Uh oh… Your favorite pitcher left his previous start early complaining of forearm tightness. Two days later he’s placed on the 15-day DL and that ominous term inches closer to its next victim — Tommy John surgery.
So what actually is Tommy John surgery? What does a seemingly simple complaint like forearm tightness have to do with it? Why do pitchers end up gaining velocity and losing command once they return from TJS? These are questions I can answer.
I work in the physical rehabilitation industry, treating injuries solely of the upper extremity. I’ve been following the scouting aspect of baseball heavily for the past 5 years or so. I can tell you that there is quite a bit of misinformation out there and people have been basing their opinions on said information.
Contrary to what you’ve heard, the throwing motion is a natural motion at the shoulder joint. We actually have a muscle solely responsible for this movement. The problem with pitching lies with the volume of repetitions. The upper extremity of a human being was intended to do many, many things. It was not intended to do these things over 200 times in a 4 hour time period.
Now, I am providing an extreme over-generalization of pitching mechanics by saying that only one muscle is involved. The flexor muscles on the inside of the forearm are responsible for gripping the baseball and wrist flexion at the point of release. Forearm tightness comes from overusing these muscles. The point that use becomes overuse varies by pitcher. All pitchers use these muscles similarly, but subtle variances in mechanics, pitch selection and even anatomy can either decrease or increase the chance of overuse.
The reason that forearm tightness, or in Dylan Bundy’s case “flexor mass tightness”, is so detrimental is based on the anatomy at the elbow. These flexor muscles attach on what is actually the bone of the upper arm, or the humerus. For reference, the muscles that extend the wrist, or pull the wrist back, insert on the opposite side of the humerus. Chronic overuse of these muscles is known as Tennis Elbow. If you have had the misfortune of having Tennis Elbow, you can understand what we are dealing with here. The best rehab for muscles of the forearm, be it the flexors (Golfer’s Elbow) or extensors (Tennis Elbow), is rest and activity modification. You can’t exactly modify your pitching mechanics to stop using these muscles, so the only thing that can be done is rest. The magnitude of the injury will obviously impact how much rest is required.
The tight grip on the baseball and the wrist flexion during release creates a tremendous amount of stress where the flexor muscles attach at the elbow. With every pitch, micro-tears are created in these muscles as the ball is released. The pitcher’s body determines these micro-tears to be bad things and sends whatever it can to help heal in the form of blood and fluid for nutrition. This causes swelling and inflammation on a microscopic level. The more the muscle tears without being allowed to heal, the more inflammation and swelling. This is why pitchers ice the crap out of their elbows, to constrict the flow of more fluid to the area. After a day or so, the body realizes the tears are minuscule and allows them to heal on their own without added assistance. Given 4-5 days rest, these muscles fully heal just in time to do it all over again. The problem with this is some pitchers don’t heal as fast for whatever reason and require more rest. If they aren’t given that rest, the tears accumulate. Scar tissue, inflammation and edema (swelling) build and cause pain and/or tightness. This is the point of overuse.
So great. We have a guy with some forearm tightness. What does that have to do with Tommy John surgery? The wrist flexor muscles that have become inflamed and overused attach at the very same spot as the UCL, or ulnar collateral ligament. When this ligament becomes damaged, the stability of the elbow suffers greatly. The elbow joint is called a hinge joint, meaning it only goes one way or the other in a single plane of movement. The ulnar collateral ligament helps keep everything in line, attaching the bone of the upper arm to the bones of the forearm. Tommy John surgery reconstructs this ligament using a tendon from another part of the body. This is usually the palmaris longus tendon, which is harvested from the forearm. We no longer need this particular tendon. You’ll have to ask God/evolution why. Some people, I want to say 7%, don’t even have this tendon. Not kidding, look it up. Anatomical abnormalities are more common than you think.
I won’t get into how surgeons perform TJS, but it involves drilling holes in bones and weaving this new tendon through and then suturing it together. This new tendon is stronger than the damaged ligament was. There are several ways to reconstruct the UCL, but they all result in a stronger ligament capable of withstanding greater torque. In turn, this provides greater stability to the joint, which I believe is why some pitchers gain velocity. I attribute the loss of control/command that some pitchers experience to the reconstruction creating a decrease in what is called proprioception. In layman’s terms, this is your brain’s awareness of a joint and it’s location in space relative to it’s environment. This is purely speculation, but if you don’t know where you elbow is going, you don’t know where the ball is going.
I believe the baseball industry has fallen into a dogmatic spiral of misguided cautiousness. What I’ve touched on in the previous paragraphs isn’t exactly rocket science. Every clubhouse in baseball has team doctors, trainers and physical therapists who know all of what I’ve said and more. However, until more research comes out detailing proper pitcher usage, these medical professionals will continue to get strong-armed by their respective front offices who have millions of dollars tied up in their pitchers and don’t want to risk their arms by straying from the traditional pitch counts and rest periods.
Personally, I don’t believe there is much difference between 100 pitches and 110 pitches. Or 125 pitches. Yes, there will be more acute (immediate onset) damage to tendons and ligaments with more pitches. I think the biggest difference comes in the days between rest. Baseball will eventually get to 6 man rotations and I definitely think we will see pitcher injuries decrease when we do. More rest should equal higher pitch counts, but I doubt we ever see that. The days of the 300 inning pitcher are long gone. Pitchers are bigger and stronger than ever. Players are bigger and stronger than ever. But their bodies are no more capable of supporting themselves than they were 25, 50, or 100 years ago. I’m not surprising anyone when I say that pitchers require more rest than ever and certainly more rest than they are getting. It appears that overuse injuries in pitchers are on the rise, and they have been for a while. We will get to a point when enough is enough, and front offices around baseball will begin to catch on. Then and only then will we see a decrease in elbow injuries.