Strasburg and the Tommy John question

Stephen Strasburg returns to the major leagues today, barely over a year after he underwent the procedure commonly known as "Tommy John surgery," or affectionately known as "the zipper" by many players who have had the operation to replace a torn ligament in their throwing elbow. To think about what Strasburg's future may hold as he continues his recovery from the surgery, it's worth looking at what happens from the end of the surgery itself to the point at which the pitcher returns to full competition.

According to a paper published by the American Sports Medicine Institute in October, 83 percent of the pitchers who have Tommy John surgery make it back to their pre-injury levels of velocity and command, while only 4 percent of the 743 patients they followed or contacted reported major complications. The conclusion is that it's a high success-rate surgery, especially compared to operations on the shoulder, which is a much more complicated joint than the elbow is. But within the 83 percent is a range of results and timetables that comes down in large part to how the pitcher pursues his rehabilitation.

Even before the surgery, Dr. Kevin Wilk, a physical therapist who oversees rehab efforts for Tommy John patients and is director of rehabilitative research for ASMI, will map out a plan for the pitcher that goes beyond simply rehabbing the elbow. "A lot could have something going on with their shoulder that causes the elbow problems, so pre-op, we'll look at their shoulders, scapula, muscle balances, any limitations they have, and we try to develop a post-op program to address that during the first three months." He tells patients that those first few weeks are the time to get their shoulders in shape, which has an added benefit -- the pitcher is in an elbow brace for six weeks, so he needs to focus on strengthening other parts of his delivery.

When Dr. Wilk first started working with Tommy John patients over 20 years ago, the standard time in the brace was eight weeks, but within the last few years that's been reduced to six weeks to cut down on the main post-op complication, flexion contracture -- a stiff elbow that the patient can't fully straighten. (Within the first two weeks, the main concern is the healing of the incision, after which elbow stiffness tops the list.) That said, the brace is necessary to prevent the otherwise-unlikely injury of the new ligament before it has had time to set.

In Tommy John surgery, formally known as ligament transplant surgery, the surgeon takes a tendon from another area of the pitcher's body (usually the wrist, but now more often the gracilis tendon from the thigh*) and uses it to replace the damaged ulnar collateral ligament (UCL) in the pitcher's elbow. The UCL connects the ulna (forearm) and humerus (upper arm) bones, so the surgeon must attach the replacement tendon to both of those bones; putting too much torque on that new ligament soon after surgery could cause it to tear or detach, an almost impossible complication for a pitcher who obeys the rehab rules and keeps the brace on his elbow.

*The reason for the increasing use of the gracilis tendon isn't related to the rehab story, but is still interesting. According to Dr. Lyle Cain of the Andrews Sports Medicine and Orthopedic Center, pitchers who have developed calcification along the torn UCL end up with a "tissue deficit" in the elbow after the surgery. Using the gracilis tendon rather than one from the wrist allows the surgeon to add more collagen and tissue to the elbow. The reason it's not used all the time, per Dr. Cain, is that "you hate to go mess with a joint that doesn't have to be messed with." However, the gracilis tendon is becoming more popular in these surgeries "because it always seems to do better when you add more of the collagen" to the reconstructed elbow. Dr. Wilk says of gracilis transplant recipients, "Personally, I think they do better," even with the slower early rehab as the leg heals, because they don't have "nuisance" discomfort in the wrist to get past.

The biggest question pitchers have at this stage, according to Dr. Wilk, is "When am I gonna throw?" Dr. Wilk sees part of his job as keeping the pitcher occupied with strengthening the shoulder, scapula and core until the brace comes off after Week 6. That includes lighter weights in rotational and circulatory movements designed to strengthen the cuff, plus some larger weights with bigger movements for the scapula and upper back muscles.

Pitchers who have undergone Tommy John surgery typically don't resume throwing until 16 weeks after the surgery, but the brace comes off around Week 6 and the pitcher can begin rehabbing and strengthening the elbow. "From Weeks 6 to 16," Dr. Wilk says, "we work on hips, core, scap, shoulder and elbow, but it's all body -- only 20 percent of the work is elbow, so that by the time they start to throw at four months, we want to have built a better machine." That program, which ASMI calls its "Throwers' Ten Plus Two" protocol, adds to the earlier strengthening work around the shoulder and scapula with new exercises, still largely rotational, that focus on muscles around the elbow and wrist. This period also includes more core strengthening work, but still no throwing until the pitcher has reached Week 16, assuming he's had no setbacks. Dr. Wilk says most pitchers will feel good enough at the two-month mark to get back on a mound, sooner than they can safely do so, meaning that part of his job is to keep those guys motivated through the rehab process, including using plyometrics to simulate some of the movement of throwing without the actual risk of getting on a mound and releasing a pitch.

If the pitcher reaches the sixteen-week mark without any setbacks, he gets to begin throwing -- but it's slow going from here. Dr. Wilk has his pitchers begin by throwing from 45 feet -- like long toss but at such a short distance that it is, in Dr. Wilk's words, "a nothing throw" -- and has them progress to 60, 90 and finally 120 feet while also increasing the number of throws. If they reach the 120-foot mark successfully, which nearly all do, the pitcher gets his first modest reward: He can throw 15 fastballs at 50 percent effort off a mound, and that's all. In between throwing sessions, Dr. Wilk is looking for signs of discomfort or residual soreness that indicate the need to back off.

"One point to emphasize is that the majority of people coming back, even high school kids, have some setbacks," according to Dr. Cain. "It's not unusual for someone to get back to full throwing, full mechanics, full pitching and have something happen where they have to be shut down. They have some soreness, take a step back after three more steps forward. There can be a lot of different reasons, such as muscular soreness because muscles aren't used to the endurance issues, but it's very rare to retear the ligament. Something like nine out of 1,200 re-tore it traumatically [in the ASMI study]." That's why Dr. Cain doesn't worry about the elbow as pitchers rehab from Tommy John surgery -- "I worry about the shoulder. We work on mechanics, and make sure they get the strength and the core back."

Of course, some guys reach this point and find that they can't progress any further. Chris Leonard needed Tommy John surgery at the time of the 2002 Rule 4 draft, when the Blue Jays (my employers at the time) reached a deal with him to take him in the eighth round and immediately send him out for surgery. Leonard had excelled the previous summer in the Cape Cod League and could have been a late first-rounder had he not injured his elbow, so at the time it seemed like a good gamble for the club and a way for Leonard to have the surgery and rehab paid for by a professional organization.

Unfortunately for Leonard, his upper-80s velocity never returned after the surgery. "After all the rehab, the thing that dumbfounded me the whole way through was that my arm felt as strong as it ever had," Leonard says now. "I was throwing the ball -- it legitimately felt upper 80s/low 90s out of my hand; that's the thing that perplexed me until I got released, 'This feels great out of my hand, but the velocity just isn't there.' I think I topped out at 84. Maybe my body just didn't let my arm relax enough to get to that arm speed that I needed." Leonard pitched one summer in the New York-Penn League and was released the following spring training once it was clear that his velocity wasn't coming back.

From that first time on a mound until Month 11, the pitcher is only throwing fastballs, but increasing the intensity of his throwing and the number of pitches he throws in each session. During this time, says Dr. Wilk, pitchers "should be working on touch and feel. If they mindlessly do their throwing programs, they don't have the feel and location -- but the best time to work on location is at lower velocities." Once the pitcher gets past 80 percent intensity, Dr. Wilk "wants [the pitcher] to be aware of his mechanics -- that's not the time to cut corners when you're ramping up from 80 percent."

Arizona Diamondbacks prospect Jarrod Parker had the surgery in the summer of 2009 and didn't pitch in a real game -- one with the scoreboard turned on, so to speak -- until spring training of 2011. He says he couldn't work on a lot of those finer points until he was back in the competitive environment. "Twelve to 14 months you start, but it's really 14 to 17 before you're at 100 percent with command, normal stuff you don't think about when you're healthy," Parker says. Once back on the mound in spring training and again in April in Double-A Mobile, Parker says he "battled that whole first month with arm slot, command, all the stuff you can't really simulate in bullpens -- plus the emotions and stuff you do in the middle of the game" when there's something on the line for the team. Even Parker's three appearances last year in instructional league, while positive steps for him, weren't the same because they're "semi-simulated and structured. You're not facing an outside opponent with fans in the stands."

<p.Once the pitcher hits all his milestones and is ready to get back on a mound, he can also resume throwing breaking balls, which stress the ligament too much to enter the picture before this point. Dr. Wilk targets a rehab start around Month 10, but Month 11 is more common, and as Parker's example shows it can go beyond that even when everything's fine. At that point, the pitcher should have consistent mechanics, whether he's back to his pre-injury mechanics or has made an adjustment in conjunction with Dr. Wilk and his pitching coach, and can continue working on command and feel. Dr. Cain believes that for the typical TJ patient, it's "16 to 24 months when they pick up their normal velocity and control -- the first year isn't all the way back."

Cleveland reliever Chad Durbin was one of the quick ones, reaching the majors just a year after his August 2003 surgery, and worked with Lee Kuntz, now the head trainer for the Nationals, with whom Strasburg worked. Durbin said after the surgery, Dr. Andrews told him, "Ninety-five percent of my work is done. The last 5 percent is up to you," referring to the rehab process. "Purgatory beats you up," Durbin says. "You're hurt but there's nothing for you to do but rehab, so you go through the rehab. I flew through it, but Lee kept fighting me to slow it down, saying 'Let's do the last two weeks over again,' and had to tell me to go do laps around the lakes several times. You go that hard to get to throwing the ball 120 feet for nine minutes and they tell you you're doing it all over again. Once you start to sniff throwing and the mound session is coming up, you start to sniff it as a competitor, saying, 'I'm going to face hitters in a month,' while your trainer says 'My job is to have you pitching ten years from now.'"


[It] took a good four years to get that confidence back.


-- Indians pitcher Chad Durbin