Concern with early youth specialization grows as ‘Tommy John surgeries’ increase

Experts say the tendency for young baseball pitchers to experience a heavy year-round throwing load often causes the development of chronic elbow injuries from overuse.

Gabe Cramer was a 17-year-old pitcher bound for Stanford and in the midst of his senior year of high school. But instead of dominating hitters, he struggled as pain in his elbow increased with each outing. On the last game of the season, a pitcher’s nightmare unfolded on one pitch.

“It felt like a grenade went off in my elbow,” Cramer recounted. “I knew something was wrong immediately.”

The diagnosis was a torn ulnar collateral ligament, or UCL, an injury that has become increasingly prevalent in youth baseball. Cramer’s surgeon, Dr. Marc Safran of the Stanford University Department of Orthopedic Surgery, saw very few options.

Cramer was told that the surgery was the only answer if he wanted to continue to live and play baseball without pain. The torn ligament was replaced and reinforced by another ligament in his body, and he rehabilitated his arm and didn’t pitch competitively for over a year.

The surgery was developed by orthopedic surgeon Dr. Frank Jobe in 1974 and first used on major league pitcher Tommy John, whose torn UCL was the first to be successfully surgically reinforced, allowing him to return to professional baseball. The surgery — also called ulnar collateral ligament (UCL) reconstruction — became widely known as “Tommy John surgery.”

Four decades later, the procedure has been developed and perfected to a stage in which the rate of recovery is relatively high. A recent study published by the American Journal of Sports Medicine examined the careers of 216 major league pitchers who had undergone the procedure at some point during their careers in professional baseball. The study found that 83 percent of the pitchers returned to the majors following surgery, and that 97 percent were able to throw again competitively at some level of professional baseball.

However, the medical community has expressed dismay over the number of surgeries in sport, particularly among younger players. Dr. Steven Isono, a sports orthopedic surgeon based in Oakland, Calif., said that the tendency for young pitchers to experience a heavy year-round throwing load often causes the development of chronic elbow injuries from overuse.

The sport’s top young talent — who according to Isono are primarily players who specialized early in their careers — are becoming increasingly vulnerable to Tommy John Surgery.

Sports Illustrated reported that 12.8 percent of top 30 high school draft picks underwent the surgery in 2002, while 31.3 percent of the top 30 picks in 2010 have undergone the surgery.

“These kids are starting way down in middle school and Little League and have pitching coaches,” Isono said. The early specialization and prioritization on skills development has accounted for higher workloads at earlier ages, he added.

The physical effects of youth baseball on players can be observed by comparing durability of Latin-American and American-born pitchers in their early professional careers. Without the prevalence of organized competition seen in the United States, young Latin-American pitchers typically pitch fewer innings year round.

The result is a significant difference in the number of Tommy John operations between the two groups. Of the first twenty Major League pitchers to need the surgery in 2014, nineteen were born in the United States, despite roughly a quarter of Major League Baseball claiming Latin-American origin.

“From a medical standpoint, it’s tough,” Isono said. “The overuse injuries are so much more prevalent and devastating.”

The allure of early specialization can be hard to resist. Playing an extra six to nine months each year increases the likelihood of stress injury, but also provides players with an opportunity to improve their skills and experience. As a result, a player can see increased playing time during the next season, and a higher likelihood of college and professional exposure.

“Now your level of baseball is higher coming into the next season than the guys who didn’t specialize,” Isono said.

Cramer and his surgeon believe his injury was the result of over-pitching from an early age. “I was playing baseball ten months out of the year,” Cramer said. He was pitching nearly year round.

Cramer was just 13 years old when he began to notice pain and weakness in his elbow. In one instance after pitching a complete game, he struggled to lift a fork while eating dinner with the team. “My dad had to feed me because my UCL was quivering,” he said.

The consequences of recent early specialization may now be visible at baseball’s highest level. Over the course of the last several years, emerging young stars such as Jose Fernandez (age 22), Matt Harvey (age 24), and Stephen Strasburg (age 23) have had to undergo the procedure after short stints in the Major Leagues.

Preventative resources are emerging from a variety of sources and angles, including, a recent initiative launched by Major League Baseball and USA Baseball to try to provide medical information and recommendations to young players and their parents, including pitch counts, rest and warning signs for possible injury.

For Dr. Isono, pitch counts and other regulations are a good start but can also be misleading. “You can’t put the intensity of throwing into the equation,” he said. In other words, pitchers throw at differing levels of intensity depending on the stakes involved in a particular game, or the part of the game in which they are throwing.

It’s also difficult for younger pitchers to self-regulate on the basis of pain. “When you’re 10 and 12, you’re not going to say, ‘I’m not throwing, I’m going to rest. I need physical therapy,’” Isono said.

Cramer looks back at his rigorous competitive schedule with some regret, but also perspective. “I wish I could go back and tell myself that those innings don’t matter. I threw hard from a young age and put irreversible innings in my arm.”

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