a big step.

Finally, around the six-month mark, if all the previous steps are completed, a pitcher can begin a throwing program. The Kerlan-Jobe protocol is very conservative through this phase, though other similar protocols are slightly more aggressive. The focus here is building arm strength, concentrating on mechanics (specifically correcting noticeable flaws that may have caused the injury in the first place), and proprioception. Proprioception is the sense we all have of where our body is in space. If you close your eyes and hold your hands out to each side, you know where they are. You can move them, touch your nose, or go through a pitching motion without looking at them.

Getting that sense back after surgery is one of the more difficult things. It's one thing for an NFL receiver like Wes Welker to "not feel right" after ACL reconstruction, but for a pitcher, it's make or break. A 1/8th inch difference in release point can mean an eight-inch difference in pitch location as it crosses the plate. Regaining the proprioception and confidence is usually the last step, coming after a pitcher returns in some cases. Watching a pitcher like Volquez return and struggle with command is a sign that both have not been completely regained.

It's not just major league pitchers that get this same level of care. Back in 2006, I worked with a group of young pitchers in New Jersey, including Anthony Montefusco. He was a solid young pitcher with good mechanics, a nice frame, and a solid work ethic. He went to George Mason, where he was a freshman All-American. He got that honor despite having his season end on May 1, when he felt something in his elbow pop. His father, Keith, called me and within days, Anthony was headed to Cincinnati, where Dr. Kremchek rebuilt his elbow.

While Montefusco won't be pitching this season -- it's simply smarter to take the redshirt year than rush back at the collegiate level -- he's already throwing from a mound. I discussed the rehab process with Keith Montefusco, Anthony's father, who told me, "Dr. Kremcheck encouraged [Anthony] to take his time. He's followed the throwing program to a T." Anthony had solid mechanics and an easy motion, despite his 93 mph fastball. "The ligament just pulled away from the bone," Keith told me, "so Doc just tacked it back in, overlayed that tendon on there."

There have been few surprises during the process, from sitting in Kremchek's operating theater, where the father could watch the surgery from just feet away, to the conditioning program that has Anthony back to a point where he's back on a mound with the same stuff he had.

I spoke to a scout who had seen Anthony in high school, and while he wouldn't share the details of their file, he did say that Anthony was someone they liked, due to his body type, easy delivery and his results. He hadn't seen his collegiate numbers, but was impressed. When I explained that Anthony had his elbow repaired, the first question was who did it. When I said "Dr. Kremchek," the immediate response was "That's real good." He didn't feel that having the surgery would affect the scouting process at all for the kid. "Known surgery, known surgeon who we could go to, and no problems before. If he can come back and throw the same way next season, he'll get plenty of looks."

This operation has leapt from a long shot, something in the imagination of a doctor who loved baseball, and has become something that may have saved or at least changed the game. In '09, one out of every nine pitchers in a major league rotation had that triangular scar on the back of their pitching elbow. While we might consider it routine and know that the results are very solid, it's still a long process that we must hope becomes outdated through prevention and "prehab." It's not that pitchers are coming back better, stronger, or faster; it's that they're coming back the same, keeping talent in the game.