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Tommy John Injury Prevention: From a Former Pitcher, Patient, and now, Therapist.

Written by: Greg Harris, OTR/L, CSCS, TSAC-F

Virtual Hand to Shoulder Institute

Therapy Fellow ‘21

As the post-MLB season approaches, and playoffs begin, more people will be watching their favorite teams and players. Baseball pitchers, in particular, have a unique position with the tremendous stress placed on the entire body. As a former pitcher myself, and as someone who has experienced athletic-related injuries, namely the Tommy John Injury, I’ve committed myself to advance my practice in the specialty of treating athletes with upper extremity, hand injuries, and overall strength and conditioning.

One of the most typical complaints for baseball pitchers is pain to the inside of the elbow, namely the area at and around the medial epicondyle, resulting from a tear to the ulnar collateral ligament (UCL). Most people know this injury as “Tommy John,” named after the pitcher who had the first ulnar collateral ligament reconstruction in 1974, commonly referred to as a Tommy John Surgery.

Since the mid-1970s, UCL injuries have increased due to more specialization in sports resulting in less variety of physical demands. Also, there have been changes in pitching mechanics, contributing to excessive valgus stressors to the elbow. Therefore, there’s the need also to consider hip mechanics, such as leading with hips to home plate, hip flexibility, overall lower extremity strength, and overall shoulder range of motion. For example, research shows that pitchers who require UCL reconstruction have a higher prevalence of lower extremity injuries both before and after surgery, indicating we need to look at the body as a whole rather than just one piece (Kantrowitz et al. 2018).

Nearly 25% of all MLB pitchers have had ulnar collateral ligament reconstruction (Conte et al., 2015). With the growing prevalence of ulnar collateral ligament injury to pitchers, and the need for invasive surgery for these athletes, the importance of injury prevention is more important than ever. In New York State, alone, from 2002 to 2011 they saw an increase of 193% of new reconstruction surgeries, and the overall rate per 100,000 people more than tripled (Hodgins et al, 2016) indicating this is more of an epidemic than just a concern in the baseball world.

What is Tommy John Surgery?

Tommy John surgery or UCL reconstruction is indicated for ulnar collateral ligament tears to restore elbow stability, and ultimately upper extremity and hand function. Typically the surgery involves using the palmaris longus tendon from your forearm to replace the stabilizing function of the ulnar collateral ligament. The goal of the surgery is to eliminate the pain, stabilize the elbow, restore range of motion of the upper extremity, and for the athlete, get them back to sport (John Hopkins Medicine).

Common Symptoms of an Ulnar Collateral Ligament Tear

Pain on the inner side of the elbow Unstable elbow joint Elbow tenderness Swelling of the elbow Limitation in movement. A popping sound is often associated with UCL tears. Decreased performance in activities such as throwing baseballs or other objects Reduced throwing velocity Poor grip strength Numbness in the ring & pink finger

Typical causes for injury to the UCL

Overuse of throwing arm research indicated that any pitcher throwing over eight months (500% increase) of the year and over 80 pitches (400%) is at increased risk (Hodgins et al., 2016). Shoulder Flexibility Rotator cuff weakness Poor pitching mechanics Poor hip and posterior chain strength Inadequate rest and fatigue levels Children's elbow epiphysis do not close until age 21. This growth process puts elbows at risk for instabilities and OCD (osteochondritis dissecans).

Prevention tips for UCL tears

Always complete dynamic warm-up before any throwing Improving shoulder flexibility and implementation of the sleeper stretch Implementation of the throwers 10 program for strengthening of the rotator cuff and flexor/pronator groups. Examples from Andrews Sports Medicine included in the link below: Hip flexibility/strengthening

The best advice if you develop pain on the inside of your elbow

Keep active communication with your OT, PT, coaches, and athletic trainer. Always they are the trained professionals who can adjust, modify, and implement changes to your program. Rest, if possible, taking a few days and then revisit throwing with easy progression, which can allow the initial inflammation to subside. Vary workout routines to ensure adequate blood flow to the area while not placing stress on the elbow through throwing. Remember always to use a dynamic warm-up before exercise. Ice the affected area

If pain persists If pain persists, the best plan of action is to contact your healthcare professional, therapist, trainer, or coach. Your physician can order further diagnostic testing to pinpoint the cause of the pain and prescribe the best course of action. Rehabilitation may be recommended whether surgical intervention is needed or not. An occupational therapist who specializes in upper extremity conditions can rehabilitate the patient through an analysis of biomechanics, musculoskeletal alignments, and compensatory strategies to restore function, prevent further injuries, and optimize athletic abilities. Resources

1. Conte SA, Fleisig GS, Dines JS, Wilk KE, Aune KT, Patterson-Flynn N, ElAttrache N. Prevalence of Ulnar Collateral Ligament Surgery in Professional Baseball Players. Am J Sports Med. 2015 Jul;43(7):1764-9. DOI: 10.1177/0363546515580792. Epub 2015 Apr 29. PMID: 25925603.

2.Elbow Sprain and UCL Tear Treatments - Houston, Beaumont, Cypress TX. (n.d.). Retrieved September 23, 2020, from

3. Hodgins, JL, Vitale, M, Arons, RR, & Ahmad, CS. (2016). Epidemiology of medial ulnar collateral ligament reconstruction A 10-year study in New York State. American Journal of Sports Medicine, 44(3), 729-734.

4. Tommy John Surgery (Ulnar Collateral Ligament Reconstruction). (n.d.). Retrieved October 02, 2020, from

5. Kantrowitz, D. E., Trofa, D. P., Woode, D. R., Ahmad, C. S., & Lynch, T. S. (2018). Athletic Hip Injuries in Major League Baseball Pitchers Associated With Ulnar Collateral Ligament Tears. Orthopaedic journal of sports medicine, 6(10), 2325967118800704.

6. Marks, K. (2019, December 16). How Many MLB Players Have Had Tommy John Surgery? Retrieved September 23, 2020, from 7. Ulnar Collateral Ligament (UCL) Injury. (n.d.). Retrieved September 23, 2020, from



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