Tommy John in Youth Athletes: The Specialization Problem

Have you ever reached out to your side, bent your elbow to 90 degrees, placed 6 12-pound bowling balls in your hand, and let the weight torque your elbow backwards toward the ground? Of course not! But this is precisely the amount of force a high-caliber baseball pitcher exerts on his throwing elbow each and every pitch he delivers.

The ulnar collateral ligament (UCL) is found on the inside part of the elbow. If you feel the inside half of your own elbow you can find where the ligament lies by finding the groove between the two bony bumps.

As you can imagine this places a lot of stress on the structures holding your elbow together over time. One particular structure called the ulnar collateral ligament (UCL) absorbs much of this force and is subject to tearing in overhead throwing athletes.

Tommy John surgery is considered by some an “epidemic” in baseball today due to the startling frequency of the surgery. Headlines in the sports section of newspapers highlight new casualties each week as professional pitchers succumb to the repetitive UCL trauma they endure during the marathon season lasting from March through October. But these headlines only capture the professionals; what about those who never make it to the pros or fizzle out as a teen due to the same injuries that grown men receive at the professional level?


New research done by the American Orthopedic Society for Sports Medicine finds that 56.7% of Tommy John surgeries in the United States are done on 15-19 year-olds. Clearly something needs to change. As a college baseball player I often look to see what does and does not work for my teammates. In 3 seasons, I have seen the most significant arm injuries occur in the players who throw throughout the entire off-season, and relatively few injuries in guys who take the winter off. What if the answer for teenage athletes is as simple as playing more sports?

Specialization of sport — that is, focusing on only one sport for the entire year rather than playing different sports — is becoming more common and has been linked to depression and burn out. Unfortunately, athletes and parents alike feel the need to push  to attain scholarships and professional attention. Biomechanically, throwing is an unnatural motion. As pitchers become more specialized, they throw as many as 12 months out of the year while they participate on at least one team at a time and perform in showcases. By playing football or soccer in the fall, basketball or hockey in the winter, athletes use different muscle groups and, most importantly, that precious throwing arm gets left alone!

Dr. James Andrews is a world-renowned surgeon with a career that includes operations on athletes like Michael Jordan, Adrian Peterson, Peyton Manning, and John Smoltz. In an interview with Grantlandhe says that over time he’s observed a trend with his baseball patients: Tommy John surgery used to be found almost exclusively in professionals and is now done predominately on teenagers. He is quick to look towards sport specialization as a key factor in this trend. Dr. Ed Khalfayan, team doctor for the Seattle Mariners, discusses this below.

To confound the issue of sport specialization, some exercise physiologists hypothesize that not only are athletes throwing more, they are also training harder. Due to these special regimens, athletes are stronger and have the ability to produce more force. Thus, during the throwing motion, a larger amount of force must be resisted by the stabilizing structures of the elbow like the UCL. A combination of specialization and the rapidly induced rate of physical maturation caused by training programs creates a deadly combination. It’s one parents and athletes alike should think about.