Injury Guide To Tommy John

Let's find out how to handle Tommy John.

Welcome to this year’s Injury Guide! In the past, we have done a weekly version of the Injury Report where we would dissect each player, their injuries, and their outlook for the rest of the season.

This year, we will take a deep dive into individual injuries and look at historical data to better understand what each injury means for your player for the rest of the year and beyond.

First on our list is an injury that has impacted all of us in some shape or form: Tommy John. But do we know precisely how much TJ has impacted our fantasy baseball lives? This article will look at MLB pitchers since 2012 and their pre-TJ and post-TJ data to clarify how to handle a pitcher who has had Tommy John.

Since 2012, we have had 286 MLB players undergo surgery, the large majority of whom are pitchers.

Tommy John History 2012-2021

Ulnar Collateral Ligament


What is the ulnar collateral ligament (UCL)? The UCL is a ligament on the inside portion of the elbow that connects the humerus (upper arm bone) and the ulna (elbow). The UCL creates stability within the elbow for overhead throwing.

UCL injuries can occur in one of two ways. The first is a traumatic experience; think of someone kicking your elbow while trying to do a push-up. The second is a series of micro-traumatic events over time, and this is how most pitchers tear their UCL.


Treatment Options 


For UCL injury management, there are a handful of current options utilized by the medical community. Platelet-rich plasma injections, UCL reconstruction surgery, and internal bracing are currently the most common routes for treatment. Each option has its unique pros and cons with all treatment routes. Let’s take a look, starting with platelet-rich plasma.


Platelet-Rich Plasma


Platelet-rich plasma (PRP) injections are used primarily for partial torn UCLs. PRP utilizes the patient’s blood to create a platelet-rich (genius, right?) solution to be injected into the injured area. Platelets contain increased levels of growth factors that accelerate the healing process. But does it work?

History has shown that PRP injection for partial torn UCLs is a successful treatment option. 73-98% of players return without complications depending on the study you read, with an average return time of 12 weeks. We can look at Masahiro Tanaka as a recent example of this working out.

A major pro for PRP is the quick return time. When facing the risk of undergoing Tommy John, being presented with PRP injections, and returning to the mound after 12 weeks vs. being out for over a year is an appealing option for both pitchers and MLB teams.

Another pro is the risk of the procedure. With all medical procedures, there is an inherent risk of complications. PRP injections carry a low risk of potential complications due to the nature of the injection.

PRP is an excellent choice if the UCL is not fully torn. We know that PRP for a fully torn UCL is not a viable option. The failure rate is too high.


UCL Reconstruction


UCL reconstruction is the gold standard for UCL tears. The surgeon will take a graft from somewhere in the body (usually a tendon in the wrist or the hamstring) and use that harvested tendon to become the new UCL.

Due to how violent and demanding pitching is on the elbow, the recovery time is longer than for a position player undergoing Tommy John. Typically, we can expect 12 months before a pitcher returns from Tommy John, but we have seen rehab extended to 18 months.

Reconstruction is the gold standard for a reason. While we expect pitchers to return within the 12-18 month timeline, it’s about an 85% chance that a pitcher returns to his prior level after surgery. Considering this was an injury that ended careers 60 years ago, it’s truly remarkable.

Pros for Tommy John center around the fact that surgeons are really, REALLY good at this surgery and are only making progress. This, the return rate is predictable and the risk of failure is lower than what we see with PRP injections. The main con is, of course, the long recovery time.

Originally, UCL reconstruction was a last-ditch effort to salvage an MLB pitcher’s career and not what we are seeing today from the majors down even to high school. Every year, the number of high school-age children undergoing Tommy John increases by almost 10%. So far, this hasn’t been a problem, but it might impact MLB and fantasy baseball in the future.

In the next 10-20 years, I expect to see a massive spike in pitchers undergoing their second Tommy John surgery. Is that a big deal? Well, yes and no.

The surgeon will drill into clean and intact bones with the original reconstruction. After the surgery and when the pitcher returns to the mound, scar tissue fills the hole. Scar tissue is weaker and not as durable as bone. If a pitcher is undergoing a second, third, or fourth surgery, there is an increased potential for failure at the graft site.

Currently, we are seeing Mike Clevinger return from his second UCL reconstruction surgery. His first surgery was in 2012 while in Single-A ball, and the second in 2020 with the Padres. After 18 months of rehab, he returned on May 4th.

Being 31, Clevinger could have another 5+ years left in him. He will be the standard for the time being on what to expect from pitchers who are returning from a second Tommy John.

However, a new(ish) and exciting alternative to UCL reconstruction could also save future pitchers from the doom of a second UCL reconstruction.


Internal Bracing


Internal bracing is the newest wave of elbow surgeries coming to an MLB player near you and is exactly how it sounds. The surgeon goes into the elbow and wraps it in a collagen brace. This procedure is mainly used for pitchers who are either a bad fit or failed with PRP but don’t have a complete tear needing a full-blown reconstruction.

This procedure saves the surgeon from drilling into the bones, and the graft does not need to undergo the transition from tendon to a “ligament.” These pros are why pitchers can return to pitching in 6 months vs. 12 months or longer.

The only MLB pitchers who have undergone the internal bracing procedure are Rich Hill, Matt Bush, and Kenta Maeda. Combined, we have just 252 innings of data. We need more time before truly knowing how this will impact MLB and fantasy baseball long term.

This procedure might be the next big thing, and it could save future pitchers. The exciting part of the internal bracing procedure is that there will be scenarios where a pitcher might need two surgeries in the future and could be a candidate for a traditional UCL reconstruction and an internal bracing procedure.

The only real con against the internal bracing is that we don’t have a longstanding track record or long-term data. This surgery is about ten years old, so we will see how the procedure holds up over time. But I fully expect this to gain notoriety in the years to come.


Results After Surgery


Now for the million-dollar questions, how do pitchers fare after Tommy John?

I think it is safe to say that we are aware of the shift in pitching within the last five (2017-present) years, and that is where I want us to focus on. As we would expect, the biggest drop in performance is the first year back from Tommy John. On average, we see a decrease of 47 innings pitched between the first year returning compared to the year before the injury. If we want to assume the average starting pitcher will pitch six innings per start, that will give us about eight fewer starts in the first season back.

When looking at how a pitcher fared with ERA and FIP in their first season back, we see FIP rise 0.988 and ERA rise 1.116. The sharp increase in BB/9, HR/9, and decrease in strikeouts all lead to a decrease in performance.

By and large, all of the stats that we analyzed returned to near baseline in their second year after surgery. Games and innings pitched show a decrease during the second year, but a decent portion of the data is part of the shortened 2020 season. Had there been a full season, the innings pitched and games pitched would be closer to baseline.


Rostering Players After Tommy John


The significant finding of our research was that pitchers have recovered and performed well after Tommy John surgery. The first year is rough, and we see a considerable drop in all counting stats.

We should expect the pitchers to return to their pre-injury form by year two. Of course, if you have a pitcher nearing a return around the start of the season or Spring Training, we shouldn’t be too worried about their performance. Moving forward, I am going to value pitchers returning from Tommy John at about 73% of their pre-surgery value for their first year returning from injury.

This change in value considers the increase in earned runs and FIP, a decrease in control, velocity, and ability to keep the ball in the yard.

Of course, we can’t predict how players will perform, let alone after a significant injury and surgery. But after the research and deep dive we took for the article. I’m changing my opinion on targeting and rostering players returning from Tommy John.


Featured graphic by Michael Packard (@artbyMikeP on Twitter & IG)

In article graphic created by @visual_endgame on Instagram & Twitter

This information is used for entertainment purposes and to help with fantasy baseball decisions. This is not medical advice and should not be used as a source for making health and/or wellness decisions. 

Thanks for reading Injury Guide to Tommy John! I will answer all questions as I can and would love your feedback about what injuries to cover next! 

Jake Robinson

What's up, everyone! I'm Jake, and I (painfully) love all things with Texas A&M, Texas Rangers, and Dallas Cowboys. I'm your guy for all things injuries here at Pitcher List. Catch me on Twitter and IG @jakerobinsonDPT

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