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Why is Tommy John Surgery So Common in Baseball?

What could be causing this Tommy John Epidemic?

Ask any physician, physical therapist, athletic trainer, or coach about the surge in UCL injuries and you're likely to hear a range of theories. Is it throwing mechanics, the quest for increased velocity, the use of sweepers, early sport specialization, current training methods, or the impact of weighted balls? While each factor may contribute, the prevalence of Tommy John surgery among baseball players is influenced by a complex interplay of many elements.

Research into the nuances of elbow injuries has expanded our understanding, highlighting a spectrum of contributing factors. These include overuse, poor workload management, and inadequate physical preparation of athletes. The approach to addressing these issues is multifaceted, touching on everything from training regimes to recovery protocols.

In this post, I will explore some of the primary contributors to the rise in UCL injuries and discuss strategies to mitigate these risks and offer practical solutions for athletes, coaches, and sports medicine professionals.


Workload Management

Poor workload management stands as one of the primary reasons we see so many Ulnar Collateral Ligament (UCL) injuries, and it mostly comes down to not managing how much, how hard, and how often players throw. This problem usually shows up in two ways:

Undertraining: Sometimes, athletes don't throw enough or don't spend enough time getting ready for the big moments coming up, like showcases or tournaments. Imagine a high school player who has a big showcase in the fall but hasn’t really been throwing much leading up to it. They're more likely to get hurt because their arm isn't ready for that intense activity.

Overtraining: On the other hand, some players throw way too much without enough breaks. When you throw hard too often and don’t rest enough, your arm gets fatigued, and that's when you start seeing muscle strains and ligament tears. The structures around the elbow just can’t handle the stress anymore.

Both situations point out how important it is to have a well-thought-out plan for how much and how often athletes should throw. This plan needs to balance building up throwing fitness. Take a look at the image below to get a nice visual on proper workload management.

'Workload' refers to the frequency, intensity, and volume of throws. Proper workload management involves tracking both chronic (long-term, typically over 28 days) and acute (short-term, about a week) workload. Advanced tools like the Driveline PULSE sleeve can provide accurate workload measurements. For those without access to such technology, monitoring the number of throws and the intensity of those throws is crucial.

The Acute to Chronic Workload Ratio (ACWR) is a key tool for managing how much athletes throw. It helps compare their recent throwing activity to what they’ve been doing longer-term. This way, we can make sure players aren’t ramping up their throwing volume or intensity too suddenly. Research shows that big jumps in an athlete's usual and recent training loads can really up the chances of getting hurt.

When we talk about ACWR, we aim to keep an athlete's ratio between 0.8 and 1.2. This means we try to maintain their recent workload within roughly +/- 20% of their regular, longer-term workload. Sticking to this range helps ensure that changes in their throwing routine, either through adding or removing workload, are gradual enough to avoid injury while still allowing for progressive training enhancements and optimal recovery.

Driveline PULSE Sensor used to measure throwing workload and keep track of ACWR


General Physical Development and Preparation:

Societal trends toward early sport specialization have significantly reduced the time young athletes spend developing general physical qualities. The vast majority of the young athlete’s year is spent in some form of competitive play, when it should be the minority. This focus on a single sport at an early age can limit their overall physical development, increasing the risk of overuse injuries. It’s not necessarily about multi-sport participation being superior to single-sport specialization; rather, the key is involvement in diverse activities or structured training programs that expose young athletes to a variety of physical challenges. 

For young athletes under the age of 12, the emphasis should be on activities that foster foundational strength, flexibility, and broad motor skills. This can include a mix of calisthenics, play-like activities that include lots of climbing, crawling, and tumbling with various fun and engaging task-demands, and general arm care exercises. These activities are crucial for developing the basic physical capabilities that support athletic growth without the pressures of competitive play.

As athletes grow older, incorporating structured strength and conditioning programs becomes essential. These programs should focus on foundational strength training through simple, effective movements designed with long-term athletic development in mind. This approach gradually prepares the athlete’s body for the increasing demands of their sport by reinforcing key areas of strength and stability.

For high school and collegiate athletes, the training can advance to include more specialized strength exercises, powerlifting, and detailed arm care routines tailored to meet the high demands of competitive baseball. At this stage, the focus shifts towards optimizing performance, reducing the risk of injury, and preparing for peak competition levels.

By ensuring young athletes engage in a broad range of activities and focusing on fundamental skill development rather than early competitive play, they can achieve a more balanced and sustainable athletic development. This strategy helps in nurturing well-rounded athletes who are physically and mentally prepared to handle the specific demands of their chosen sports as they mature.


Underdevelopment of Dynamic Elbow Stabilizers:

The stability of the elbow during the demanding activity of pitching is critically dependent on the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor carpi ulnaris (FCU). These muscles are essential for absorbing and managing the stresses that occur with each throw. However, if these muscles are weak or become fatigued, their capacity to protect the elbow diminishes, increasing the risk of microtears in the UCL. This risk escalates with the frequency of pitches, underscoring the need for strength and conditioning programs that focus specifically on enhancing the endurance and shock-absorption capabilities of these muscles.

Traditional training programs often neglect these specific tendons, which are critical for elbow stability in pitchers. Research by scientists like Kubo has shown that these tendons require intense, prolonged training to undergo material changes that increase their stiffness and improve their ability to shield the elbow from stress. To effectively enhance these qualities, the tendons must be subjected to high-intensity exercises that progressively load them, allowing for adaptations that contribute to greater resilience and durability.

This approach involves incorporating exercises that specifically target the FDP, FDS, and FCU, ensuring they are not only strong but also capable of sustaining high loads over extended periods. Exercises designed for this purpose might include advanced grip strengthening drills, wrist flexor and extensor exercises, and other forearm conditioning work that focuses on tendon health and performance. Such targeted training is essential to build up the tendons' capacity to handle the intense demands of pitching, thereby reducing the likelihood of injury and enhancing overall elbow stability.

A promising development in this area is the introduction of the FlexPro Grip, a device that is gaining popularity among professional organizations for its effectiveness in forearm and grip training. I have personally used this tool extensively with athletes to enhance their grip strength and forearm resilience, which in turn helps alleviate elbow pain and improve overall arm health. The FlexPro Grip offers a structured way to strengthen these critical muscles and tendons, making it an invaluable component of a pitcher's training regimen.

Incorporating these insights into training regimens will provide pitchers with a more robust defense against the common injuries associated with the repetitive and high-intensity nature of their sport. It’s about shifting the focus from general strength training to a more nuanced approach that prioritizes the specific needs of the elbow's dynamic stabilizers.

In conclusion, preventing Ulnar Collateral Ligament injuries involves more than just fine-tuning throwing mechanics. A comprehensive approach that includes appropriate workload management, targeted physical conditioning, and encouraging a broad athletic foundation from an early age is essential.

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