Former Cy Young Award winner John Smoltz calls it "the greatest surgery in the world."
No procedure has saved more pitchers' careers than Tommy John surgery, which replaces a torn ulnar collateral ligament in the elbow with a tendon from another part of the body.
But Smoltz, who had Tommy John in 2000, said it has become way too commonplace. When Rays All-Star left-hander Matt Moore has the surgery today in Pensacola, performed by team medical director Dr. James Andrews, he'll be the 13th major-league pitcher this season to do so, just six fewer than all of last year. Moore will join front-line starters such as the A's Jarrod Parker and Braves' Kris Medlen on a 12- to 15-month recovery.
"I hate it," said Smoltz, an eight-time All-Star starter and closer, now an MLB Network analyst. "It's a great epidemic. A lot of future studs are on the shelf. It's alarming."
Part of it is that UCL tears are more easily diagnosed due to technology, and the success rate of the surgery is strong. A study published in December in the American Journal of Sports Medicine showed an 83 percent rate of return to the majors among 179 pitchers who had it, and 97.2 percent return to pitching in the pros.
But while Andrews said the large number of Tommy Johns this year is likely an "outlier," there has been a gradual increase on these procedures — at every level — since 2000.
Andrews believes a key culprit is the youth baseball culture, with pitchers throwing harder, and more innings, year-round. Risk factors include velocity, usage, fatigue and mechanics, with genetics playing a role, which is why it has been difficult to pinpoint one cause or solution.
But Andrews said that though there's no way to completely prevent UCL tears, much like ACL injuries, he's searching for ways to curtail them so he's not so busy with Tommy Johns.
"I've done too many to count, and not enough to quit," Andrews said. "I'm trying to put myself out of business with prevention. That would be great."
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Andrews said many of these young big-league pitchers having Tommy John are likely the prodigy of their youth and high school baseball days.
He points out that there has been a significant jump in school-age players having Tommy John — up "five- or sevenfold" since 2000 — with the youngest he has operated on being 12 years old.
The UCL is key to the stability of a pitcher's fragile elbow, absorbing the force of a furious whiplash as he makes each throw. Think of it like a rubber band that frays as you stretch it over and over. Slowly, it cracks, reducing its strength.
Andrews said younger pitchers, whose ligaments are still developing, are being pressured to light up radar guns, pitching more competitive innings year-round to impress scouts or colleges. They're not getting enough rest to recuperate.
He also said studies by the nonprofit American Sports Medicine Institute, of which he is a founder, have shown that high school pitchers who throw with fatigue increase their odds of injuring their shoulder or elbow by 3,600 percent. The risk factors for velocity begin at 85 mph, with 90 a "high risk" in damaging the ligament.
"I think it's insane," Rays manager Joe Maddon said. "I think too many parents are trying to have their kids become professionals at an early age to fulfill their lifelong dreams and not necessarily the kid's, and I think that's where maybe it's starting to all break down. … It's been part of the fabric of baseball for many, many years. I think the recent epidemic, to me, might be tied to what they do before they even get here, professionally."
Smoltz thinks it's "backwards" that as much as major-league teams micromanage innings and pitch counts for their minor-leaguers, youths are playing 100 games a year. Andrews, in a research committee funded by MLB, has put out guidelines and educational programs for youth sports (www.stopsportsinjuries.org).
"If we don't do anything about these kids getting hurt in high school," Andrews said, "we're not going to have anybody to draft."
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When the late Dr. Frank Jobe replaced the torn ulnar collateral ligament in the elbow of Dodgers lefty Tommy John in 1974, he likely didn't think he pioneered the most famous surgery in sports.
John, then 31, went on to pitch 14 more years after the operation, winning 164 extra games without ever missing a start due to an elbow problem. Before the procedure, named after John, the injury was often career ending.
"This was death to pitching," Smoltz said. "To come back was unheard of."
Smoltz was 34, having pitched 12 big-league seasons (and in five World Series) when he was talked into having the surgery by John himself. Smoltz, having pitched for three or four years with a partially torn ligament, was considering retiring before John's surprise phone call.
"I thought somebody was pranking me," Smoltz said. "He encouraged me. I was down and out, I was done. I was in the last year of my contract, 34 years old, who is going to wait? Lo and behold he talked me through the process. Greatest thing I ever did."
Smoltz would pitch nine more seasons, converting to a closer, making another four All-Star appearances and racking up 154 saves. Next year, Smoltz could become the first pitcher to have Tommy John and get elected into the Hall of Fame.
"That speaks volumes to the unknown of the surgery," Smoltz said.
A 2013 study by Bleacher Report injury analyst Will Carroll found that one-third of active big-league pitchers had Tommy John surgery during their career (124 of the 360 who opened the season). Nationals ace Stephen Strasburg and the Cardinals' Adam Wainwright are among those who have come back strong. But Andrews points out that while the success rate is high, there are many possible complications, including nerve problems.
Around 40 pitchers have had to have multiple Tommy Johns, according to Yahoo's Jeff Passan, who is writing a book on the surgery called The Arm.
"When you blow out once," Passan says, "chances are you're going to blow out again."
Passan, who followed two pitchers from their surgery through recovery, said it's a brutal process and very tough to come back from. The lack of a solution, the "mystery," makes it fascinating to study, he says.
"In baseball, arm injuries are a malady," Passan said. "It's the thing that loses more money than any other sport loses for any other reason. The fact (MLB) is just finally choosing to invest money and time into this is ludicrous.
"For an industry that does such a good job of focusing on the inefficiencies and trying to lessen them, these arm injuries have lasted far too long."
Joe Smith can be reached at firstname.lastname@example.org.