There is no doubt that Tommy John surgery is on the rise, especially within the baseball community. In 2024, nearly 36% of all active MLB pitchers have undergone Tommy John surgery. This surgical procedure has been on the rise within the last two decades. For some, this surgery is a beacon of hope for many athletes when facing a potentially career-ending injury.
Tommy John surgery was first performed in 1974 after a major league baseball pitcher named Tommy John had the first
UCL reconstruction. The UCL, or ulnar collateral ligament, is a ligament on the inside of the elbow that helps protect against valgus stress. It provides stability to the inner elbow. When the UCL tears, UCL reconstructive surgery becomes a likely option. If you or someone you know has been through this surgical procedure, then you will be familiar with the lengthy recovery time it needs. This post will review the anatomy of the elbow and UCL, what is done during UCL reconstruction surgery, the time it takes to fully recover, and what rehabilitation looks like after Tommy John surgery.
Take me straight to how long recovery time will take after Tommy John surgery.
**This is not medical advice. Please consult your medical provider for more information.
Anatomy of the Elbow
The main elbow joint is formed by the humerus (upper arm bone) and the ulna (forearm bone). These two bones form the humeroulnar joint, which is the main joint responsible for bending and straightening the elbow. The elbow is meant to flex and extend. It is not meant to move inward or outward. So what provides stability to the elbow to prevent it from moving in these directions?
The ulnar collateral ligament (UCL) of the elbow is what provides stability to the inside of the elbow. It’s a fibrous band of connective tissue that connects the humerus to the ulna. This prevents valgus (inward) stress at the elbow joint. If there is trauma or repetitive stress to the inside of the elbow, the UCL may be the victim. Imaging will be able to confirm if there is a tear of the UCL or if it is a strain from overuse. Make sure you are differentiating a UCL injury from medial epicondylitis, or golfer’s elbow. Your PCP or physical therapist can help determine the source of your pain.
What Exactly is Tommy John Surgery?
If you find you are dealing with a UCL tear, surgery becomes an option. UCL reconstruction, otherwise known as Tommy John surgery, is the go-to for this type of injury. The nickname “Tommy John surgery” comes from the first MLB pitcher who underwent this procedure. As you can expect, his name is Tommy John.
This surgery repairs the damaged UCL ligament with a tendon from another part of the body. At times, a donor may be used. Usually, the palmaris longus tendon is harvested, which is a tendon in the forearm. However, other tendons used can come from the gracilis or the hamstring.
The success rate of Tommy John surgery speaks to it’s ability to offer athletes a second chance at their careers. The success rate is 80-90%. But still, it’s not without its risks and challenges. Surgery can come with complications and there is a lengthy rehabilitation process to get back to playing at sport level again. The road to recovery demands patience and resilience. Returning to daily activities might take a few months, but getting back to the level of pitching that athletes aspire to can take a year or more. This timeline underscores the importance of a meticulously planned rehabilitation process set forth by expertly trained physical therapists.
The Rise of Tommy John Surgery in Sports
Since its initiation, the prevalence of Tommy John surgery has seen a rapid rise among athletes. This is especially true for athletes in major league baseball and in youth sports. Since the first UCL reconstruction in 1974 and through the 1990s, there were, on average, 2.5 Tommy John surgeries per year. From 2015 to present, there is now an average of 30 surgeries performed each year. This phenomenon is not just a reflection of the surgery’s success rate. It also underscores the growing awareness and acknowledgment of the risks involved in overhead sports.
So what exactly are risk factors that increase the chance of injury to the UCL? Two of the biggest factors are improper throwing biomechanics and the sheer volume of throwing. Lets review the two more in depth.
Improper Throwing Biomechanics
When throwing at elite levels and throwing at max velocity, the tiniest adjustments make a big difference. Your biomechanics need to be dialed in in order to ensure there is no extra stress going to the elbow. This means making sure you limit any obvious muscle imbalances at the shoulder, elbow, forearm, or wrist. It means you have to have adequate strength of the rotator cuff muscles to be able to handle the load of throwing at max velocity. It also means handling the volume of throwing needed to compete.
The lower body will also help out the upper body. Think about it—the legs have the largest, and therefore, strongest muscles compared to the arms. Your lower body generates your power to throw. The core acts as the link between your upper and lower body, generating the transfer of power from the legs and up to the arm. This is what puts so much power behind a pitcher’s throw. Everything has to be perfectly timed. If any one link in this entire system is off, it can lead to overuse and/or injury.
Volume of Throwing
The volume of throwing has increased over the years. Before, baseball players would only play for a season and then have the rest of the year off. Nowadays, competitive players are competing year round. This leaves little room for time off. On top of this, pitchers are playing more with less time off between games. They are also throwing more pitches per game. There isn’t enough focus on longevity, only recovery between games. Because of this culture, pitchers are trying to go the distance and increasing they’re risk of injury. If you combine this along with poor pitching mechanics, this is a recipe for disaster.
Recovery Time After Tommy John Surgery
The recovery time it takes after having Tommy John surgery to return to what you were doing pre-surgery will vary depending on what activities you are trying to get back to doing. If you are looking to get back to normal daily activities that don’t involve a lot of lifting, then 3-4 months may be all you need. If you are looking to get back to competitive baseball and you’re a pitcher, the process can take 12-18 months, potentially longer. A definitive timeline should never be set in stone. It should adjust as time goes on and based on what is seen in rehab and whether you body is recovering in a timely fashion.
Early (and gentle) throwing won’t even begin until around months 4-8, depending on where your strength testing is measured at. Once you are cleared to begin to start throwing, you will start a comprehensive throwing program. This will set out how many throws you are allowed to make, at a specific percentage of effort, and with definitive rest between throwing days. Beginning to return to pitching with harder velocities won’t begin until near the 1 year mark (months 9-12). Again, this all depends on how rehab is going during the early throwing phase and return to throwing program.
What Does Rehabilitation Look Like After Tommy John Surgery?
Rehabilitation after surgery is divided up into phases based on when it is appropriate to begin different things the body needs. When you do int he first few weeks will look very different from what you do two months after surgery. The biggest thing is that you don’t want to progress too fast to avoid risking injury again. This is where physical therapy is crucial. Your physical therapist will help guide you on your recovery journey, helping to establish what is appropriate for you and determining when it is time to progress you.
Early Protection Phase (0-4 weeks)
The initial phase post-surgery focuses on protection of the elbow and to minimize pain and swelling. You will have a brace on your arm which will be locked to a certain degree to protect the newly formed UCL. This biggest precaution to watch for in this phase is no valgus stress, which will immediately place stress on the UCL. After a UCL reconstruction, you need to give this new structure time to heal and adhere to the surfaces it was just attached to.
In physical therapy, you can expect to work on wrist, shoulder, and gentle elbow range of motion exercises. This is meant to restore range to multiple joints within your throwing arm, but also is gentle enough that it won’t injure anything. While it is important to protect the elbow at this time, gentle movement (in the right directions) is important to improve blood flow, bring nutrients to the joints, reduce swelling, and prevent your arm from getting stiff.
Intro to Basic Strengthening Phase (4-8 weeks)
As healing progresses, gentle strengthening exercises may begin. Strengthening will begin for the muscles of the wrist and shoulder, but no resistance at the elbow yet. You will still be working on gaining full range of motion at the elbow. Low load, long duration stretching is great for gaining full range of motion at the elbow if you are still having challenges here.
Starting to slowly load the rotator cuff muscles and accessory muscles of the shoulder will be beneficial. All overhead athletes should have strong rotator cuff muscles. When looking at statistics on injuries to overhead athletes, weak rotator cuff muscles are commonly found. This is true for the shoulder, elbow, and wrist. Believe it or not, having a strong rotator cuff reduces injuries at both the elbow and wrist.
This leads back to common causes of UCL injury an poor throwing biomechanics. If you are using poor mechanics, you are probably using the wrong muscles, thus demonstrating a lack of rotator cuff and accessory muscle strength. This will be essential for correcting moving forward after surgery. Because if you don’t address this part, it is likely that as you return to throwing, stress to the elbow will increase if these muscles are not keeping up and doing their job as intended. The body will always find a way to compensate and this is usually what leads to injury.
Progressive Strengthening Phase (8-16 Weeks)
Progressing strength during this phase will incorporate additional resistance at the wrist and forearm and beginning to introduce weightbearing exercises to the upper extremity. While we can gentle load the elbow with some weight, this does not mean you are ready and able to lift weights that you were lifting pre-surgery. You really want an emphasis on stability at the shoulder, wrist, and elbow, as this lays a solid foundation moving forward.
You also want to look into progressing lower body strengthening. Keeping you lower body strong is paramount. This is where the power from your throw generates from. You are not limited with what you can do with your lower body, as long as you are racking weights and using your surgical arm to do this. Incorporating thoracic mobility will also be beneficial to a pitcher as you have to have decent thoracic rotation and extension to be able to get to the cocking phase of the throw and then again on the follow-through.
In the later weeks (around weeks 12-16), incorporating more advanced functional strength exercises will play a key role in the next phase. This next phase is where throwing will be introduced. If you are not looking to go back to sports, your rehab journey will be close to finishing here. For position players that aren’t pitchers (infield, outfield, utility), you will still have to continue on your rehab journey because you have to reintroduce throwing. The journey may not be as long through this phase as it will be for a pitcher.
Intro to Throwing Phase (4-9 Months)
By this time, a throwing program begins. It will have a very specific routine to follow. This includes, how often to throw, rest days, percentage of effort to throw, and how many throws to make. This is a great way to get your arm used to tolerating throwing again without overloading the elbow or any other part of the arm. It gives adequate rest to recover and lays out what to do if you feel pain after throwing. During this time, you will continue to progressively load your arms and legs to keep the rest of your body strong.
Advanced Throwing Phase (9+ Months)
This is where pitching comes into play. With routine healing, you should be throwing at about 80% velocity from where you are at before injury. This is where velocity training begins. The intent is to still provide adequate recovery between throwing days, but the ultimate goal is to have the elbow withstand the velocity and torque produced from throwing a pitch at 100% effort. On top of this, you have to withstand the number of pitches that are expected at top levels of competition. This will take you all the way up to the end of your rehab journey. Total time will be around 14-18 months post-surgery.
Remember, everyone’s recovery journey after Tommy John surgery will look different. It isn’t about comparing to others. You are on your own timeline. Dedication is really something that will take you to the next level if you are looking to return back to competitive play and being a pitcher at the top level. It takes serious commitment to dedicate hours of work on a daily basis for almost a year. But, it can be done. With each step, returning to the game becomes reality. The success rate after this surgery is high, but it’ll take lots of dedication, effort, commitment, and grit to reap the rewards after and to ensure you’ll stay in the game for a long time to come.
Prevention Strategies
Preventing UCL injuries, especially for young athletes, revolves around understanding and implementing several strategies. First and foremost, pitching mechanics need to be addressed. Proper form is not just about enhancing performance. It’s about minimizing stress to the medial elbow. This involves coaching and continual refinement of techniques to ensure the elbow is not overburdened during pitching.
Next, you should be focusing on workload management. Monitoring and limiting the number of pitches young athletes throw, both in practice and in games, is essential to prevent overuse injuries. This includes adhering to pitch count guidelines set forth by sports medicine professionals and ensuring adequate rest between pitching sessions. You can have the best pitching mechanics in the world, but that still can’t outrun workload and overuse. Our body’s are machines, but all machines break down at some point if you don’t take care of them in the long run. Taking care of them involves appropriate rest and recovery. Don’t forget this part!
A well-rounded exercise regimen that focuses on the entire body can provide support needed to protect the UCL. While pitching mechanics are a requirement, so is an adequate and comprehensive strength and conditioning program. The entire body is connected one way or another. While you are looking at protecting the elbow, your shoulder has to have the strength to keep up. Your thoracic spine has to have enough mobility to allow you to whip and turn your trunk at high velocities. Your core has to act as the transfer of power between your upper and lower body. And your legs have to be very strong to generate the force and power to initiate everything. You can’t forget any one of these links or the chain will be broken. Incorporating all of this will help ensure a longer and healthier career in sports.
TL;DR
Tommy John surgery repairs a torn UCL in the elbow—an injury common in throwing athletes due to poor mechanics or overuse. Recovery involves a lengthy rehab process, often taking a year or more to return to competitive pitching. Physical therapy plays a vital role in restoring strength, mobility, and safe throwing mechanics. Preventative strategies are also important for long-term shoulder, elbow, and wrist health and for athletic performance.
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