Ulnar collateral ligament (UCL) reconstructive surgery, now known as Tommy John surgery, is a surgical procedure meant to repair a torn UCL in the elbow. An incision is made on the inside of the elbow, close to the funny bone, and then the damaged ligament is replaced.

“These days you can use two types of tendons,” Dr. Alan Micev (CQ) said. “You can use an autograft, which is a tendon from the patient having surgery. Or you could use an allograft tendon, which is a tendon from a cadaver that has been sterilely processed."

The recovery time for this type of injury is normally 12-18 months, but not everyone heals the same and there can be complications that cause a longer recovery timeline. Physical therapy is needed to strengthen the elbow/arm.

For former minor league baseball pitcher and current youth pitching coach Brett Schneider (CQ), this process caused a longer recovery.

“You just think it’s career-ending because it happened at 25, which is pretty old for a prospect’s age in baseball,” Schneider said. “But then going through the rehab process, it was during COVID, so my rehab process came to a halt and I kinda had to do it on my own. So I had a different recovery than the average Tommy John survivor.

“I guess the surgery is at a point now, versus a decade ago, everyone comes back, so it’s not as demoralizing anymore. You kind of expect it as a player.”

The success rate for Tommy John surgery has risen to between 80 and 90%.

According to USA TODAY, studies reveal that as of 2024, “36% of all active Major League pitchers have undergone Tommy John surgery, and the rate continues to increase every year.” However, teen athletes are undergoing this surgery much more frequently. In fact, “the injury rate for the ligament injury in youth sports is 10 times greater than it was in 2000.” 

According to Chicago’s Rush University Medical Center, “the biggest age group that needs the surgery in the country is from ages 15-19.” Among that age group, according to the Foundation for Orthopaedic Research and Education, “the incidence is increasing by 9.12% per year.”

According to the American Medical Association, by 2014, “67.4% of UCL reconstruction surgeries were performed on athletes 16–20 years old.”

What is causing this huge increase in surgeries and what are coaches, players, teams and leagues doing to combat this? There are a few theories. The main theory is that pitchers are throwing much harder than they used to, and that creates more stress on the elbow and arm.

“Baseball has turned pitching into a science, not just an art,” Micev said. “It’s an actual science and the amount that pitchers can load their elbows these days is beyond what an ulnar collateral ligament was designed to handle. So it’s such a common injury with how fast these pitchers are throwing the ball and how much torque they are putting across their elbow.”

According to Baseball America, the average fastball velocity in MLB was 91.9 mph in 2008. In just 15 years since, that number has risen to 94.2 mph in 2023. At the high school and youth levels, young pitchers are throwing harder as well.

“Right now everyone wants to light up the radar gun and throw hard,” Arcadia High School baseball coach Jeffrey Fierro (CQ) said. “Velocity is such a huge thing where guys feel like if they’re not hitting a certain number on the radar gun that they’re not gonna go play college ball, that they’re not going to be recruited, all of those types of things.”

“Tommy John’s are more likely to happen on fastballs than people may think,” Schneider said. “Tommy John’s are most likely created from just overuse of the fastball, or possibly throwing too hard for too long.”

This can lead to long-term issues.

The Houston Public Media reported that, “kids are going through changes between the ages of 8-14. During a growth spurt, growth plate injuries are common with repetitive sports.”

Growth-plate injuries can lead to major complications in young athletes, including stunted growth.

Another theory is that between club baseball, high school baseball and traveling teams, baseball is now being played year-round and that can put extra stress on the elbow.

“Kids are playing a ton of games,” Fierro said. “Whether they’re 9 or 10 years old, or high school guys.” 

Fierro has many theories on this subject as a long-time baseball coach, one of which is that strengthening one’s legs can be the key to elbow/arm health.

“What happens is guys are not conditioning properly,” Fierro said. “So a lot of the conversation in baseball circles is like guys’ legs not being ready enough to handle the stress of high-inning pitching.

“Because really when you’re throwing and you’re getting downhill, you’re throwing with your legs and everything else is just following through.”

To combat this, Fierro has his players run to strengthen their legs and have proper conditioning. 

“That’s a leading cause of Tommy John surgery,” Schneider said. “Just not taking care of yourself and then just the wear and tear adding up.”

Another theory is that the types of pitches being thrown, as well as the arm-slot plays into it. The emergence of new pitches such as the sweeper causes the arm-slot to change. With that being said, it’s hard to change one’s mechanics once they get to a certain age when they’ve been doing this their whole life.

“The more you move the slot lower from high three-quarter, three-quarter, low three-quarter to sidearm, if the mechanics are off and the pitchers open up too soon, they’re gonna lead with the elbow, which puts stress on that joint,” Chicago White Sox scout John Kazanas (CQ) said.

“So when guys have bad mechanics, they have a chance of doing damage to that area,” Kazanas said. “If certain mechanics occur, there’s pitchers we may ignore because of poor mechanics.”

This means that scouts could decide not to sign or draft a certain pitcher because their mechanics could lead to Tommy John surgery, which teams and players alike would obviously like to avoid.

Fierro also believes communication is key when preventing this issue.

“Making sure there’s communication between high school coaches, between club coaches and between the players themselves,” Fierro said. “That way they’re not being (overused). So we always tell our kids to just communicate with us.”

Finally, players being self-aware of the risks involved in baseball is important in order to avoid injury.

“It’s a fairly substantial risk,” Micev said. “I think when you’re young, when you’re a teen-ager or in your 20s, you don’t think much about injuries until they happen. But I think that part of being an elite-level athlete is saying, ‘how do I perform at an elite level and also preserve my body,’ so you don’t potentially need surgery and physical therapy and long recoveries.”

Baseball from the youth level, all the way up to the major leagues is dealing with a major epidemic, according to MLB Insider and USA TODAY columnist Bob Nightengale (CQ).

“Teams are spending so much on injuries and Tommy John surgeries,” Nightengale said. “I know the Player’s Association is very upset at what is going on. So I think there’s gotta be widespread awareness that let’s go back to the way the game was meant to be played and just pitch.”

So what can be done to change this trend?

“There’s gotta be a change in culture with it throughout baseball,” Fierro said. “Whether it’s 5 years old, all the way up to where we gotta start teaching kids to pitch rather than just throw.”

What Fierro and Nightengale mean by ‘pitch rather than throw’ is that many pitchers today throw as hard as they can, but can’t locate their pitches. Fierro said if you can’t locate your pitches, you’re not going to be a very good pitcher or last very long in the major leagues.

“It’s going to come from the youth level too,” Nightengale said. “And whether it’s parents or coaches that say, ‘hey, learn how to pitch’. Don’t just throw as hard as they can.

“And I think it’s going to be major league teams too saying, ‘hey we don’t care how hard you throw. Learn to pitch.’ Nobody cares how hard you throw a ball.”

While Nightengale and many others believe there are ways to alleviate this epidemic, Schneider believes this uptick can’t be stopped and will remain looming over the heads of baseball pitchers.

“It’s a tough question because there’s no proven way to stop Tommy John surgeries from happening,” Schneider says. “I believe it’s one of those things that’s inevitable.”