How to Avoid a Second Tommy John Surgery

In part one of this series, we looked at why Tommy John surgery can help a pitcher improve dramatically. In part two, we’ll look at how to avoid re-injury.

G. Russell Huffman, MD, MPH

Tommy John procedures repair a torn ulnar collateral ligament (UCL) in the elbow that usually stems from overuse, basically throwing too many pitches. The surgery is so effective that many athletes think it actually helps them perform better.

So, here’s the dilemma: If Tommy John surgery is so good, why do so many athletes end up re-injuring themselves and needing a second surgery?

G. Russell Huffman, MD, Director of the Shoulder and Elbow Fellowship Program at the Penn Musculoskeletal Center, explains how pitchers and other athletes can avoid a repeat injury and round two of Tommy John surgery.

The Problem

According to ESPN, nearly 35% of pitchers who had Tommy John surgery in 2014 had the procedure before. The reason so many pitchers need a second Tommy John surgery? The underlying issues or problems that caused the ligament to be torn weren’t corrected in the first place.

Dr. Huffman says that this can happen due to four key issues:

  1. Not stretching your shoulder regularly
  2. Weak core strength
  3. Poor body mechanics with hip and leg rotation
  4. Not resting properly

He adds that if these are the fundamental problems and “just the ligament is reconstructed, it may be a temporary fix.”

Taking a Second Look

When Dr. Huffman sees patients, he performs in-office evaluations to assess potential issues and the likelihood of a second surgery, including:

  • Hip examinations
  • Core strength tests, such as single-leg squats
  • Shoulder strength and motion assessment
  • Elbow range of motion assessment
  • X-rays
  • MRIs

The key, however, to not having to endure revision surgery in the first place has to do with proper rehabilitation, which typically takes about 18 months.

Rehabilitation Following Tommy John Surgery

Although rehab is different for everyone, there are typically three phases patient needs to go through to get back to their previous level of ability.

Phase 1 (after surgery until six weeks): Immediately following surgery, the elbow is placed in a brace with no movement in a 90-degree position. The patient will typically need to wear this for close to two weeks. During this time, the patient may start to do gentle range-of-motion exercises for the wrist, hand and shoulder. This will help to maintain motion, strengthen those areas of the body and help to control pain.

Phase 2 (six weeks to four months): After about six weeks, most patients are able begin elbow-strengthening exercises and other mild-intensity workouts (such as cardiovascular, lower extremity and core stabilization exercises). At this stage, the main goal is to continue to protect the elbow and UCL. This is the time where movement/posture dysfunction and kinetic chain issues can be examined, so that they can be changed in an attempt to prevent future injuries.

Phase 3 (four months to six months): At this point, athletes may start to toss a ball without a wind-up motion. Once this is able to be done with no pain, they can begin to add an easy wind-up motion. It is recommended that the distance and number of throws is initially limited and gradually increased every couple weeks or after consultation with the rehab team.

The athlete should cut back the number of throws and distance if any pain is felt at this point. If the pain persists for a couple days, halt throwing and contact your physician.

Phase 4 (eight to 10 months): This is the final stage and where the athlete can return to pitching and throwing from a mound. It is still important to continue to build up strength and gradually increase the number of pitches thrown in a given session.

Pitching at 100% should not occur until about 11 or 12 months, depending on how rehab progressed.

Ultimately, avoiding repeat surgery comes down to knowledge. “Educating individuals in terms of knowing when their own body’s fatiguing and looking at warning signs are important,” adds Dr. Huffman.

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