Searching for Tommy John: Sizing up the key culprits in MLB's elbow injury epidemic

First things first: Never trust anyone who says they know why so many pitchers are succumbing to Tommy John elbow reconstruction surgery.

If that person truly had a solution, they’d likely be touching up their bust in Cooperstown, possessing a billion-dollar formula to preserve arm health, careers and the championship hopes of teams on every level of baseball.

Yet here we are in 2024, just five months from the 50^th anniversary of orthopedist Frank Jobe’s first, groundbreaking surgery on left-hander Tommy John, and the industry is only so much the wiser.

Evolution is wonderful, and Jobe’s breakthrough was the most crucial step on a spectrum where careers once ended because a pitcher "blew their arm out" to today, when a hurler can return in a year to 18 months, and orthopedists can even choose a path to ulnar collateral ligament reconstruction, be it old school TJ or the newer, internal brace procedure.

Yet the frequency with which pitchers are succumbing is now a full-blown crisis for Major League Baseball.

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March and April are always spooky season for arm care, with pitchers aiming to safely ramp up for a season of velocity-driven violence, often with grim results. Shane Bieber’s imminent surgery and Atlanta ace Spencer Strider’s UCL injury were just the latest, most high-profile blows in a 13-month period that has seen 38 major league pitchers require elbow reconstruction.  

But why?

Well, a legion of orthopedists, biomechanics experts and trainers are aiming to best answer that on behalf of Major League Baseball, though separating signal and noise has been a challenge going on a half-century.

Meanwhile, sober analysis can’t slow down harmful and misleading discourse. So let’s break down the potential or even likely reasons why we’re in what future Hall of Famer Justin Verlander calls a "pandemic" of arm injuries:

The pitch clock

It is new – at least to major league pitchers – and it arrived at the game’s highest level just as a flurry of high-profile arms blew out. Jacob deGrom, the two-time Cy Young Award winner freshly signed to a $180 million contract, didn’t even make it past six April starts with the Texas Rangers before succumbing to his second elbow reconstruction.

In the 13 months since, the hits haven’t stopped coming:

Two-way superstar Shohei Ohtani. Reigining Cy Young Award winner Sandy Alcantara. All-Star ace Shane McClanahan and a bevy of his friends in Tampa Bay. Dominant closer Felix Bautista.

And now Bieber and Strider likely headed to the operating table, with blinking red lights of concern around New York and Houston aces Gerrit Cole and Framber Valdez.

It took less than a year for this issue to become politicized.

In the pitch clock-blaming business: The Major League Baseball Players’ Association claiming the high-profile and high-salaried arms going under the knife absolutely coincides with the implementation of the pitch clock, which likely counts as commissioner Rob Manfred’s biggest win thanks to reduced game time.

In the correlation does not imply causation camp: Major League Baseball, which is loathe to say its baby is to blame for the injury wave.

In the middle: The players themselves, who know their working conditions are growing more dangerous to survive yet can’t slow the arm carnage nor the need to maximize their pitch velocity.

We unearthed this tension in February, when none other than Strider, unprovoked, voiced concern about a two-second reduction on the clock with runners on base.

"If anything," Strider told USA TODAY Sports, "the league is making rule changes despite an injury epidemic that could very well be encouraging injuries, such as the pitch clock, limiting the number of pitchers on roster, how many pitching changes you can make, how many mound visits you can have – all those things are making pitching harder and potentially, I think, making health more difficult to manage.

"With injury rates where they are, I don’t know how we can blindly decrease the clock after the worst injury season in baseball, arguably, without having a conversation about injuries. The league talks about creating more action on the field.

"Well, when the best players in the league are hurt, how much interest is there in the game?"

MLBPA executive director Tony Clark sounded a similar alarm then, bemoaning that "rather than give us another year to adjust and adapt to it, why are we adjusting again, and what are the ramifications going to be?"

MLB fired back then and now, twice citing a Johns Hopkins study that found "no evidence to support that the introduction of the pitch clock has increased injuries."

Either way, it’s still just one year of data. The pitch clock was first attempted at the Class AA and AAA levels in 2015 and implemented across the minor leagues in 2022, and ostensibly the next generation of pitchers might be more conditioned to deal with it.

Yet biomechanics experts acknowledge that pitching in the major leagues, where almost every pitch is a high-leverage moment, is a different beast than the minors, where development trumps all.

Cole, the Yankees ace working his way back from elbow fatigue, took on the voice of reason Monday after the union and league sniped at each other, noting that a five-year trove of data is probably necessary to truly understand the effects.

"But to dismiss it out of hand, I didn't think that was helpful to the situation," he told reporters. "I think the players are obviously the most important aspect of this industry and this product. And the care of the players should be of utmost importance to both sides."

The verdict: It’s too soon to tell – and everyone needs to chill out a little bit.

The chase for velocity

Strider, whose 98-mph fastball is the battering ram he used to punch out a major league-high 281 batters in 2023, can boil this one down easily.

"Front offices are paying for strikeouts," he says.

Indeed, the max-velocity craze is something of a disharmonic convergence where analytics, high-impact training and, yes, the desire to put food upon one’s table come together. The drive toward so-called "three true outcomes" baseball – walk, strikeout, home run – on both sides of the ball made the end goal not necessarily getting outs but controlling the result of a plate appearance.

That led to a more stultifying game, which spurred MLB to implement radical rule changes before the 2023 season that included, yes, the pitch clock.

But there’s no going back – even as injury rates skyrocket in lockstep with velocity readings.

The average fastball velocity leaped from 90.5 mph in 2008 to 93.9 mph in 2022 and topped 94 for the first time last year. Glenn Fleisig, head of biomechanics research at American Sports Medicine Institute and part of MLB’s study group on arm injuries, notes that the injury curve is almost in lockstep with the velocity rise.

By the end of last year, 31 of the 64 hardest throwers based on Statcast metrics had undergone Tommy John surgery at some point in their careers.

Injury analyst Joe Roegele, who tracks Tommy John surgeries at every professional level, noted that the percentage of major league pitchers who have undergone Tommy John surgery hit 35.3% in 2023, a 29% increase since 2016.

This era of hard fastballs and harsh injuries has produced few paradigms, but here’s one that will never go away: Velocity wins. Pitchers, executives and franchises are still trying to determine the appropriate opportunity cost.

The verdict: Where there’s smoke, there’s fire.

Too much spin, too much throwing – or not enough throwing?

Wanna know how long it’s gonna take to figure this thing out?

In April 2015, MLB and USA Baseball rolled out the Pitch Smart compliance program, designed to limit wear and tear on young arms as they shuttle between Little League, travel and school-affiliated ball.

The policy, updated multiple times in the nine years since, can’t prevent overzealous coaches from abusing arms, or kids and their parents from fudging on availability if there’s a showcase or a tournament they just can’t miss.

But let’s just assume this heavily-workshopped program is both sound in its construction and largely adhered to by coaches, parents and players. That means 12-year-olds in 2015 are only now hitting their 21^st birthday – and such guidance was not memorialized for the pitchers now in their late 20s, many of whom are undergoing their second Tommy John surgeries.

Even if Pitch Smart is a gold standard, the question of how much to throw – and what to throw – remains subject to significantly differing opinions.

Nowadays, the school of thought is major leaguers avoid the early-season danger zone by taking only a nominal break in the off-season; rather than starting up a throwing program, it’s easier to virtually never stop, and most are throwing full-fledged bullpen sessions weeks before spring training begins.

Veteran pitcher Alex Wood notes how significantly that paradigm has shifted since his 2013 debut, and that the righteous desire to develop new pitches and alter pitch shapes can only be achieved through, you know, getting on a mound and throwing more.

Oh, and about those pitch grips and pitch shapes.

For decades, it was believed that kids throwing curveballs was the devil’s work. And that, at a higher level, the split-finger fastball was a devastating weapon but an arm-wrecker.

Now? Depends on who you ask.

Veteran trainer Stan Conte believes the max-effort fastball places the most stress on the ulnar collateral ligament, which, as future Hall of Famer Justin Verlander notes, doesn’t stop "10-year-olds on my Instagram feed trying to throw as hard as they can."

Meanwhile, Dallas-based orthopedist Keith Meister, who has supplanted the retired James Andrews as the Man No Pitcher Wants to See, cites the prevalence of the sweeper and power changeup as adding stress to UCLs.

It is, as with almost everything Tommy John-related, a moving target. But all theories, circuitous in their routes, arrive at the same destination: Throwing a baseball at the most hypercompetitive level is incredibly stressful on the arm – the shoulder, the rotator cuff, and most of all, that tiny little ligament whose efficacy means the difference between winning and losing, riches and ruin.

The verdict: Don’t expect a quick fix – because there may never be one.