He was the Mets head team physician from 1991 to 2001 and medical director from 2005 to '24, physician of the U.S. Davis Cup team from 1999 to 2003, and North American medical director of the ATP Tour. Dr. Altchek was co-chief of HSS's sports medicine and shoulder service from 2005 to '14.

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Strider received an InternalBrace™ for his revision in lieu of the standard UCL repair process. Theodore A. Blaine, MD, sports medicine physician at HSS explains what this means for Strider and how the InternalBrace™ surgery is different from the standard "Tommy John" UCL reconstruction. 

“The decision to perform a UCL reconstruction ("Tommy John" surgery) or a UCL repair (with or without an internal brace) or both is based on many factors,” Dr. Blaine explained, with “each of these weighed to determine the best options for each individual.” It’s a significant list of factors, as well. “The age of the player, the location of the injury to the UCL, the desired activity level of the athlete moving forward, the quality of the tissue, and any prior elbow injury history are all factors that must be considered.”

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In baseball, the words “Tommy John surgery” are uttered every day. And with a rash of injuries sidelining stars around the league, we are hearing the phrase more than ever. The number of injuries to pitchers’ ulnar collateral ligaments keeps rising, an epidemic swallowing the sport and leading to changes in the surgical landscape. But it’s no longer as simple as a pitcher tearing his ligament, going under the knife, and returning a little over a year later. Now there are many pitchers undergoing second, or even third, surgeries, known as revisions, with slightly different techniques and recovery times at play. And many players are gravitating towards a newer option, the internal brace procedure, which is adding a dimension to a seemingly familiar landscape. One thing is clear: Tommy John surgery, in its various forms, is going to continue to be an important part of baseball for the foreseeable future. 

Once viewed as a last-chance operation, Tommy John in the 21st century no longer has such a negative stigma. But the idea that all pitchers return from Tommy John as harder-throwing superhumans comes with misconceptions.

“In the first four or five months after Tommy John surgery, we’re really not even throwing a baseball,” Dr. Dines said. “You’re working on core strength and shoulder rotation and all these other things that when you’re playing baseball often get neglected. But because you have nothing else to do, you’re focusing on them. I think if anything that’s what makes these baseball players better and throw harder.” 

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In the 50 years since Dr. Frank Jobe ‘s first Tommy John surgery, the operation has saved careers and earned fortunes.

Dr. Altchek performed Tommy John surgery on Zack Wheeler in 2015, and he returned to the field just two years later. 

Texas Rangers team physician Dr. Keith Meister combined traditional Tommy John ligament replacement with the internal brace promising increased longevity and enhanced strength for pitchers undergoing the surgery, known as a hybrid procedure. 

“His theory is that players are throwing so much harder, with also so much spin, that they are putting so much stress on that ulnar ligament,” Altchek said. “He thinks the failure rate is creeping up — we just haven’t proven it statistically yet — and therefore adding this synthetic strong suture will protect the the reconstruction over time.”

Innovations such as laser therapy and Piezoelectric therapy stimulate tissue healing by promoting the release of nitric acid, which causes blood vessels to widen. Blood flow resistance is another technique.

“It sounds crazy,” Altchek said. “You put a tourniquet on the arm, you blow it up to a certain percentage of the patient’s blood pressure, cutting off part of the blood supply and then you exercise in that range for 10, 15 minutes, and then you let the tourniquet down. ... The local muscles actually release hormones in a fight or fight way and it stimulates healing.”

These innovations reflect a broader shift towards prioritizing better healing and long-term outcomes in sports medicine.

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“The baseball throwing motion is probably unnatural and stressful motion you can do to the elbow. Especially that ulnar collateral ligament," said Dr. Carr.

“There are sports that don't require as strong as a UCL. Unfortunately, baseball is one of them where you have to have robust, strong UCL, or the body can't hold up to the stresses of throwing 90 plus miles an hour,” explained Dr. Carr. 

When it comes to Tommy John Surgery, “What we are trying to do is restore a strong ligament to the inside of the elbow. Typically, with the classic Tommy John Surgery, we take a tendon from elsewhere. So if there is an extra tendon in the wrist or we take a hamstring tendon and create a new ligament for the elbow,” said Dr. Carr. 

“Teaching pitchers how to pitch and not necessarily just go for velocity is important. Really strengthening the shoulder and elbow is important. A lot of pitchers try to use weighted baseballs to increase velocity. That has been shown to increase the risk of injury, so focusing more on mechanics using your lower extremities, trying to make sure your elbow is supported throughout your mechanics is important. Keeping a strong shoulder and elbow to support the ligaments is important. Those things have been shod to help reduce the risk of injuries, but we still haven't found that magic key, but hopefully in the next few years, we will have more information there,” explained Dr. Carr. 

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Can UCL tears be prevented? “That’s an enormous area of debate,” said Dr. Altchek.

“There’s a direct correlation between the velocity you throw and the incidence of UCL tears,” Dr. Altchek said. “So a particular player throwing 100 mph puts them in the high-risk category, in my opinion. What adds to the high-risk category can be throwing weighted balls. I understand that throwing weighted balls increases your velocity, but they also, in my opinion, increase your risk of injuring your UCL.”

Dr. Altchek discusses the success rate of players returning from Tommy John Surgery. “It works,” he said. “Done correctly, people can come back at the same level.”

For patients seeking to come back after more than one Tommy John surgery, however, the chances of returning at the same level begins to decrease,  Dr. Altchek said.

“Once you start getting out there, that number drops in half,” explained Dr. Altchek. “So three Tommy Johns, you’re fighting to get back.”

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Baseball continues to be stricken with their nightmare epidemic: elbow injuries. Elbow and shoulder injuries have increased 44% from just a year ago, according to Baseball Prospectus research.  

“There have been a lot of studies done and looked at variables about the ulnar ligament injuries,’’ said Dr. Altchek, “but the only issue that clearly stands out is velocity. Guys throwing harder will have higher incidents of injuries that ligament. Throwing harder really seems to make a big difference. 

“The second thing is there’s a lot of debate over using weighted balls in workouts. Throwing those does increase velocity, but at what cost? If it’s not done effectively, it does increase incidents and injuries to the UCL,’’ he added.  

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Some players worry this change in policy may contribute to an increase in injuries, specifically Tampa Bay Rays’ pitcher Tyler Glasnow, who was recently diagnosed with a partially torn ulnar collateral ligament (UCL).

Dr. Altchek has performed around 1,500 Tommy John operations since 1988, and said this theory is plausible due to the sudden and major adjustment. He noted, “I’d rather have them use the sticky stuff and figure this out in the offseason.”

Dr. Altchek encouraged the MLB to explore alternative options for player health and safety. He said, “We already have an epidemic of elbow injuries. Tyler Glasnow sent a warning shot over the league. A pitcher of his level – saying that he made whatever the sudden changes were, grip pressure or something else – and then immediately developing an elbow problem, is scary. We have a few too many strikeouts, who cares?”

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Dr. Carr explained he takes a personalized approach to care by listening to patients to better understand their goals and help them get back in the game. He treats athletes of all ages - from middle school, to high school, college, professional and weekend warriors.

The initial physical exam is important to Dr. Carr as well as imaging, such as radiographs, x-rays or MRIs. He noted, “My biggest goal is the right diagnosis, because if you have the right diagnosis then you can have the right treatment plan.”

Dr. Carr said he starts with non-operative measures whenever possible for his patients, and often surgery is the last resort. He explores several first-line options, such as physical therapy, injections, braces, rest or anti-inflammatory medication.

Dr. Carr also addressed the increase of Tommy John elbow injuries in recent years the potential causes.

As someone who regularly treats baseball players, Dr. Carr attributed the rise to an increase in higher pitching velocity and disregarding pitch count rules, as this correlation is especially apparent in youth players. Further, he advised while younger players are resilient they should ease into pitching. “It’s really important to not pick up a ball and throw as hard as you can. Take time, at least a month or two, to get your arm and body ready for max effort pitching.”

The segment aired on May 27, 2021.

Dr. Altchek explained elbow injuries are categorized into three problem areas: tendon injuries, bony problems and ligament injuries. Tennis elbow is an injury to the extensor group tendon, originating at the outer part of the elbow extending through the forearm. Discomfort arises when extending the wrist against resistance and resolves in two to 12 months. Treatment involves ice, nonsteroidal anti-inflammatories (NSAIDs) and avoiding aggravating activities.

Elbows can develop “bone spurs” as a result of degeneration from osteoarthritis. In younger individuals, it can result from the repetitive overload of throwing or racquet sports. Most spurs occur in the back of the elbow, and limit ability to extend the elbow fully. Spurs can be easily removed with minor arthroscopic surgery.

According to Dr. Altchek, the most common elbow ligament injury is the ulnar collateral ligament (UCL) on the inside of the elbow. Causes include trauma, or aggressive throwing, as seen in baseball pitchers. In athletes, this usually requires Tommy John surgery. Injuries also occur at the outside of the elbow, generally because of trauma or degeneration from tennis elbow. This injury can create significant disability and requires surgery.

This article appeared in the print edition on February 21, 2021.

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