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Dr. James Andrews releases a position paper on the Tommy John surgery epidemic

May 28, 2014, 5:53 PM EDT

tommy john surgery

We have posted about this a few times when Dr. James Andrews has given interviews on the subject of what he calls an “epidemic” in UCL tears and attendant Tommy John surgery. But now he and his American Sports Medicine have released a position paper on the matter.

In it he outlines the risk factors for Tommy John surgery, common misconceptions about it and his recommendations for pitchers and teams to limit the risk of needing it. As for that last part, this recommendation is likely to get the most play and, if heeded, affect the most change:

Do not always pitch with 100% effort. The best professional pitchers pitch with a range of ball velocity, good ball movement, good control, and consistent mechanics among their pitches. The professional pitcher’s objectives are to prevent baserunners and runs, not to light up the radar gun.

I think major league teams know that in practice once they have a pitcher and are developing him. But the defining trait of a scout is his radar gun, and young pitchers are conditioned to want to light it up when they see a scout checking them out. Good pitchers change speed and create movement. Young pitchers get noticed, however, when they throw in the 90s. It’ll be interesting to see if this changes that at all.

Anyway, consider thus must-click material. And something to bookmark if you’re at all interested in the subject.

  1. Conner012367 - May 28, 2014 at 5:57 PM

    I think every young pitching prospect needs to read this because they are too many young guys having the surgery, we need less not more.

    • rbj1 - May 28, 2014 at 6:00 PM

      Coaches and parents too.

      • Conner012367 - May 28, 2014 at 6:04 PM

        them too

    • dowhatifeellike - May 28, 2014 at 9:15 PM

      I wish someone had told me this when I was 12. As I got older, people only ever talked about how hard I threw, so I just kept doing it. I managed 1 year of college ball before my arm told me it was done.

    • Chris K - May 29, 2014 at 1:16 AM

      I’m not sure how you solve this problem. Parents holding their kids back might ensure their kid has a potentially long MLB career…assuming they get noticed and get any opportunities over the other young ones pushing their bodies to the limit throwing 90+….

      • Conner012367 - May 29, 2014 at 2:12 PM

        I think people should watch Zack Greinke pitch because he is 30 yrs old and hasn’t had Tommy John surgery, because he changes his style of pitching as well as his velocity.

  2. schmedley69 - May 28, 2014 at 6:06 PM

    So basically, Dr. Andrews is concurring with Dr. Papelbon’s prognosis that “velo is overrated.”

    • jcmeyer10 - May 28, 2014 at 6:24 PM

      *Checks over shoulder for Horses of the Apocalypse*

    • mikhelb - May 28, 2014 at 7:21 PM

      Papelbon, Greg Maddux, Tom Glavine, John Smoltz, Jim Kaat, some of the names who have said in the past that velocity is overrated and pitchers should learn to mix pitches, velocity and location instead of trying to K everybody with fastballs.

      We don’t have a lot of pitchers right now, instead we have a lot of rock-throwers.

  3. jrob23 - May 28, 2014 at 6:12 PM

    Young pitchers have been throwing too hard for a century. His ‘position’ does nothing to explain why all of a sudden there is a rash of injuries. One glaring omission is that pitchers are working out, some taking PEDs, and teams are babying them unlike in the past. Other than that..great insight

    • mikhelb - May 28, 2014 at 7:18 PM

      Not true, young pitchers nowadays are throwing harder than they had done in the past 30 years. In the 1980s and 1990s to throw 90 mph was considered a good speed. In the past 10 years or so, pitchers who can not throw above 94 mph are considered one of the bunch, while throwing 95+ mph puts them as “elite”.

      In the 1970s pitchers who could throw heat could also manage to throw offspeed pitches very well, now you can ask any young pitcher to throw an offspeed pitch and he’ll throw a changeup which is also a fastball albeit a “slow” one touching mid to high 80s.

      Also, take in mind modern pitchers do not work out, it seems like they work out but in reality they just do a bit of cardio, a bit of lifting weight and between starts they rest. Pitchers in the past had to throw two or three times between starts to keep their arms “warm”, and they did it with repetitions, not with speed but just tossing the ball 150 to 200 times per session, that way they were ready to pitch 150 or more pitches per start without the feeling that they can not breath, which happens to lots of pitchers nowadays once they hit 80 pitches, not to mention 100-110 pitches.

      The whole babying pitchers is what I also think pitchers are different in modern baseball because teams invest millions of dollars and want to get the most out of their arms even if it means they won’t go the playoffs (see: Strassburg) or will lose one or two seasons out of them (see: Matt Harvey and others). High pitch counts and high amounts of innings are not the culprits per se, but a mere consequence of not training young pitchers as they should.

      • jrob23 - May 28, 2014 at 7:52 PM

        the only reason you are seeing increased velocity is because there are more specialized pitchers i.e. 7th, 8th, 9th inning guys. These guys can air it out for short bursts but cannot maintain that over several innings. Back just a decade ago starters went deeper and long relief actually worked long innings. If you asked any starting pitcher to pitch their best for one inning in any era you’d have similar velocity. Of course PED use in the last two decades has helped as well. Roger Clemens pitched in the mid 90s occasionally hitting high 90s as a starter. If he closed he would have been in triple digits.

        Pitchers DO work out. They work out their cores (relatively new over last 10 years) their legs and backs. It’s like a night and day difference. Not sure what you are talking about. Unless you are referring to long toss and throwing between starts. In that I agree. They do way less throwing now than even 15 years ago

    • paperlions - May 28, 2014 at 7:27 PM

      For most of that century, kids pitched until they tore their UCL and just didn’t ever pitch (or pitch well) again.

      You should have just prefaced your comment by admitting that you didn’t bother to read the ASMI statement.

      • yahmule - May 28, 2014 at 7:58 PM

        I’m glad you read it, Lions. The things I’ve been saying the last few weeks (that you scoffed at) are in agreement with ASMI’s report.

        Open communication between a pitcher and the professional coaching and medical staff is paramount. The pitcher’s elbow and body are living tissue. Pitching and training create small tears in the tissue; rest, nutrition, and hydration repair the tears. A pitcher and his team should have a plan, but that plan needs to be monitored and sometimes adjusted depending on how the pitcher feels. Specifically, the pitcher should keep his trainer or coach up to date about any soreness, stiffness, and pain. That way when there is an issue, the player and team can consider rest, modified activity, or examination from the team physician to allow the elbow to heal and avert serious injury.

        When I said some young prospects were not reporting arm pain, you said that it was impossible.

        Exercise, rest, and nutrition are vital for a pitcher’s health. Performance-Enhancing Drugs (PEDs) may enable the athlete to achieve disproportionately strong muscles that overwhelm the UCL and lead to injury.

        The true legacy of the steroid era.

      • paperlions - May 28, 2014 at 8:03 PM

        How in the world do you turn that information into the legacy of the steroid era? Do you think all of these guys are using steroids right now? If TJS was steroid induced, then MLB should have seen a huge spike in TJS during the actual steroid era, which didn’t happen.

        Feel free to explain how steroid use, which has been common since before TJS was invented, just started to result in the TJS epidemic the last 3 years, but mysteriously did not lead to TJS when at least 1/2 the league was juicing from the early 90s through the early 2000s

      • yahmule - May 29, 2014 at 11:11 AM

        Paper Lions: “How in the world do you turn that information into the legacy of the steroid era? Do you think all of these guys are using steroids right now? If TJS was steroid induced, then MLB should have seen a huge spike in TJS during the actual steroid era, which didn’t happen.

        Feel free to explain how steroid use, which has been common since before TJS was invented, just started to result in the TJS epidemic the last 3 years, but mysteriously did not lead to TJS when at least 1/2 the league was juicing from the early 90s through the early 2000s”

        You know, it suddenly occurs to me I’ve greatly overestimated your intelligence for quite some time.

        I’M TALKING ABOUT KIDS USING PEDS, NOT THE MAJOR LEAGUERS FROM THE NINTENDO ERA THAT YOU MISS SO MUCH.

        Maybe you’re just being deliberately obtuse since you know you’re so wrong.

    • sportsfan18 - May 28, 2014 at 11:09 PM

      kids, not only in baseball but in most sports, now play year round, especially in the south.

      there is NO off season, no rest.

      10, 11, 12 yrs old and up can’t keep pitching that much.

      high school seasons are LONG in the south, 50 plus games or more and that goes right into summer leagues and then into fall leagues.

      then, they are working out, throwing and pitching in their tiny bit of “down time” which they are NOT down at all…

      they cannot pitch year round year after year.

      THAT is different than pitchers 50, 70 and 80 yrs ago. Heck, players could come into spring training out of shape and use that to get into shape.

      Now and for quite a while, players have to be in TOP shape from the moment they arrive at spring training and to do that they have to work out during the offseason.

      Most every player begins right after New Year’s day and many don’t stop and are working out after a couple of weeks from the season’s end right into the next season.

      of course, back in the day, pro ballplayers HAD to get jobs in the off season to support themselves to live too so they were not playing and training at the 24 hr gyms, with personal trainers, having their training sessions filmed so their workouts could be broken down to see how to improve their performance etc…

      that’s a bit of what is different.

  4. miguelcairo - May 28, 2014 at 6:24 PM

    I have a feeling Greg Maddux could be Dr. Andrew’s favorite pitcher, based on that snippet Craig included.

    • nothanksimdriving123 - May 28, 2014 at 7:08 PM

      He might fill out his staff with Phil Niekro and Don Sutton, among others.

  5. teamobijuan - May 28, 2014 at 6:39 PM

    The need for speed is also why you don’t see knuckleballers.

  6. beaston - May 28, 2014 at 7:10 PM

    My theory consist of three parts. Young athletes diet in the past ten years. The amount of pitches thrown without proper arm strength and not taking proper care after games. Fast food seems to be a vast majority of young people’s diet. Face it fast food is not health and dose not provide proper nutrition. Second, I see kids thrown 200 to 300 pitches a weekend and not ice arms after. They do nothing for the longevity of their arms. These kids don’t throw during the week and come out on the weekends and light up radar gun. This all leads to failure when they reach high level competition. That’s my theory on the recent incline of Tommy John victims. Please comment with your theory.

    • mikhelb - May 28, 2014 at 7:24 PM

      Yes, I agree for the most part, that’s basically what was said in the MLB Network special about pitchers and TJ Surgery:

      Pitchers do not train enough, do not throw between starts, throw too hard, their biomechanics are off because they do not train properly.

      Regarding ice on the arm, the specialists (James Andrews and others) said that it didn’t help a lot, but instead could do more harm.

  7. paperlions - May 28, 2014 at 7:11 PM

    Here are the 10 most effective pitchers this year and their average FB velocities. You don’t have to light it up to be effective. You mostly need control and movement…even the guys here that throw hard have great control and movement.

    1 Adam Wainwright 90.6
    2 Johnny Cueto 92.8
    3 Julio Teheran 91.1
    4 Masahiro Tanaka 91.5
    5 Jeff Samardzija 94.1
    6 Sonny Gray 92.8
    7 Mark Buehrle 83.4
    8 Yu Darvish 92.6
    9 Tim Hudson 89
    10 Dallas Keuchel 89.2

    • mikhelb - May 28, 2014 at 7:51 PM

      The 10 most effective based on… ?

      The 10 best based on WHIP, with mph and % of usage of their fastball

      Johnny Cueto ; 0.75 WHIP ; 93.4 mph ; 50.80%
      Adam Wainwright ; 0.85 WHIP ; 90.2 mph ; 43.30%
      Tim Hudson ; 0.88 WHIP ; 89 mph ; 53.70%
      Jason Hammel ; 0.9 WHIP ; 92.1 mph ; 59.90%
      Julio Teheran ; 0.94 WHIP ; 90.1 mph ; 64.70%
      Masahiro Tanaka ; 0.98 WHIP ; 91.3 mph ; 44.20%
      Dallas Keuchel ; 0.98 WHIP ; 89.3 mph ; 52.60%
      Scott Kazmir ; 1.01 WHIP ; 90.4 mph ; 51.20%
      Josh Beckett ; 1.02 WHIP ; 91.9 mph ; 37.00%

      Bottom 10 under the same WHIP premise:

      Kevin Correia ; 1.5 WHIP ; 89.4 mph ; 39.40%
      Justin Verlander ; 1.51 WHIP ; 92.1 mph ; 54.50%
      Zack Wheeler ; 1.53 WHIP ; 94.5 mph ; 64.50%
      Eric Stults ; 1.54 WHIP ; 87.2 mph ; 51.60%
      Ubaldo Jimenez ; 1.54 WHIP ; 90.3 mph ; 55.20%
      Justin Masterson ; 1.54 WHIP ; 89 mph ; 78.10%
      Franklin Morales ; 1.56 WHIP ; 91.3 mph ; 58.90%
      Ricky Nolasco ; 1.57 WHIP ; 90 mph ; 48.50%
      Homer Bailey ; 1.59 WHIP ; 94 mph ; 61.50%
      Tim Lincecum ; 1.61 WHIP ; 89.7 mph ; 47.60%

      Any difference on their average FB velocity and the % of usage? Same if you were to judge by ERA (which I would not do).

      • paperlions - May 28, 2014 at 8:08 PM

        I don’t think it matters what you use to judge production, the point is the same. Velocity does NOT lead to effectiveness, it just gives guys a little more room for error. If you throw a meatball 100 MPH, it’ll just leave the park faster than one at 89 MPH, regardless of velocity, you’ll get hit if you miss your spots or if guys can sit on your FB because you can’t throw strikes with anything else.

        I wouldn’t judge effectiveness with WHIP either as hits and walks aren’t all equal and all hits aren’t equal. I used RA9-WAR, which I prefer to WAR because it helps account for pitchers that regularly out pitch (or under pitch) their FIP.

  8. schlom - May 28, 2014 at 7:14 PM

    The problem is that there solutions are really just common sense ones that could apply to any sport – watch your form, don’t overtrain, be sure to communicate any potential injury concerns, etc. Not that this is bad it’s just that it isn’t breaking any new ground on exactly why there have been so many TJ surgeries lately.

  9. badsequel - May 28, 2014 at 7:23 PM

    I know he is a doctor and all that but let me tell you why they are getting hurt…..

    • raysfan1 - May 28, 2014 at 8:02 PM

      10-year prospective studies that show overwork as a 10-14 year pitcher leads to more injuries? Pah! I, the anonymous internet expert, say it is clearly because major league pitchers are coddled.

  10. irishdodger - May 28, 2014 at 7:39 PM

    Nolan Ryan & Bob Gibson disagree w/ this assessment.

    • mikhelb - May 28, 2014 at 7:55 PM

      Did you know that Nolan Ryan had to develop other pitches beside the fastball to keep pitching all those years? He did it once he noticed that high velocities were not a panacea. Same thing happened with Trevor Hoffman.

      As for Bob Gibson the fastball was not the only above average pitch he had, and thats why his fastball was so devastating, for the FB to be effective you have to set them up with offspeed pitches and mix location and speeds. It is one of the reasons why Greg Maddux’s 89 mph fastball looked like it went at 95 mph.

    • shawndc04 - May 29, 2014 at 11:23 AM

      Gibson also threw three quarters, and not over the top. Three quarters is a more natural motion; that over the top motion is an arm killer.

  11. keltictim - May 28, 2014 at 8:57 PM

    I think a much bigger piece of the puzzle is just how many innings these pitchers are throwing now a days from the start. Traveling leagues, youth league. Winter ball, the older generations didn’t have all that crap. The guys pitching today have thrown an older generations lifetime of pitches before leaving college.

    • sophiethegreatdane - May 28, 2014 at 10:30 PM

      That’s an interesting point and may have some merit (though I don’t know how to do the research there). If it’s true that today’s pitchers are, ultimately, throwing more pitches before reaching the major leagues, then the fact that they are doing it with young and under- developed bodies exacerbates the problem.

  12. rationalitybias - May 29, 2014 at 3:52 AM

    You repeat the same motion thousands of times in a six-month span. And usually it is as hard as they can possibly throw. It’s a damn shame seeing these pitchers get hurt

  13. bender4700 - May 29, 2014 at 8:16 AM

    Ask the best hitters in the game if a 100 MPH fast ball really scares them.

    These kids need to learn how to throw multiple pitches, not just Ricky Vaughn it all day.

  14. ctony1216 - May 29, 2014 at 10:16 AM

    It would be great to see research on Japanese pitchers. Do they need TJ surgery at the same rate as MLB pitchers? If not, what could be the reasons?

  15. pmcenroe - May 29, 2014 at 11:07 AM

    “1.Optimize pitching mechanics to ensure using the whole body in a coordinated sequence (kinetic chain). ”

    I find this to be a pretty interesting tidbit from the link. When you compare the mechanics of todays pitchers vs. those from the past I think there is a pretty stark contrast (esp from the windup). I wonder when that shift began or whether it was gradual. Did it coincide with the increased use of the radar gun? Obviously there is no way to know how many pitchers careers would have been extended with TJ surgery pre-1975 or even how necessary it would have been but its seems like a valid point

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